Say You're Home Too

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required Annual Inspection. LPA Rodgers was granted entry into the facility Licensee Lisa Sayre after identifying herself and stating the purpose of the inspection. According to the facility’s license, the facility serves six non-ambulatory elderly residents: ages 60 and above of which one (1) can be bedridden. LPA was accompanied by staff during a tour of the facility, which was conducted inside and out and included a sample of resident bedrooms, common area, dining area. Exterior and interior passageways were free from obstructions. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Resident’s room temperatures were within a comfortable range. Hot water temperature at taps accessible to residents were all compliant. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings and appropriate lighting to ensure the comfort and safety of residents. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Non-skid mats are present in the showers. Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Medications are locked in a locked closet, not accessible to residents. Medications were labeled and kept in compliance with label instructions. LPA interviewed staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. No deficiencies were observed or cited at the time of visit An exit interview was conducted and a copy of this report and Licensee/Appeal Rights - LIC 9058 (rev. 03/22) was provided to the , Licensee Lisa Sayre whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 12, 2026

Allegation investigated: Licensee did not ensure staff were associated to facility Licensee did not keep medications stored in original packaging.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to invistagte and deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Lisa Sayre. On January 06, 2026, Community Care Licensing Division (CCLD) received a complaint alleging that the Licensee did not ensure staff were associated with the facility and that the Licensee did not keep medications stored in their original packaging. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Substantiated (Continued from LIC9099) Regarding the allegation, the Licensee did not ensure that the staff were associated with the facility. More specifically, Staff #1 does not have Department background clearance and is employed at the facility. It was discovered through Department interviews with staff and residents, as well as records reviews. Staff #1 (S1) is currently employed at the facility. Review of the Department’s background clearance database revealed S1 was not associated to the facility and did not have a background clearance. Based on the evidence obtained, the deficiency was cited in an LIC 9099-D form. An immediate five-hundred-dollar ($500) civil penalty was assessed in an LIC 421BG form. Regarding the allegation, Licensee did not keep medications stored in their original packaging. More specifically, It was reported that staff fill medication containers designated for residents and place the medications into 7-day pill organizers. During the facility tour LPA observed medications being stored in plastic containers with different sections for morning, noon, evening, and bed time. An interview with Staff #2 (S2) revealed that S2 transfers medications into the corresponding time residents are supposed to receive their medication. These medications were not stored in the original medication packages. LPA explained to the licensee that medications must not be transferred into different containers in this way and in accordance with licensing guidelines must stay in their original packaging. Based on evidence obtained , the licensee did not store medication in original containers, the deficiency was cited in an LIC 9099-D Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D) and an immediate civil penalty was assessed. A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Licensee Lisa Sayre, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099) Regarding the allegation that staff did not provide incontinence care to residents. More specially, It was alleged that staff failed to provide timely incontinence care to R1 as outlined in the care plan. Department interviews with staff revealed inconsistent responses—some staff stated care was provided as required, while others were unsure or gave conflicting accounts. Department interviews with outside sources indicated they had not observed any issues related to incontinence care for any residence. OS1 reported frequent visits to the facility, including body checks for R1, and stated they had not noticed any urine odors in the facility or from other residents. Regarding the allegation that staff did not reposition bedridden resident(s) per care plan. More specifically, it was alleged that staff failed to reposition R2 according to the care plan schedule. Department interviews with staff revealed that all staff agreed they were following repositioning schedules and care plans, and that R2 was assisted out of bed almost daily. Department interviews with outside sources indicated they had not observed any problems related to repositioning. They further reported frequent visits to the facility and noted no skin issues concerning R2. Regarding the allegation that staff #3 (S3) may have consumed alcohol while at the facility. Department interviews with staff indicated they did not witness S3 providing care while under the influence. Department interviews with staff indicated they did not observe S3 providing care while impaired or under the influence to a degree that would affect job performance, safety, or effectiveness, as prohibited by CCLD regulations. Interviews revealed that alcohol was present during a celebratory events at the facility, and some staff reported witnessing brief toasts. There was no indication that any staff, including S3, were impaired or that resident care was negatively impacted. Department interviews with outside sources indicated they had not observed any staff appearing impaired or under the influence of alcohol Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Licensee Lisa Sayre to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 08-AS-20260106153022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(b)(2) · Plan of correction due date: Jan 14, 2026

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement was not met as evidenced by: Based on interviews, and review of records, the Licensee did not ensure S1 had a criminal records clearance, which posed an immediate health, safety, and personal rights risk to 6 residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: Licensee agreed to obtain criminal records clearances for all new staff prior to employment. LIcensee stated S1 will no longer work at the facility until cleared. The LPA did not observe S1 at the facility, therefore, the POC was cleared on today's date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Feb 16, 2026

87465(h) The following requirements shall apply to medications which are centrally stored:(5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. Based on records reviewed and interviews the licensee did not store medication in original containers which poses an potential Safety risk to 5 persons in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: Licensee states they will schedule outside source medication training and provide proof to LPA by POC.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Licensee, Lisa Sayre. According to the facility’s license, the facility has a maximum capacity of six (6) clients, all of whom can be non-ambulatory. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry and visitation. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to clients were all compliant. Refrigerator and Freezer temperature were complaint. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [Continued on 809-C] [Continued on 809] No pools or bodies of water were observed on the premises. Per the licensee no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Licensee Lisa Sayre, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Apr 17, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Licensee, Lisa Sayre. According to the facility’s license, the facility has a maximum capacity of six (6) clients, all of whom can be non-ambulatory. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry and visitation. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to clients were all compliant. Refrigerator and Freezer temperature were complaint. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [Continued on 809-C] [Continued on 809] No pools or bodies of water were observed on the premises. Per the licensee no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Licensee Lisa Sayre, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Apr 24, 2024