Stewart Oaks Villa

Type of visit: Case Management - Other

On 07/31/2025, Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to conduct a case management inspection. LPA Lee met with licensee Kanwal Randhawa and explained the purpose of the visit. The census is 0. The purpose of this visit was to finalize the facility’s closure and confirm that no residents remained on-site. On July 18, 2025, the licensee emailed LPA Lee to report that the property located at 1099 Stewart Road had been sold and escrow closed on July 17, 2025, resulting in the loss of control over the property. As a result, Licensee Randhawa forfeit the facility license. Additionally, on July 31, 2025, at 2:08 PM, LPA Lee received a formal letter from Licensee Randhawa confirming the decision to surrender the license. During today’s visit, LPA conducted a walk through of the facility and observed that no residents or personal belongings remained in the facility. The licensee officially surrendered the original facility license to LPA Lee on July 31, 2025. An exit interview was conducted with the Licensee Kanwal Randhawa. Link to survey for Facility Closure provided to Licensee. A copy of this report was provided to the Licensee at the end of the visit. www.surveymonkey.com/r/facilityclosurethe state’s words, verbatim · CDSS document, Jul 31, 2025

Type of visit: Required - 1 Year

On 02/06/25 at 8:25 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection and a non-compliance quarterly visit. LPA Lee met with administrator Ajeshni Mohan. LPA Lee explained the purpose of the visit. Administrator assisted with today’s visit. Administrator certificate # is 6065121740 and will expire on 04/15/25. The current census is 2 with 1 facility staff. This facility is a single story building licensed to serve six (6) non-ambulatory residents and the facility is approved for two hospice waivers. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. The facility does have a pool and it was made inaccessible to residents. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. LPA observed knifes kept and made inaccessible to residents in care. Hot water temperature was measured at 120.0 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 10/03/24. The last fire drill was conducted on 01/02/25. LPA observed the facility has a has a public telephone in the kitchen. Facility thermostat observed at 70 degrees Fahrenheit. LPA observed toxins located in the laundry room which is kept locked and inaccessible to residents. LPA checked medication storage and found medication to be locked away and inaccessible to residents. Continued LIC 809-C LPA reviewed and compared 2 out of 2 medication administration record (MAR) and it was complete; however, it was learned that staff are pre-pouring medications into a container and initialed that the medications are administered to residents since the medications are pre-poured. The first aid kit was checked and contained the required components. LPA requested resident and staff files for review. LPA reviewed 2 out 2 resident files and 3 staff files, and they were complete. LPA reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 07/05/2024 by 5:00 PM by end of day: (1) LIC 308 Designation of Administrative Responsibility (2) LIC 610D Emergency Disaster Plan (3) Proof of Current Liability Insurance As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Feb 6, 2025

Allegation investigated: A resident sustained serious injury while on AWOL.

On 12/11/2024, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Ajeshni Mohan and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 4. A brief interview with Licensee Kanwal Randhawa was conducted via telephone call. It was alleged that a resident sustained serious injury while on AWOL. This investigation consisted of interviews with staff and resident responsible party and records review. It was learned that on October 7, 2023, at 10:00 PM staff 1 (S1) who arrived for the NOC shift from 10:00 PM to 6:00 AM noticed that resident 1 (R1) was not in the facility and is missing. Law enforcement was called and at 10:10 PM, R1 was located on the street by law enforcement. Administrator Mohan arrived at the scene at 10:16 PM and found R1 in a confused state and with a black eye. Paramedics transported R1 to UC Davis for evaluation. Continued LIC 9099-C Substantiated A review of R1's physician report, dated February 23, 2024, and care plan which states that R1 has a diagnosis of dementia and was not able to leave the facility unattended with safety checks conducted by facility staff every shift from 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and from 10:00 PM to 6:00 AM. Additionally, a hospital discharge summary confirmed that R1 was admitted to UC Davis on October 7, 2024, with a diagnosis of blunt/critical trauma level II due to a fall. When LPA Lee questioned administrator how R1 sustained the injury to R1’s eye and administrator admitted that R1 sustained the injury to R1’s eye during the AWOL. Based on interviews and document reviewed, the preponderance of evidence standards has been met therefore the allegation is substantiated. As a result, an immediate $500.00 civil penalty shall be assessed on December 13,2024 for bodily injury and severe pain, which posed an immediate threat to the Health, Safety, and Personal Rights of R1. Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiency was observed during today’s visit. Citation can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to facility. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 13, 2024 · control 27-AS-20241023072313

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 20, 2024

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: Based on observation, file review, and interviews the licensee/administrator did not ensure staff provide care and supervision to R1. Due to not providing care and supervision R1 sustained serious injure during an AWOL. This posed an immediate health and safety risk to R1the state’s words, verbatim · CDSS document, Dec 13, 2024

Plan of correction: Administrator agrees to conduct Basic Services training for all staff. Administrator will read and understand the regulation cited and provide LPA Lee a letter of acknowledgment of the regulation cite was review. Administrator will email documents used for training and training sign in sheet by POC Date 12/20/2024 end of day 5:00 PM.

