Sally Residential Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, there were two (2) staff and four (4) residents present. The LPA was greeted by staff and at this time the reason for the visit was explained. The facility designee, Sara Jackson arrived at approximately 10:10 a.m. Entrance interview conducted. During today’s inspection, the LPA along with the facility designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA inspected the kitchen/food service area at approximately 10:30 a.m. Knives and sharps were observed locked and inaccessible in a kitchen drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed the fire extinguisher to be fully charged with a purchase date of 07/07/2025. Required postings were observed throughout the common space. There is a working telephone on premises. Cameras observed in the common areas. Activities were observed in the living room. No hazards/obstruction observed inside or out. Report Continued on LIC 809C... Report Continued from LIC 809... RESTROOMS: There are two (2) restrooms for resident use. The first bathroom is located by the main hallway and the second bathroom is located in bedroom #4. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:19 a.m., the hot water temperature was measured in both bathrooms, and they measured within the required range of 105 – 120 degrees Fahrenheit. Personal hygiene items were observed locked and inaccessible to residents in care. BEDROOMS: There are four (4) bedrooms for resident use. Two (2) bedrooms are designated as double / shared occupancy, and two (2) bedrooms are designated as private rooms. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a staff bedroom on premises. GARAGE: The garage was locked and inaccessible to residents at the time of the visit. The LPA observed an adequate amount of emergency food and water. Washer and dryer were observed inside the garage. Additional cleaning supplies are kept in the garage locked and inaccessible to residents in care. BACKYARD: The backyard has a covered patio area with patio furniture for resident use. All passageways were observed to be clear of any obstructions. There is (1) side gate with latching mechanisms. No bodies of water noted at the time of the visit. RECORDS: The LPA began record review at approximately 09:35 a.m. Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were in order. Report Continued on LIC 809C... Report Continued from LIC 809C... Three (3) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. Interviews with staff revealed that the Administrator designated by the licensee is not present at the facility during normal working hours and a notice to the department was not sent designating a facility manager which will be present at the facility when the Administrator is temporarily absent from the facility. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; the last one was conducted on 07/07/2025. MEDICATIONS: Medications review began at approximately 12:00 p.m. Medications are centrally stored and kept in a locked file cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications are properly documented on the Centrally Stored Medication & Destruction Records and appear to be administered as prescribed at the time of the visit. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC809-D). Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 8, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Martha Arroyo conducted a Subsequent Pre-Licensing Visit to the facility today. The reason for this visit is to update the fire clearance approved after the pre-licensing visit initiated on 08/08/2024. LPA met with Applicant Representative, Sara Jackson as this is a change of ownership application from Sally’s Residential Care Home #565800494 to Sally Residential Care Home #565850407. The applicant has obtained fire clearance for a total capacity of six (6) residents, all of which may be bedridden in bedrooms #1 - #4. The facility has a dementia program in place. During today’s visit, the LPA toured the physical plant areas to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations and conducted a medication review. The following was observed: The LPA observed two (2) resident restrooms, which were clean and sanitary and in operating condition with non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The LPA observed four (4) resident bedrooms; two (2) bedrooms are designated as single occupancy; and two (2) bedrooms are designated as double occupancy. All resident bedrooms were observed to be furnished appropriately and had sufficient lighting. Fire clearance also approved for staff bedroom on premises. The LPA inspected the kitchen/food service area. The facility has a sufficient supply of perishable and non-perishable food. All indoor and outdoor passageways were free from obstructions in case of an emergency. No bodies of water noted at the time of the visit. Report Continued on LIC 809C... Report Continued from LIC 809... Physical plant is consistent with the updated facility sketch/floor plan and fire clearance approved from 08/14/2024. The physical plant of this facility location is in compliance with Title 22 regulations at this time. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. The report was reviewed, and a copy was provided.the state’s words, verbatim · CDSS document, Aug 29, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: Census (if any clients in care): 3 COMP II Participants: Joseph Jose (Board Member) & Trieg'e Surratt (Administrator) Interview Method: Virtual interview via Microsoft Teams On August 14, 2024, applicant(s)/administrator participated in COMP II for the below pending facilities: Sally Residential Care Home/565850407, Sally Residential Care Home 2/565850409. Identification of the applicant(s) and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant(s) and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Aug 14, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA), Martha Arroyo conducted a pre-licensing visit to this property. LPA met with Applicant Representative Sara Jackson as this is a change of ownership application from Sally’s Residential Care Home #565800494 to Sally Residential Care Home #565850407. The applicant has obtained fire clearance for a total capacity of six (6) residents, all of which may be bedridden in bedrooms #1 - #4. The facility has a dementia program in place. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The smoke alarms and carbon monoxide detectors were tested and function properly. LPA observed one (1) fire extinguisher to be new and fully charged on 08/04/2024. There is two (2) double occupancy bedrooms and two (2) single occupancy bedrooms for resident use and one (1) staff room. Each bedroom is equipped with clean mattresses, pillows, and bedding. Bedrooms have sufficient lighting. There is a cabinet in the hallway with a sufficient supply of linens, including blankets, bath towels and wash cloths. There is a locked closet with the resident’s personal hygiene items. The facility has two (2) bathrooms for resident use. Resident bathrooms contained appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products. Hot water temperature was measured in both bathrooms, and they measured between 105- and 120 degrees Fahrenheit. LPA observed trash cans with tight fitting lids at the time of the visit. LPA toured the kitchen area at 10:10 a.m. The facility has at least seven (7) day supply of non-perishable food and two (2) days perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives and sharps were observed in a locked drawer next to the gas range. The kitchen has a sufficient supply of plates, cups, cookware, and utensils. Report Continued on LIC 809C... Report Continued from LIC 809... The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Enough seating for six (6) residents at the same time in the dining room table. A working telephone is present. There are activity supplies in the living room. Night-lights were present in the common areas. All doors have functioning auditory alarms when opened. Medications are stored and locked in a file cabinet adjacent to the dining room. Facility records and First aid kit was by the medications. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual. Facility has an adequate 30-day supply of Personal Protection Equipment (PPE). The garage is attached to the house and inaccessible to residents in care. There is one (1) additional refrigerator in the garage with extra food for resident use. The washer and dryer was observed inside the garage. Detergents, disinfectants, and cleaning supplies are stored locked and inaccessible. There will be no firearms/ammunition stored on the property. There is a sufficient supply of emergency food and water. The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights. The exterior passageways were clean and clear of any obstructions. There is one (1) self-latching gate for emergency use. There are no bodies of water on the premises at the time of the visit. LPA observed the backyard, which has a covered outdoor area with a table and chairs for resident use. Comp III conducted with Applicant Representative. Physical plant is NOT accurate with the submitted facility sketch / floor plan. There are five (5) rooms total. Sketch submitted only shows four (4) bedrooms. Fire clearance only approved for four (4) bedrooms. Report Continued on LIC 809C... Report Continued from LIC 809C... The following needs to be completed prior to licensure: · Submit a new facility sketch / floor plan and obtain fire clearance for additional rooms. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. The report was reviewed, and a copy was provided.the state’s words, verbatim · CDSS document, Aug 8, 2024