Supercare Guest Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Janet Oliveros, direct support staff for the facility, and explained the purpose of the visit. Owner Ruby Cruz arrived shortly thereafter. There are five (5) residents currently living in the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. The facility consists of a kitchen that contains the washer and dryer, an attached garage the contains extra supplies for the facility, a dining room, a living room, three (3) resident bedrooms, one (1) staff room, two bathrooms which both measured between 105 - 120 Degrees Fahrenheit, and a backyard with shaded area. The facility was observed to be in good repair. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has a fully charged fire extinguisher kept in the facility. Operational Requirements: · Fire clearance was approved by LA County Fire Department for a capacity of six non-ambulatory (6) residents, one (1) of whom may be bedridden, one (1) of whom may be bedridden, and a hospice waiver approved for six (6) residents. · Care and supervision to meet the clients’ needs was observed. Staffing: · Seven (7) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Five (5) staff files were reviewed for criminal background clearance and training. · All Five (5) staff records reviewed have a health screening with a Tuberculosis clearance, and five (5) staff have First Aid/CPR trainings that are active. · The administrator’s certificate expires on 3/26/2026. Resident Rights/Information: · Physician orders were reviewed for five (5) resident files. · Medications were also reviewed for five (5) residents. Resident Records/Incident Reports: · Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan (LIC610E) was posted in the facility. · The last emergency and disaster drill was conducted on 11/82025. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs · All residents who utilize half and full bed rails have physician orders on file. · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 9, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools to complete the annual inspection that had begun on 11/15/2024. LPA met with Janice Jabonero, administrator for the facility, and explained the purpose of the visit. There are six (6) residents residing within the home. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Items Covered in the initial visit on 11/15/2024: Infection Control: · Infection control practices were observed. · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, six (6) of which may be non-ambulatory, one (1) of which may be bedridden, and a hospice waiver approved for four (4) residents. The facility consists of a kitchen, a dining room, living room, one (1) staff bedroom, three (3) resident bedrooms, one (1) resident bathroom of which had a hot water temperature of 109.5 Degrees Fahrenheit, along with a backyard that contains a shaded area and an attached garage which contains extra toiletries, and food supplies The facility was observed to be in good repair. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has one (1) fully charged fire extinguisher in the facility. ·Water temperature readings for one of the bathrooms in the home fell within the required range of 105 - 120 degrees Fahrenheit. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, six (6) of which may be non-ambulatory, one (1) of which may be bedridden, and a hospice waiver approved for four (4) residents. · Care and supervision to meet the clients’ needs was observed. Staffing: · Five (5) full-time staff members provide care and supervision to the clients. Resident Rights/Information: · Physician orders were reviewed for six (6) resident files. · Medications were also reviewed for six (6) residents. Resident Records/Incident Reports: · Six (6) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. · An appraisal for one (1) out of six (6) residents has not been completed within the past year. Food Service: · The kitchen was inspected and did not have a sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Items covered during today's visit on 11/19/2024: Staffing: · Eight (8) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Five (5) staff files were reviewed for criminal background clearance and training. · All staff records reviewed have health a health screening with a Tuberculosis clearance, and all staff have First Aid/CPR trainings that are active. · The administrator’s certificate expires on 3/26/2026. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan was publicly posted within the facility. · The last emergency and disaster drill was conducted on 10/1/2024. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs: · There are five (5) residents who are currently receiving hospice services, however the facility license currently has an approved hospice waiver for four (4) residents. Administrator emailed LPA the hospice increase request for six (6) residents and the POC will be cleared during the visit. · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the LIC809D page. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 19, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Pamela Joaquin, Caregiver for the facility, and explained the purpose of the visit. Licensee Ruby Cruz arrived shortly thereafter. There are six (6) residents residing within the home. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control practices were observed. · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, six (6) of which may be non-ambulatory, one (1) of which may be bedridden, and a hospice waiver approved for four (4) residents. The facility consists of a kitchen, a dining room, living room, one (1) staff bedroom, three (3) resident bedrooms, one (1) resident bathroom of which had a hot water temperature of 109.5 Degrees Fahrenheit, along with a backyard that contains a shaded area and an attached garage which contains extra toiletries, and food supplies The facility was observed to be in good repair. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has one (1) fully charged fire extinguisher in the facility. · Water temperature readings for one of the bathrooms in the home fell within the required range of 105 - 120 degrees Fahrenheit. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, six (6) of which may be non-ambulatory, one (1) of which may be bedridden, and a hospice waiver approved for four (4) residents. · Care and supervision to meet the clients’ needs was observed. Staffing: · Five (5) full-time staff members provide care and supervision to the clients. Resident Rights/Information: · Physician orders were reviewed for six (6) resident files. · Medications were also reviewed for six (6) residents. Resident Records/Incident Reports: · Six (6) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. · An appraisal for one (1) out of six (6) residents has not been completed within the past year. Food Service: · The kitchen was inspected and did not have a sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit is documented on the LIC809D pages. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 15, 2024