Allegation investigated: Staff did not prevent resident from eloping from the facility

On October 17, 2024, at 8:15 AM, Licensing Program Analyst (LPA) Pang Lee and Ombudsman Ron Carrera arrived unannounced to open and closed the complaint allegation outlined above. LPA met with Administrator Ajeshni Mohan to explain the purpose of the visit. The census is 5 with 2 facility staff. Allegation: Staff did not prevent a resident from eloping from the facility. During the investigation, LPA conducted interviews with Administrator Mohan, one additional staff member and resident. The investigation included a review of facility records, including unusual incident reports, LIC 602 Physician's Reports, and LIC 625 Needs and Service Plans pertaining to Resident 1 (R1). On October 7, 2024, during the PM shift from 2:00 PM to 10:00 PM, only one staff member was scheduled to work. At approximately 9:30 PM, R1 and Staff 1 (S1) were sitting on the couch watching TV. S1 then left to use the bathroom. Continued LIC 9099-C Substantiated At 10:00 PM, S1 opened the door for Staff 2 (S2), who was arriving for the NOC shift from 10:00 PM to 6:00 AM, and S2 noticed that R1 was missing. At 10:10 PM, R1 was located on the street by law enforcement. Administrator Mohan arrived at the scene at 10:16 PM and found R1 in a confused state and with a black eye. Paramedics transported R1 to UC Davis for evaluation. A review of R1's physician report, dated February 23, 2024, indicated that R1 was not permitted to leave the facility unattended. Additionally, a hospital discharge summary confirmed that R1 was admitted to UC Davis on October 7, 2024, with a diagnosis of blunt/critical trauma level II due to a fall. Based on interviews and document reviewed, the preponderance of evidence standards has been met therefore the allegation is substantiated. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. CIVIL PENALTIES ARE ASSESSED IN THE AMOUNT OF $500 today for immediate violations. Exit interview conducted, a copy of this report, LIC 9099-D, and appeal rights were provided. An exit interview was conducted, and copies of this report, the LIC 9099-D, and information on appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 17, 2024 · control 27-AS-20241016093029

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Oct 24, 2024

1569.312(a) Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidence by: Based on reviewed records, the facility did not comply with section cited above. R1 AWOL'd from the facility and was found in the community unsupervised by the police officer. The LIC 602 states R1 was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Oct 17, 2024

Plan of correction: The Licensee/Administrator shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. Licensee/Administrator shall send the in-service training materials, plan on how staff will ensure residents do not AWOL and a signature sheet of all staff who attended the in-service. Licensee/Administrator will also provide LPA Lee an updated LIC 500 to ensure sufficient staffing at all times and in writing staffing schedule to be put in place immediately to ensure the safety of the residents in care. POC due to LPA Lee by 10/24/2024 end of day 5:00 PM

Type of visit: Case Management - Health Checks

The Report was amended to remove the last paragraph and citation wording. Facility did not received any citations during the visit. Unannounced case management visit conducted on 10/17/2024 by Licensing Program Analyst (LPA) Pang Lee who was met by the facility designated Administrator Ajeshni Mohan. A brief interview was conducted with the facility designated Administrator at this time. The current census was 6 residents with 2 facility staff. The purpose of this visit was to follow up on the requirements set forth in the Non-Compliance Conference on 04/10/2024. LPA toured and inspected the physical plant inside and outside to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in sanitary condition. LPA observed the body of water made inaccessible to resident at this time. The hot water measured at 110.5 degrees Fahrenheit in resident’s bathroom sink. During today's visit, LPA reviewed and audit 3 out of 5 residents’ medication log sheets and it was complete. LPA verified (3) staff file to ensure staff maintained adequate annual training and it was complete. LPA reviewed 3 out of 5 resident’s file and it was complete. LPA review criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. Based on a review of this facility during today’s visit, it was determined that this facility was found to be in compliance at this time. No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 17, 2024

Allegation investigated: Staff did not allow resident to sleep. Staff do not ensure the facility is free from pests. Licensee does not ensure facility is adequately staffed to meet residents' needs.

On 09/17/2024 at 8:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Ajeshni Mohan and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 4 with 2 facility staff. A brief interview with conducted with the administrator. Allegation: Staff did not allow resident to sleep. It was alleged that staff did not allow resident to sleep. This investigation consisted of interviews with staffs and residents and outside agencies. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Lee was unable to corroborate the allegations. LPA Lee interviewed 3 out of 3 residents who have no concern with staff not allowing residents to sleep and denied the allegation. LPA Lee also interviewed 3 out of 4 facility staff who denied the allegation. Moreover, LPA Lee interviewed 2 out of 2 hospice nurse and 1 home health nurse who has no concerns with the allegation and has not witness the allegation. Based on the information gathered it is unclear that the staff did not allow resident to sleep. Continued LIC 9099-C Unsubstantiated Allegation: Licensee does not ensure facility is adequately staffed to meet residents' needs. It was alleged that staff did not ensure facility is adequately staff to meet the resident's needs. This investigation consisted of interviews with staffs and residents and outside agencies. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Lee was unable to corroborate the allegations. LPA Lee interviewed 3 out of 3 residents who have no concern with facility not adequately staffed to meet the residents needs and denied the allegation. Moreover the 3 residents provided statements of being treated with respect and kindness. LPA Lee also interviewed 2 out of 4 facility staff who denied the allegation. Moreover, LPA Lee interviewed 2 out of 2 hospice nurse and 1 home health nurse who has no concerns with the allegation and provided statements that the facility staff are very attentiveness to resident’s needs. Based on the information gathered it is unclear that the licensee does not ensure facility is adequately staffed to meet the resident’s needs. Allegation: Staff do not ensure the facility is free from pests. It was alleged that staff do not ensure the facility is free from pests. This investigation consisted of observations, records reviewed, interviews with staff, residents, and outside agencies. Based on observations on 07/16/2024, LPA Lee observed 4 mouse and insect glue trap in the kitchen. LPA Lee did observe all four mouse and insect glue trap to have roaches caught on the glue trap. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Lee was unable to corroborate the allegation. LPA Lee interviewed 3 out of 3 residents who stated that they have not seen any roaches in the home. 4 out of 4 facility staff also confirmed that the Clark Pest Control comes out to the home to service the home. Moreover, LPA Lee interviewed 2 out of 2 hospice nurse and 1 home health nurse who stated they have not observed any pest in the home. Based on records review the facility is in contract with Clark Pest Control on 05/25/2023. It was also learned that the service months are as follow: February, April, May, June, August, October, and December. LPA Lee was also provided with exterminating and disinfecting services document for the following dates: 02/07/2024, 03/07/2024, 04/07/2024, 05/07/2024, 06/07/2024 and 07/07/2024. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted, and a copy of this report was provided to facility at the end of this visit.the state’s words, verbatim · CDSS document, Sep 17, 2024 · control 27-AS-20240711104807

