Sam's Homecare

Allegation investigated: Staff did not notify authorized representative about change of resident health condition.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the two allegations listed above. LPA was greeted and granted entry by facility staff after introducing himself, stating the purpose of the visit and listing the allegations investigated. Administrator Juhayna Diaz was notified of the visit via telephone and gave house manager staff permission to sign the report after being informed of the findings. The initial complaint investigation visit was conducted by LPA Kathrina Chin on July 19, 2021. During the visit, licensing staff interviewed staff, residents and reviewed and obtained documentation. Additional witness interviews were conducted during the investigation. During the present visit, LPA requested additional documentation and interviewed staff members present. CONTINUED ON FORM LIC9099-C Unfounded CONTINUED FROM FORM LIC9099-A Resident R1 was admitted to the facility on October 3, 2020 and assessed as the time as diagnosed with multiple comorbidities such as: "dementia, [stage III] chronic kidney disease, obstructive sleep apnea, hypothyroidism, atherosclerotic aorta, atria fibrillation, hypertension, [congestive heart failure]" as well as a pacemaker implanted. R1's condition is well documented in both their physician report and individual needs assessment established upon admission. Per an incident report submitted on May 4, 2021, R1 was admitted to the hospital after sustaining a low oxygen saturation episode in spite of being provided oxygen as prescribed. Regarding the allegation that Staff did not seek medical attention to resident in a timely manner, the following has been concluded: Based on staff interviews and incident reports submitted in May and July 2021, staff were trained to regularly check R1's oxygen saturation levels and reacted accordingly if concerning vitals were measured. As R1 sustained a health emergency on July 3, 2021, paramedics were called by a family member who was visiting at the time. There is however insufficient information corroborating that staff would have been untimely in requesting medical assistance if that had not been the case. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 Resident R1 was admitted to the facility on October 3, 2020 and assessed at the time as diagnosed with multiple comorbidities such as: "dementia, [stage III] chronic kidney disease, obstructive sleep apnea, hypothyroidism, atherosclerotic aorta, atria fibrillation, hypertension, [congestive heart failure]" as well as a pacemaker implanted. R1's condition is well documented in both their physician report and individual needs assessment established upon admission. Per an incident report submitted on May 4, 2021, R1 was admitted to the hospital after sustaining a low oxygen saturation episode in spite of being provided oxygen as prescribed. Upon readmission after being discharged from a skilled nursing facility, R1 was reassessed on May 26, 2021. A written statement by R1's responsible party and attorney-in-fact confirms that R1's condition at the time of their passing was consistent with the documented condition on file as well as with earlier communication with facility staff via text, telephone and/or verbal exchanges. As a result, the allegation that Staff did not notify authorized representative about change of resident health condition is determined to be Unfounded, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report and the list of Confidential names LIC811 were provided to the facility.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 22-AS-20210713111719

Type of visit: Case Management - Annual Continuation

On August 11, 2025, at 9:00 AM, Licensing Program Analysts (LPA) Edward Kim arrived to complete the required 1-year annual visit that started August 4, 2025. LPA Kim met with Administrator Juhayna Diaz and explained the purpose of today's visit. During the visit, LPA Kim conducted a full audit of all staff files and medication and medication administration record that were all in order and complete. LPA conducted interviews with two staff and two residents. The first aid kit was reviewed and contained all the required items. LPA observed the facility has a tablet that has internet capability and video conferencing technology dedicated to the residents. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Administrator Juhayna Diaz.the state’s words, verbatim · CDSS document, Aug 11, 2025

Type of visit: POC

On August 11, 2025, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management POC visit in conjunction with the annual continuation visit on August 11, 2025. LPA met with Administrator Juhayna Diaz and explained the purpose for the visit. LPA observed R1, R2, and R4 had all their Appraisals Needs and Service Plan updated dated August 5, 2025. LPA observed that auditory devices in the front entrance, vacant resident room, and backyard exit were all in working order. The deficiencies (See LIC 809D dated 8/4/2024) have been cleared. A facility representative was provided with the POC letter documenting the corrections. An exit interview was conducted, and a copy of this report, LIC811, and POC letter were provided to Administrator Juhayna Diaz.the state’s words, verbatim · CDSS document, Aug 11, 2025

