St. Joseph's Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by staff, and LPA explained the nature of the visit. Damien Martinez, Administrator, arrived shortly after and met with LPA. The facility currently has six (6) residents at the facility and there are two (2) residents receiving hospice services currently. The facility is a one story home with a living room, kitchen, staff room, two bathrooms, four resident bedrooms, dining room, and attached garage. LPA accompanied by staff began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. Facility pantry is located in the garage. There is additional food storage in a spare refrigerator in the garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage closet located in the living room. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care, LPA observed the first aid kit. LPA inspected the facility bathrooms and LPA measured the hot water temperature which measured 117.5 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants Continued on LIC809-C are stored in a locked storage cabinet in the garage. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which had sufficient lighting to ensure safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors/carbon monoxide detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there are shaded seating areas for residents’ enjoyment in the backyard of the facility. LPA observed a fire extinguisher with service date of April 15, 2026, charged and mounted in the kitchen. Fire drills are conducted every three months, LPA verified fire drill logs are kept and last drill was conducted July 12, 2026. LPA began reviewing records. LPA reviewed three resident records. All the required documentation was present and reviewed in the residents’ files. LPA reviewed three employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Administrator, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 13, 2026

Allegation investigated: Facility staff do not properly assist resident with toileting needs overnight Licensee did not ensure suppositories are administered by resident or an appropriately skilled professional

On January 29, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Leah Fajardo was notified via telephone but was unable to assist with today’s inspection. During the course of the investigation, the Department interviewed residents, interviewed staff, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, facility staff do not properly assist resident with toileting needs overnight, the following has been concluded: It was alleged that facility staff did not properly assist Resident #1 (R1) with toileting needs overnight. The Department was unable to conduct an interview with R1 for this allegation due to R1 passing away on November 12, 2024. The Department reviewed R1’s Reappraisal dated March 28, 2024, which stated that R1 required assistance with toileting and with incontinence care. The Department conducted five resident interviews. Three out of the five residents were unable to be qualified for an interview. CONTINUED ON LIC9099-C Substantiated Two out of the five residents interviewed stated that they do not require assistance with incontinence care. The Department conducted four staff interviews. Four out of the four staff interviewed confirmed that R1 was receiving assistance from the facility with incontinence care. Staff interviewed stated that the facility would put two diapers, and a liner on R1 at night for her incontinence issues, since the facility does not provide awake staff overnight. However, three out of the four staff interviewed stated that there were incidents in which R1 was soiled in the morning since she was not being changed overnight. Regarding the allegation, licensee did not ensure suppositories are administered by resident or an appropriately skilled professional, the following has been concluded: It was alleged that the licensee did not ensure suppositories were administered to R1 by an appropriately skilled professional. The Department was unable to conduct an interview with R1 for this allegation due to R1 passing away on November 12, 2024. The Department reviewed R1’s Physician Report dated March 28, 2024, which stated that R1 was unable to administer her own prescription medications. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and stated that suppositories were administered by R1’s hospice agency. The Department reviewed R1’s medication administration records. The Department observed that R1 was administered a suppository on April 7, and July 16, 2024. The Department reviewed R1’s hospice visitation log and observed that R1 was visited on July 16, 2024, but was not visited on April 7, 2024. Therefore, a suppository was administered to R1 on April 7, 2024, without an appropriately skilled professional present. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegations that, facility staff do not properly assist resident with toileting needs overnight and licensee did not ensure suppositories are administered by resident or an appropriately skilled professional. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D pages. An exit interview was conducted via telephone with Administrator Leah Fajardo. A copy of the report and Appeal Rights were provided to an authorized facility representative. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and stated that call buttons have always been available and within reach of residents. Due to conflicting information received during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted via telephone with Administrator Leah Fajardo. A copy of the report was provided to an authorized facility representative.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 22-AS-20240423163628

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Feb 27, 2026

87625 Managed Incontinence: (b) ... the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement was not evidenced by: Based on records reviewed and interviews conducted, the Licensee did not ensure that R1 was properly assisted with toileting needs overnight. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: The Administrator stated that she will complete a written statement to comply with the regulation with any future residents that may require assistance with incontinence needs. The Administrator agreed to provide LPA the written statement via email or fax by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87622(a)(2) · Plan of correction due date: Jan 30, 2026