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 8/22/24 at 11:45am. This visit is to confirm ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY. LPA was met by Ajeshni Mohan, Administrator and stated the purpose of the visit. LPA spoke with Administrator Ajeshni Mohan who stated that S1 used to be the administrator for the facility prior to her employment as the Administrator. S1 does not work at the facility any longer. S1 was not present at the time of visit. Facility understands this is an Immediate Exclusion effective 8/22/2024. S1 is excluded and prohibited from being a licensee, owning a beneficial ownership of 10% interest or more in a licensed facility, or being an Administrator, officer, director, member, or manager of a licensee or entity controlling a licensee. S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. LPA provided a copy of the Declaration of Service and ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY during this visit. Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview held, Copy of report giventhe state’s words, verbatim · CDSS document, Aug 22, 2024

Allegation investigated: Staff did not tell family members any information about the resident.

On 07/16/2024 at 11:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 5 with 2 facility staff. A brief interview with administrator Ajasani Mohan was conducted. Allegation: Staff did not tell family members any information about the resident. It was alleged that staff did not tell family members any information about the resident. This investigation consisted of records reviewed and interviews. Based on interview with administrator Ajasani a family member wanted health information disclosed to them regarding resident 1 (R1). LPA Lee attempted to interview (R1); however, (R1) was not alert. Based on records review (R1) does have a Power of Attorney documents in placed and POA was given rights to (R1)’s advance health care directive and the right to write checks on, deposit funds to, and withdraw funds from accounts. Continued LIC 9099-C Unsubstantiated The standard for the preponderance of the evidence was not met and the Department finds this allegation to be UNSUBSTANTIATED. A finding of Unsubstantiated means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. Moreover on 06/18/2024, (R1)’s power of attorney admitted that she/he has rights for (R1)’s health and financial decision only. POA also admitted that there is no stipulation in place that (R1) is not allowed to have certain visitors visit (R1). LPA Lee attempted to interview (R1); however, (R1) was not alert. LPA Lee also observed a note posted in the kitchen and in (R1)’s file stating that (R1) can’t have any visitor or phone calls without the approval of POA and POA’s sons. Based on interview with administrator Ajasani there are no restraining order or court order in place that certain family members cannot visit (R1) and that the facility are only following POA directions of who can and can’t visit (R1); therefore, the facility can’t make decisions of who can and can’t visit (R1). As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Allegation: Staff only allow resident to have a 5-minute visit with a family member. It was alleged that staff only allow resident to have a 5-minute visit with a family member. This investigation consisted of interviews with staff and resident. LPA Lee attempted to interviewed resident 1 (R1); however, (R1) was not alert. Based on interview with administrator Ajasani Mohan, it was learned that (R1) had a visitor approximately a month ago that came approximately 2 hours and 46 minutes to visit (R1) and that per (R1)’s POA direction all visitors and phone calls has to be approved by POA. Administrator Ajasani stated, that once the visitor arrive to visit (R1) the facility is to called (R1)’s POA and informed the POA that the visitor can only visit (R1) for 5-10 minutes and that the visit needs to be monitor by a staff. Administrator admitted that the visit only lasted 5 minutes and was supervised per by the administrator per POA direction. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Jul 16, 2024 · control 27-AS-20240612115021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 19, 2024

87468.1(a)(1) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on records review and interview the administrator the facility did not comply with the section cited above. Administrator did not ensure that (R1) is allowed to have a family member visit (R1) without approval from (R1)’s POA. (R1)’s POA does not have the power granted to make decisions of who can and can’t visit (R1). This poses an immediate health, safety, or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Licensee will remove the note posted in the kitchen and in (R1)’s file stating that (R1) can’t have any visitor or phone calls without the approval of the POA and POA’s sons. There is no court order in placed for the facility to make the decisions of who can and can’t visit (R1). The facility also can’t make decision of who can and can’t call (R1). Administrator will also review regulation cited and provide LPA Lee a statement of acknowledgment that the regulation cited has been review and understood. POC will be email to LPA Lee by 07/19/2024 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468 PersonalRights · Plan of correction due date: Jul 19, 2024

87468 Personal Rights (a) Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to… This requirement is not met as evidenced by: Based on records review and interview with the administrator the facility did not comply with the section cited above. The administrator did not ensure that (R1)’s family member was able to visit (R1) for more that 5-10 minutes and that the visit was supervised by the administrator. This poses an immediate health, safety, or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Licensee will remove the note posted in the kitchen and in (R1)’s file stating that (R1) can’t have any visitor or phone calls without the approval of the POA and POA’s sons. There is no court order in placed for the facility to make the decisions of how visitation is for (R1) and that the visit needs to be supervised. . The administrator will also review regulation cited and provide LPA Lee a statement of acknowledgment that the regulation cited has been review and understood. POC will be email to LPA Lee by 07/19/2024 end of day 5:00 PM.