Type of visit: Required - 1 Year

On August 4, 2025, at 1:30 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with House Manager (HM) Rosallie Gabriel. A phone call was attempted to Administrator (AD) Juhayna Diaz. ADMIN Diaz did not respond and who could not attend today's visit. HM Gabriel signed on behalf of the facility because ADMIN Diaz was absent from August 1, 2025, to August 4, 2025.. The facility is licensed to operate for six (6) non-ambulatory residents and have a hospice waiver for four (4) residents. The facility is a two-story building located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, five (5) staff bedrooms, six (6) bathrooms, living room, family area, dining room, office, kitchen, attached 2-car garage, and 2 outside covered patio areas. LPA Kim toured indoor and outdoor of the physical plant with HM Gabriel. There are no obstructions or bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Staff Room 1, Staff Room 2, Staff Room 3, Staff Room 4, and Staff Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. Bathroom water temperature measured between 107.6 degrees F and 108.1 degrees F. A comfortable temperature of 76 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. LPA observed the left side burners were covered and the knobs had child safety locks on them. The Licensee was not present for the LPA to test if the burners were operable. Emergency food, water, and supplies are stored in the kitchen pantry and in the garage. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The facility conducts Fire/Safety Drills quarterly and was last conducted on June 1, 2025. A working telephone (714-312-0054) remains available. Smoke detectors and carbon monoxide detectors were operable. LPA audited resident files (R1-R4). LPA observed appraisal from R1 dated 11/25/2023, R2 dated 3/24/2024, and R4 did not have any appraisal on file. LPA observed medical assessment from R1 dated 11/29/2023 diagnosed with dementia, and R2 dated 6/26/2023 who is diagnosed with dementia. Due to time constraints a continuation of this inspection will be conducted at a later date. LPA Kim will: 1) conduct record review for staff, 2) Conduct interviews with staff and residents, 3) Inspect First Aid Kit, 4) inspect device with internet access dedicated residents, and 5) conduct a medication review at a later date. Based on today’s visit, deficiencies are being cited as per Title 22 Division 6 Chapter 8 of California Code of Regulations (CCR). LPA observed appraisal from R1 dated 11/25/2023, R2 dated 3/24/2024, and R4 did not have any appraisal on file. LPA observed the auditory devices for the front entrance, vacant resident room, and backdoor exit were not in working order during the visit. Technical violations were assessed during the visit. LPA observed medical assessment from R1 dated 11/29/2023, and R2 dated 6/26/2023. LPA observed the left side burners covered and with child proof safety locks at the knobs. LPA observed the LIC308 does not designate the house manager when Administrator is absent. An exit interview was conducted and a copy of this report and appeal rights were provided to House Manager Rosallie Gabriel.the state’s words, verbatim · CDSS document, Aug 4, 2025

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On August 14, 2024, at 2:25pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with House Manager (HM) Rosallie Gabriel and explained the purpose of the visit. Administrator (AD) Juhayna Diaz arrived at the facility around 4:00pm. The facility is licensed to operate for six (6) non-ambulatory and have a hospice waiver for four (4) residents. The facility is a two-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, five (5) staff bedroom, six (6) bathrooms, living room, family area, dining room, office, kitchen, attached 2-car garage, and 2 outside covered patio area. LPA Kim toured indoor and outdoor of the physical plant with Direct Care Staff (DCS) Benjie Corpuz. There are no obstructions or bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Staff Room 1, Staff Room 2, Staff Room 3, Staff Room 4, and Staff Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. Bathroom water temperature measured at 105.4 degrees F in resident bathroom #1, and 105 degrees F in resident bathroom #2. A comfortable temperature of 76 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, water, supplies are stored in the kitchen pantry. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The facility conducts Fire/Safety Drill quarterly and was last conducted on February 10, 2024. A working telephone (714-312-0054) remains available. Fire extinguisher is mounted in the dining room, fully charged, and receipt showing it was purchased on March 21, 2024. Due to time constraint a continuation of this inspection will be conducted at a later date. LPA Kim will: 1) conduct record review for staff and residents, 2) Conduct interviews with staff and residents, 3) Test smoke detectors and carbon monoxide detectors, 4) Inspect First Aid Kit 5) and conduct a medication review at a later date. An exit interview was conducted and a copy of this report and was provided to Administrator Juhayna Diaz.the state’s words, verbatim · CDSS document, Aug 14, 2024