87622 Fecal Impaction Removal, Enemas, and/or Suppositories: (a) The licensee shall be permitted to accept.. a resident who requires .. suppositories .. (2) ..suppositories shall be.. administered.. by either the resident or an appropriately skilled professional. This requirement was not evidenced by: Based on records reviewed and interviews conducted, the Licensee did not ensure that a suppository was administered to Resident #1 (R1) by an appropriately skilled professional on 4/7/24. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: The Administrator stated that she will conduct an in-service training with all facility staff regarding the administration of suppositories. The Administrator stated that she will provide proof of the training to LPA via email or fax by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Leah Fajardo and explained the purpose of the visit. The facility currently has four residents in care. The facility is a one story home with a living room, kitchen, staff room, two bathrooms, four resident bedrooms, dining room, and attached two car garage. Facility appears clean, safe and sanitary. LPA observed four residents watching tv and lounging in their bedrooms. LPA observed all resident bedrooms to have the required components and furnishings. LPA observed clean linens in the hall closet located by the resident bedrooms. LPA tested the water in both bathrooms to be between 107.2-107.8 degrees Fahrenheit. LPA observed the bathrooms to be stocked with toilet paper, paper towels and non-slip mats. LPA observed the locked medication closet to be by the front door and made inaccessible to residents in care. LPA observed the kitchen to be free of vermin. LPA observed a seven day non-perishable and two day perishable food supply on hand. LPA observed the sharps to be in a locked drawer making them inaccessible to residents in care. LPA observed a fire extinguisher charged and with a service date of May 15, 2025. LPA observed the staff room through the kitchen to be locked making it inaccessible to residents in care. LPA observed the garage to be locked and made inaccessible to residents in care. LPA observed the toxins and chemicals to be in the locked garage. LPA observed the emergency food supply and extra food to be stored in the garage. LPA observed the backyard to be free of obstructions. LPA observed a shaded seating area for resident use. LPA and AD tested the carbon monoxide detectors and they were found to be operational. Continue on LIC 809C LPA reviewed staff files and no discrepancies were observed. LPA reviewed resident files and 2 of 4 residents do not have updated reappraisal. LPA observed a fire drill last conducted on April 15, 2025. LPA reviewed resident medication and 1 of 4 residents has an over the counter medication that does not have a physicians order. All staff present are background cleared and associated to the facility. Based on today’s observation a technical violation and a deficiency are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Leah Fajardo and a copy of this report along with LIC809-D, appeal rights, LIC858, LIC 9102 were given at the time of the inspection.the state’s words, verbatim · CDSS document, Jul 22, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual inspection using the CARE Tool. LPA was greeted and granted entry by Caregiver Jocelyn Regalado. Administrators (Admins) Miguelito and Leah Ann Fajardo arrived on premise approximately 2:00pm. During today's visit, LPA observed five residents in care and two caregivers on duty. LPA observed the facility to be clean and sanitary. There are five resident bedrooms and two resident bathrooms. All common areas were inspected including the attached two car garage which doubled as a laundry room. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for each residents' personal belongings were observed. Bathrooms were found to be in compliance, clean, and operational. The water temperature measured at 114.8 and 125.0 degrees Fahrenheit. LPA observed the indoor temperature was within a comfortable range. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available. LPA toured the exterior portion of the facility. LPA observed the outdoor passageway free of obstruction. The exit gate was in good repair. LPA observed sufficient seating and shading. Facility maintains fire extinguishers which were observed to be mounted, charged, and serviced on May 28, 2024. The auditory devices and smoke/carbon monoxide detectors were tested and operational. Emergency disaster supplies including food/water were present. Emergency evacuation drills were not conducted on a quarterly basis with the last drill approximately 2021. The first aid kit contains all necessary elements. LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size. The Administrator's Certificate for Leah Ann Fajardo expires on March 10, 2025. LPA conducted an audit of five residents' files and two personnel files. No discrepancies noted. Residents/staff interviews were conducted and medications were audited. No discrepancies noted. Based on the observations made during today's visit, one deficiency is being cited. An Advisory Note is also issued. An exit interview was conducted with Administrators Miguelito and Leah Ann Fajardo, and a copy of this report, and the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Jul 29, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.