Type of visit: Case Management - Health Checks

On 07/16/2024 at 1:48 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a health and safety case management visit. The facility is on quarterly visits due to non-compliance concerns discussed during an teams meeting on 04/10/2024. LPA met with administrator Ajasani Mohan and explained the purpose of the visit. The census is 5 with 2 facility staff. LPA Lee and administrator Ajasani toured the physical plant to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed resident bedrooms and bathrooms to have necessary furniture and furnishings. Bedrooms were equipped with a bed, chair, dresser, and closet space. Bathrooms handrails and non-skid mats are in good repair. Hot water temperature was measured at 106.9 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. There is night light observed in the hallway of the facility. The fire extinguishers were up to date and was last serviced on 11/07/2023. No emergency exits were obstructed. LPA reviewed food supply to ensure that the facility had a 2-day perishable and 7-day nonperishable food supply. LPA observed laundry room and it was observed that laundry detergent and cleaning supplies were not locked and made accessible to residents at this time. Knives and medications were observed to be locked and made inaccessible at this time. LPA Lee observed the facility has a has a public telephone in the kitchen. Facility thermostat observed at 73 degrees Fahrenheit. LPA Lee inspected two shed and the pool out in the courtyard and they were kept locked and inaccessible to residents at time. The first aid kit was checked and contained all of the required components. LPA Lee reviewed 3 out of 5 resident MAR logs and they were complete. LPA Lee reviewed residents’ files and it was learned that 2 out of 5 residents did not have LIC 625 Needs and Service in their files. LPA reviewed 3 staff files and it was learned that they were not complete. The 3 staff files are missing training documentation, health screening/TB and first aid/CPR. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that staff 1 (S1) is not fingerprint cleared is in the "In Process" status and has been working at the facility. As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jul 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jul 16, 2024

87355(e)(1) 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: (1) Obtain a California clearance or a criminal record exemption as required by the Department . This requirement was not met as evidence by: This requirement was not met as evidence by: Based on record review and interview, the administrator did not comply with the section cited above when a employee worked at the facility withour being fingerprint clearedthe state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Administrator agreed that she will review section 87355(e)(1) and send LPA Lee a statement showing acknowledgement and understanding of the regulation cited. Administrator will ensure that staff (1) is fingerprint cleared before return back to work. POC due by 07/31/2024 by 5 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c) · Plan of correction due date: Jul 26, 2024

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidence by: Based on record review, the administrator did not comply with the section cited above when a employee did not sign off receiving initial and annual training; this posed/poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Administrator agrees to ensure all staff are trained prior to providing care and supervision to residents in care. Traing documents will be email to LPA Lee by POC due by 07/31/2024 by 5 PM.

Type of visit: Case Management - Legal/Non-compliance

A Non-Compliance Conference (NCC) was conducted today on April 10, 2024, via Microsoft Teams with the Sacramento South Regional Office. The purpose of this Non-Compliance Conference meeting to discuss compliance issues at the facility and the steps the facility is taking to address the Departments’ concerns. Present in the meeting is Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, Licensing Program Analysts (LPA) Pang Lee, Licensee of Stewart Oaks Villa Kanwal Randhawa and Administrator, of Stewart Oaks Villa Elisa Weathers. During this virtual meeting, the Non-Compliance Conference process was explained to the Licensee. A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and the LIC 9111 was provided to the licensee. The facility has previously received 17 Type A citations and 9 Type B citations since 09/19/2019. Issues discussed during the meeting were: · Following plan of operations · Adequate Staffing (LIC 500 consistency and when facility staff calls out) · Criminal Record Clearance/Association to the facility · Maintenance and Operation (hot water measured at 137.1 *F) · Incidental Medical and Dental Care Services (ensure that residents medications are being administer per doctor’s order) · Personal Records (adequate training for staff) · Resident Records (Missing documents, missing signatures) · Administrator qualifications and duties · Pool will be locked at all times. · Communications between licensee and administrator. Continued LIC 809-C The facility has stated they will agree to do the following: · Licensee/Administrator agrees to ensure that there is a written plan in place for staffing when there are call outs. The written plan will be emailed to LPA Lee by 04/19/2024 by 5:00 PM end of day. · Licensee/Administrator agrees to ensure that a written plan is in place for monitoring the physical plant of the facility. The written plan will be emailed to LPA Lee by 04/19/2024 by 5:00 PM end of day. · Licensee/Administrator agrees to ensure that there is a written plan in place for medication training and a plan on auditing medications. The written plan will be emailed to LPA Lee by 04/19/2024 by 5:00 PM end of day. · Licensee/Administrator agrees to ensure that there is a written plan in place for ensuring that facility staff and residents files are maintained per regulation. The written plan will be emailed to LPA Lee by 04/19/2024 by 5:00 PM end of day. Notwithstanding the above statement, the Department will take the following actions: · The facility will continue to have additional monitoring and facility inspections to verify improvement in compliance. · Facility designated Administrator and Licensee have agreed to re-enroll and enlist services from TSP. The Department will set up TSP services. Failure to maintain substantial compliance outlined on the LIC 809 reported dated 04/10/2024 will result in the Licensee/Facility being referred to the Legal Department for review and possible Administrative Action. The RO will revisit compliance in 9-12 months and begin the legal process if the facility is not in compliance. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 10, 2024

Allegation investigated: Insufficient Staffing

On 03/27/2024 at 8:23 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with direct care Dajana Brooks and explained the purpose of the visit. A telephone call was made to both licensee Kanwal Randhawa and administrator Melanie Ferreira who was not present during today’s visit. Administrator is not able to attend today’s visit and was given permission for direct care staff Dajana to signed licensing documents. LPA Lee explain via telephone the purpose of the visit to both licensee and administrator. The purpose of this visit is to deliver a complaint finding for the allegation above. The current census is 6 with 2 facility staff presents. Allegation: Insufficient Staffing It was alleged that the facility has insufficient staffing. During the investigation, LPA Lee interviewed 5 resident and 5 staff members. LPA also reviewed facility file documentation including physician’s reports and staffing schedule. Substantiated Based on record reviews and interviews, it was revealed that 4 of 6 residents required care and supervision for incontinence needs, and 4 out of 6 residents required care and supervision related to dementia care. Records reviewed and interviews also revealed that facility schedule list indicates 1 staff on duty between 6 AM to 8 AM, 2 staff on duty between 8 AM to 2 PM, 2 staff between 2PM to 10 PM and 1 staff between 10 PM to 6 AM. It was learned that 1 staff was on duty to care for 6 residents on 3-01-24 from 2:00 PM to 10:00 PM. The one caregiver on duty was assisting 4 residents with incontinence care which resulted in multiple residents with care needs not supervised and met due to the additional scheduled staff not being present in the facility and no additional staff coverage was put in place. Based on interviews, 6 facility staff admitted to the facility not having sufficient staffing. On 03/12/2024 during LPA Lee complaint investigations visit, both licensee and administrator admitted to having only one staff on duty on 03/01/2024 from 2:00 PM to 10:00 PM to care for 6 residents. Moreover, during LPA Lee’s interviews with both licensee and administrator the facility lacks a plan in place when staff calls out and coverage is needed to provide sufficient care and supervision to residents in care. Moreover, on 12/30/2023 between the hours of 2:00 PM to 10:00 PM two facility staff was scheduled to work the shift however, a staff called out therefore, leaving only 1 staff on shift only. It was learned that no staff coverage was in place which resulted in the administrator paying a facility staff’s friend to support staffing coverage without that particular individual being fingerprint clear and associated to the facility. As a result, based on interviews and record reviews, it is determined that licensee did not adhere to established facility staffing schedule, and ensure appropriate staffing levels necessary to monitor for the physical and psychosocial well-being of residents’ care needs as noted through record reviews. Therefore, this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6. An exit interview was conducted with direct care staff Dajana Brooks and a copy of this report was provided to the facility. Appeal rights provided. Failure to correct citations may result in a civil penalty.the state’s words, verbatim · CDSS document, Mar 27, 2024 · control 27-AS-20240304173808

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87413(a)(1) · Plan of correction due date: Apr 5, 2024

87413(a)(1) personnel operations (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not met as evidenced by: Based on record review and interviews licensee did not ensure appropriate staff coverage is in place to ensure the purposes of monitoring the activities of residents for their general health, safety, and well-being. This posed a immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: Licensee will read regulation being cited today and submit a signed declaration of understanding to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst Pang Lee arrived at the facility today to conduct a case management visit to follow up on the status of current Administrator, LIC 500 Personnel Report/Schedule and medication errors that was verbally advised and emailed by the administrator Melanie Ferreira to LPA. The census is 6 with 3 facility staff presents. On 03/25/2024 at 3:24 PM, LPA Lee received a text message from licensee, Kanwal Randhawa advising LPA Lee that he has hired a new administrator Elisa Weathers who will start on 04/01/2024. On 03/25/2025 at 6:24 PM, the current administrator, Melanie Ferreira advised via email that her last day at the facility will be today, Wednesday, 3/27/24. Due to LPA’s concerns about not having a certified/qualified administrator after this date, LPA contacted the licensee to obtain a plan on who will assume responsibilities. The licensee advised LPA that the current administrator, Melanie Ferreira, agreed to remain Administrator until 04/01/24 and the new administrator will take over as of April 1, 2024. LPA has requested for the licensee to provide the following documents for the change in administrator: LIC 501: Personnel Record, high school diploma or equivalent certification, LIC 9182 “Criminal Background Clearance Request”, current California I.D. or driver’s license, current administrator certificate, 503: Health screen with TB clearance or chest x-ray results. Result must be negative, current First Aid/CPR certification, LIC 308: “Designation of Facility Responsibility”, LIC 200 sign by licensee or designee and LIC 500 to indicate the days/hours the administrator is in the facility. On 03/12/2024, during a complaint visit, it was learned by licensee Kanwal Randhawa and administrator Melanie Ferreira that LIC 500 Personal Report/Facility staff’s schedules are changed every week. LPA Lee advised both licensee and administrator that if there are changes to the LIC 500 every week the department will need a copy of the LIC 500 Personnel Report every week and approved by the department. The licensee agreed that administrator will email LPA every week the LIC 500 Personnel Report. As of the week of 03/18/2024 to 03/22/2024 and 03/25/2024 to 03/29/2024, LPA Lee has not received the current LIC 500 Personnel Report from the facility. During today’s visit LPA Lee advised again to both administrator and licensee that the department needs the LIC 500 for this week and every week when staffing schedules are changed. For today’s visit LPA Lee is also following up on 3 medication errors. On 03/08/2024 at 1:44 PM, administrator Melanie Ferrera emailed LPA Lee regarding resident 1 (R1) who missed (R1) morning medication due to delay in medication. It is unclear what medication (R1) was not taken on the morning of 03/08/2024 due to the fact that there has been no LIC 624 fax over to the department. On 03/25/2024 at 6:24 PM administrator also emailed LPA Lee to advise that there are two additional medication errors. During today’s visit 03/27/2024, LPA Lee was verbally advised by the administrator via telephone of the two incidents that occurred on 03/23/2024 and 03/24/2024. Direct Care Staff Dajana Brooks provided LPA Lee with a hard copy of both incidents. On 03/23/2024, staff 1 (S1) conducted a medication audit on (R1) Oxycodone medication and it was learned that (R1) is missing 13 pills of Oxycodone. On 03/24/2024, it was learned that 4 residents did not get their PM medications by (S2) because (S2) forgot to give the residents their PM medications. LPA Lee also reviewed March PM MAR logs and records revealed that on 5 resident MAR log sheet medication was missing initials that indicate that medications were being administer to residents in care for the following dates: 03/10/2024, 03/16/2024, 03/17/2024, 03/23/2024 and 03/24/2024. As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. Failure to correct deficiency may result in failure to correct and an civil penalty issue. An exit interview was conducted with Dajana Brooks, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Mar 27, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 10, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by: The facility self reported 3 separate incidents of medications errors where residents did not administer their medications and (R1) missing medication. The Licensee did not ensure that resident is given their medication as prescribe. MAR sheet was also not maintained. On multiple dates residents’ medications MAR section was not initialed, therefore, it is unclear if medication were administered to residents in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: The licensee/administrator agrees to conduct Incidental medical and dental training for all staff by POC date 04/10/2023 by end of day 5 PM.

Type of visit: POC

On 03/27/2024, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a Plan of Correction (POC) visit. LPA met with direct care Dajana Brooks and explained the purpose of the visit. A telephone call was made to both licensee Kanwal Randhawa and administrator Melanie Ferreira who was not present during today’s visit. The administrator is not able to attend today’s visit and was given permission for direct care staff Dajana and Joshua Wright to sign licensing documents. LPA Lee explained via telephone the purpose of the visit to both licensee and administrator. The current census is 6 with 2 facility staff presents. The purpose of this visit was to follow up on the prior deficiencies and plan of corrections that were due on 03/22/2024 from a prior case management visit conducted on 03/12/2024. As of the date of this visit, 03/27/2024, the department had not received any forms or documents to support the plan of the correction and has not been completed by this facility and its designated Administrator at this time. Based upon this inspection, the LPA observed the following: 1. The deficiency cited under Title 22 Regulation 87355(e)(1) has not been cleared. The Licensee/Administrator did not comply with the terms of the POC. A POC letter was not generated and provided to the licensee. 2. The deficiency cited under Title 22 Regulation 87207 has not been cleared. The Licensee/Administrator did not comply with the terms of the POC. A POC letter was not generated and provided to the licensee. 3. The deficiency cited under Title 22 Regulation 87405(d)(1) has not been cleared. The Licensee/Administrator did not comply with the terms of the POC. A POC letter was not generated and provided to the licensee. A civil penalty in the amount of $1500 was assessed for the violations .This civil penalty was due to failure to correct the deficiency by the Plan of Correction date. The Facility was informed that the civil penalty will continue to accrue $100 per day per violation until the deficiency is corrected. An exit interview was conducted with care staff Dajana Brooks, and a copy of this LIC 809, LIC809-D and appeal rights was provided to the facility.the state’s words, verbatim · CDSS document, Mar 27, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Apr 5, 2024

87355(e)(1) 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: (1) Obtain a California clearance or a criminal record exemption as required by the Department . This requirement was not met as evidence by: Based on record review, the administrator did not comply with the section cited above when the administrator allowed and paid a staff friend's brother who did not have his background clearances completed and were not associated to the facility to come to the facility to provide care and supervision to residents in care. This posed/poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: Administrator stated she will review section 87355(e)(1) and send LPA Lee a statement showing acknowledgement and understanding of the regulation cited. POC due by 04/05/2024 by 5 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87207 · Plan of correction due date: Apr 10, 2024

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidence by: Based on interviews and records review, the administrator made false statements by telling a staff member to lie that staff friend is only volunteering at the facility and that administrator did not pay for the individual’s service.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: The administrator stated she will review section 87207 and send LPA a statement showing acknowledgement of the regulation and understanding of how to properly have individuals at the facility rather than working or volunteering fingerprint and associated to the facility prior to working or volunteering. POC due by 04/10/2024 by 5 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405 · Plan of correction due date: Apr 10, 2024

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met as evidence by: Based on interviews and records review, the administrator allows and paid a staff friend to come to the facility without fingerprint clear to help a staff with care and supervision for residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: Administrator to review Administrator qualifications and Duties regulation, and email LPA Lee a formal document stating the regulation has been reviewed by POC Date 04/05/2024 by 5 PM.

Allegation investigated: Staff did not report incident to appropriate parties Staff did not assist resident with incontinence care Staff did not assist resident with showering Staff do not ensure that resident's dietary needs are met

On 03/12/2024 at 2:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Melanie Ferreira and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 5 with 2 facility staff presents. An interview with conducted with administrator Melanie Ferreira and Licensee Kanwal Randhaua. Allegation: Staff did not report incident to appropriate parties It was alleged that staff did not report the incident to appropriate parties. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. LPA Lee interviewed 5 out of 5 residents who have not witnessed resident 1 (R1) having a fall on 12/30/2023. LPA Lee also interviewed 5 facility staff who have not witnessed (R1) having a fall on 12/30/2023. Continued LIC 9099-C Unsubstantiated Staff 1 (S1) records reveal that (S1) refused to sign that (S1) received 40 hours of training and was providing care to residents in care; therefore, it is unclear if (S1) received the required training. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. LPA Lee also spoke to (R1) responsible party who stated there was no concerns with facility staff not reporting (R1) incident report and only recall (R1) having a fall in September and that responsible party was informed. LPA Lee also checked the department’s Electronic Facility Files, and no fall incident was reported to the department. Moreover, a Hospice Home Health aide and LVN Nurse has stated they have not witnessed a resident having a fall during their visits. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Allegation: Staff did not assist resident with showering It was alleged that staff did not assist residents with showering. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible parties. LPA Lee interviewed 5 out of 5 residents who have no concerns with facility staff not assisting residents with showering. LPA Lee also interviewed 5 facility staff who denied the allegation. LPA Lee interviewed (R1)’s responsible party who has no concern with staff not assisting (R1) with showering. It was learned that (R1) gets a shower by (R1) hospice nurse once a week. Records review also revealed that in the month of November (R1) received 4 showers by hospice nurse and 6 sponge baths by facility staff and for the for the month of December (R1) received 5 showers by hospice nurse and 7 sponge baths by facility staff. For the month of January (R1) receives 4 showers by hospice nurse and 6 sponge baths by facility staff. Moreover, LPA Lee interviewed (R1) hospice nurse who has no concerns with (R1) not showers from facility staff; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Allegation: Staff did not assist resident with incontinence care It was alleged that Staff did not assist resident with incontinence care. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible parties. LPA Lee interviewed 5 out of 5 residents who have no concerns with facility staff not assisting residents with incontinence care. LPA Lee also interviewed 5 facility staff who denied the allegation. Continued LIC 9099-C LPA Lee interviewed (R1)’s responsible party who has no concern with staff not assisting (R1) with incontinence care. LPA Lee interviewed (R1) hospice nurse who has no concerns with (R1) not getting (R1) incontinence care needs from facility staff. (R1) Care Notes revealed that (R1) is getting assistance with prompting to use the bathroom along with getting brief changed throughout the day; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Allegation: Staff do not ensure that resident's dietary needs are met It was alleged that staff do not ensure that residents’ dietary needs are met. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible parties. LPA Lee interviewed 5 out of 5 residents who have no concerns with facility staff not ensuring that residents dietary needs are met. LPA Lee also interviewed 5 facility staff who denied the allegation. LPA Lee interviewed (R1)’s responsible party who has no concern with the food being served to (R1). LPA Lee also interviewed (R2) responsible party who also shares no concerns with the food being served to (R2). During 01/16/2024 LPA Lee observed for breakfast residents were served scrabble eggs, sausage, bacon, and biscuit. For lunch LPA Lee observed residents being served fish sticks, fries, salad, and green beans. For dinner LPA Lee observed residents being served pork chop, mash potatoes, salad, green beans, and apples. During today’s visit 03/12/2024, LPA Lee observed fruits and vegetables being served to residents during breakfast and lunch. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report wasthe state’s words, verbatim · CDSS document, Mar 12, 2024 · control 27-AS-20240111152353

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Mar 22, 2024

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidence by: Based on record review, the administrator did not comply with the section cited above when a employee did not sign off receiving initial and annual training; this posed/poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: Administrator stated she will review section 87411(c) and send LPA Lee a statement showing acknowledgement and understanding of the regulation cited. Administrator agrees to ensure all staff are trained prior to providing care and supervision to residents in care. POC due by 03/22/2024 by 5 PM.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced on 03/12/2024 at 8:18 AM to conduct a case management visit. LPA Lee met with administrator Melanie Ferreira. The census is 5 with 2 facility staff. The purpose of the visit is to follow up on deficiencies learned during complaint investigation 27-AS-20240308101336. Through the complaint investigation, it was learned that on 12/30/2023 a facility staff 1 (S1) was on shift from 2:00 PM to 10:00 PM and (S2) was scheduled to work from 8:00 AM to 4:00 PM however (S2) called out leaving (S1) by herself from 2:00 PM to 10:00 PM. On 12/30/2023 at 4:42 PM (S1) text Licensee Kanwal at 916-943-6336 to informed licensee that (S1) needed help with caring for the 6 residents since a resident 1 (R1) had a fall, (R2) needed to go to the restroom, (R3) was walking around saying (R3) wants to eat and (S1) needed to use the restroom. Licensee text (S1) that licensee understands and that for (S1) to do the best that (S1) can, and that licensee will try to improve staffing ASAP. It was also learned that administrator Melanie Ferreira text (S1) using her personal phone with contact number (530) 813-0316 acknowledging that (S1) does need additional support and that administrator is trying to find coverage. It was also learned that administrator has informed the situation to licensee via telephone on 12/30/2023. On 12/30/2023 at 7:01 PM administrator sent a text message to (S1) with the following: “I will pay your friend worst-case scenario first thing in the morning…Make sure to leave cash app or Venmo but you know I’ll make sure they’re paid by in the morning for sure.” (S1) asked one of her friends and her friend reached out to her brother Tamari Comauex via text to see if he wanted to make extra cash helping (S1) at her workplace. On 12/30/2023 at 7:46 PM administrator sent a payment using Cash App to Jay Jay (Jamari) for care giving. It was also learned that administrator told (S1) that if anybody ask for (S1) to say that Tamari Comauex is a volunteer helping. Continued LIC 809-C On 01/19/2024 at 5:35 PM it was confirmed with administrator that licensee contact number is 916-943-6336 and administrator’s contact number is 530-813-0316. During today’s visit the administrator also admitted to paying and having someone that is not fingerprint clear and associated to the facility. As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Mar 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Mar 22, 2024

87355(e)(1) 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: (1) Obtain a California clearance or a criminal record exemption as required by the Department . This requirement was not met as evidence by: Based on record review, the administrator did not comply with the section cited above when the administrator allowed and paid a staff friend's brother who did not have his background clearances completed and were not associated to the facility to come to the facility to provide care and supervision to residents in care. This posed/poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: Administrator stated she will review section 87355(e)(1) and send LPA Lee a statement showing acknowledgement and understanding of the regulation cited. POC due by 03/22/2024 by 5 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405 · Plan of correction due date: Mar 22, 2024

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidence by: Based on interviews and records review, the administrator made false statements by telling a staff member to lie that staff friend is only volunteering at the facility and that administrator did not pay for the individual’s service.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: The administrator stated she will review section 87207 and send LPA a statement showing acknowledgement of the regulation and understanding of how to properly have individuals at the facility rather than working or volunteering fingerprint and associated to the facility prior to working or volunteering. POC due by 03/22/2024 by 5 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(1) · Plan of correction due date: Mar 22, 2024

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met as evidence by: Based on interviews and records review, the administrator allows and paid a staff friend to come to the facility without fingerprint clear to help a staff with care and supervision for residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: Administrator to review Administrator qualifications and Duties regulation, and email LPA Lee a formal document stating the regulation has been reviewed by POC Date 03/22/2024 by 5 PM.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Pang Lee arrived unannounced on 01/30/2024 at 1:25 PM to conduct a health and safety case management visit. The facility is on quarterly visits due to non-compliance concerns discussed during a zoom meeting on 10/16/2023. LPA Lee met with administrator Melanie Ferreira and house Manager Jennifer Campos and explained the purpose of the visit. The census is 6 with 4 facility staff during today’s visit. At 1:25 PM, LPA Lee entered the facility, LPA Lee observed three residents sitting in the common area watching TV and another resident in the kitchen getting yogurt. LPA Lee observed one care staff working on resident’s care notes and another care staff doing laundry. LPA Lee spoke to 2 residents. All residents observed today appeared to be clean and comfortable. At 2:05 PM, LPA Lee toured the physical plant to ensure compliance with Title 22 regulations. LPA Lee observed resident bedrooms, bathrooms, common areas, exterior plants, garage, and storage shed. LPA Lee also observed body of water was locked. LPA Lee also observed resident bedrooms to have the necessary furniture and furnishings. Bedrooms were equipped with a bed, chair, dresser, and closet space. Resident bathrooms were stocked with toilet paper, paper towels, and soap. Resident bathroom also had handrails and non-slip mat. The temperature inside the home is 70 degrees Fahrenheit. The hot water temperature was measured at 116.2 degrees Fahrenheit. LPA Lee observed the fire extinguisher located in the kitchen. The fire extinguisher was last serviced on 12/07/2023. The carbon monoxide and fire alarm observed to be working and in good repair. LPA Lee observed no emergency exits were obstructed. LPA Lee observed chemicals and knives were made inaccessible to residents in care. LPA requested to review resident files and staff files. LPA Lee reviewed 3 out of 6 resident files and 3 staff files and they were all complete. LPA Lee reviewed and compared 3 out of 6 medication administration records (MAR) and it was complete and accurate. The first aid kit was checked and contained all the required components. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 01/30/2024 at 2:45 PM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee was greeted by administrator Melanie Ferreira and house Manager Jennifer Campos and explained the purpose of today visit. The current Census is 5 with 4 staff present in the facility. The purpose of this visit is to follow-up on a plan of correction that was due 01/17/2024. LPA Lee toured and inspected the facility to ensure the deficiency previously cited on 01/16/2024 has been corrected. On 01/18/2024 at 12:02 AM, Licensee Kanwal Randhawa emailed LPA Lee requesting an extension on citation 87204(a). On 01/23/2024 at 11:53 PM Licensee Kanwal Randhawa emailed LPA Lee a new facility sketch that reflects resident bedroom number #3, 850, and LIC 200; however, LIC 200 was missing licensee signature. During today visit, licensee emailed administrator Melanie a new signed LIC 200 and then LIC 200 was provided to LPA Lee. On 01/19/2024 administrator text LPA Lee a video of the water temperature being fix and it was measured at 117.9. During today’s visit administrator provided LPA Lee a water temperature log and LPA Lee measure the hot water and it measured at 116.2 which is within the required regulation. LPA reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. Based upon this inspection, LPA Lee observed the following: 1. Deficiency cited under Title 22 Regulation 87204(a) has been cleared. The license did comply with the terms of the POC. A POC letter was generated and provided to the licensee. 2. Deficiency cited under Title 22 Regulation 87303(e)(2) has been cleared. The license complied with the terms of the POC. A POC letter was generated and provided to the licensee. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2024

Type of visit: Required - 1 Year

On 01/16/2024 at 12:30 PM Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Melanie Ferreira and explained the purpose of the visit. Administrator and House Manager Jennifer Campos assisted with today’s visit. Administrator certificate # is 6028106740 and will expire on 12/26/2024. The current census is 6 with 3 facility staff. This facility is a single story building licensed to serve five (5) non-ambulatory residents, one (1) ambulatory resident in room #3 only and a hospice waiver for two residents. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed (R1) in resident bedroom #3 which is licensed for a ambulatory resident only and (R1) is non ambulatory; therefore, the facility is not adhering to the fire clearance. LPA Lee also observed room #3 had a sliding door and a ramp. It was learned that when the facility got licensed resident bedroom #3 had a sliding door with a deck; however, the deck did not have a ramp. Licensee stated he put in a new ramp in May of 2023. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are bodies of water present, and it was locked and made inaccessible to residents in care. LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 137.1 degrees Fahrenheit in the common area resident bathroom sink and 121.1 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 11/07/2023. Continued LIC 809-C LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed and compared 3 out of 6 medication administration record (MAR) and it was complete. The first aid kit was checked and contained all the required components. LPA Lee requested resident and staff files for review. LPA Lee reviewed 5 out of 6 resident files and 5 out of 6 staff files and they were all complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by XXXX by 5:00 PM by end of day: (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Copy of Administrator Certificate (4) LIC 610 Emergency Disaster Plan (5) Proof of Current Liability Insurance As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jan 16, 2024