Allegation investigated: Staff did not seek medical attention for resident in a timely manner. Staff did not properly assess resident before acceptance. Staff did not assist resident in a timely manner. Staff did not accommodate residents.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegations listed above. LPA arrived unannounced and met with Staff, CJ Catacutan. The purpose of the visit was explained. The licensee, Ruby Cruz, arrived shortly thereafter to assist. The investigation consisted of the following: LPA obtained a copy of the staff roster, resident roster, and documents for Resident #1 (R-1). Interviews were held with the licensee, administrator, 2 staff, 3 residents, Director of Case Management of the West Anaheim Medical Center, and the Director of the Legacy Home Health. Resident #1 was also interviewed via telephone. The investigation revealed the following: For allegation - Staff did not seek medical attention for resident in a timely manner. It is alleged that staff did not seek medical attention for Resident #1 after a fall. LPA interviewed facility staff and they were not aware Unsubstantiated that R-1 had a fall. They stated that R-1 never reported a fall and would seek medical attention right away if residents fell. Staff stated they contacted 911 on 7/1/24 due to R-1 having a fever and the oxygen level was low. LPA interviewed R-1, who stated that resident was experiencing pain on the foot and had a fever, so staff called for emergency services right away. R-1 did not state it was a fall. For allegation - Staff did not properly assess resident before acceptance. It is alleged that the administrator accepted Resident #1 who has a bedsore on the buttock and a blister on the foot. LPA interviewed the licensee, administrator, facility staff, and directors to obtain information on R-1. The administrator stated that a pre-appraisal was completed for R-1 to determine if resident was appropriate for the home. Upon admission, a body check was also performed and had indicated where they observed any skin conditions. LPA reviewed the body check form which noted the areas in which the resident had a scratch (buttock) and a blister on foot. Per the staff, R-1 was receiving wound care from home health in those areas. LPA interviewed the Director of Care Management who indicated the health conditions of R-1 was fully disclosed to the administrator prior to acceptance and is aware not to recommend anyone who has a stage 3 or 4 wound to an assisted living facility. The Director of the Home Health agency also stated that R-1 was being treated for a diabetic wound which is not stageable as it is not considered a pressure wound. For allegation - Staff did not assist resident in a timely manner. It is alleged that staff do not assist resident #1 to the bathroom when requested. Administrator and staff stated they check on the residents often and provide assistance when they need it. Staff stated they respond to residents right away when they call for them. LPA interviewed R-1 who stated staff assisted him/her to the restroom and has nothing bad to say about the care provided. The other 3 residents interviewed stated staff tend to them when they need something. For allegation - Staff did not accommodate residents. It is alleged that the facility ramps are not convenient for residents. LPA toured the facility today and observed a total of 3 ramps located in the front, back, and inside the house. It was designed to help residents in wheelchairs or walkers to navigate around the home. LPA did not observe any obstructions to the ramps or walkways. The ramps appeared wide enough to fit wheelchairs. Staff and residents do not have any concerns regarding the accommodations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted. A copy of this report along with the appeal rights were provided to the staff.the state’s words, verbatim · CDSS document, Jul 16, 2024 · control 28-AS-20240710130340

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 12/09/2023. LPA was met by Caregiver Jhonrev Jimenez and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which six (6) may be non-ambulatory and has a hospice waiver approved for four (4). LPA OBSERVATIONS: The facility is a single-story dwelling located in a residential neighborhood and consist of three (3) resident bedrooms, one (1) staff bedroom, two (2) shared bathrooms, kitchen, dining room, living room, attached garage, front yard, and backyard. Front Yard: Front yard is well maintained, and no hazards were observed. Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed one (1) knife a top kitchen countertop, next to a cutting board and veggies, to be accessible to six (6) out of six (6) residents in care. Kitchen sink water temperature was measured at 124.3-degree F. LPA Ramirez observed chemicals and cleaning solutions, located in under kitchen cabinet, accessible to six (6) out of six (6) residents in care. Kitchen appliances were observed to be clean and in working order. LPA Ramirez observed lower kitchen cabinet located next to stove to contain several dead insects. Dining Room/Living room/: Dining room was observed to contain one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed nearby thermostat in this area to read 77 degree F. Linen Closet: Contained plenty linens, towels, and hygiene products. Resident Rooms 1-3: LPA Ramirez inspected three (3) shared resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens. LPA Ramirez observed auditory devices to be operable in all resident bedroom exits. Bathrooms 1-2: Water temperature in bathroom was within 105–120 degree F. LPA Ramirez observed grab bars and non-slip mats in shower and grab bars near toilet. LPA Ramirez observed chemicals and cleaning solutions, located in under bathroom#1 sink cabinet, to accessible to six (6) out of six (6) residents in care. Backyard: No hazards were observed. Plenty of shade and seating was observed. Emergency Drills: Last documented fire drill was conducted on 11/12/23 at 2:15 pm Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable. Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed five (5) personnel records. Documented proof of required annual initial dementia training required within the first 4 weeks of employment was not observed for four (4) out of the five (5) personnel records reviewed. Staff#3 (S3) did not have documented proof of criminal clearance of criminal exemption. Administrator Certificate was observed for Janice Jabonero with an expiration date of 03/23/2024. Resident Files: Six (6) resident files were reviewed. LPA did not observe required physician’s report for R6. LPA Ramirez did not observe required annual physician’s report for R2. Liability Insurance & Infection Control Plan: LPA Ramirez obtained a copy of liability insurance during visit. LPA Ramirez observed updated infection control plan. Deficiencies and technical advisories are being cited. A copy of this report, 809-D, LIC 9120 and appeals rights was provided.the state’s words, verbatim · CDSS document, Dec 9, 2023

The state marks this report as 14 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained unexplained fall resulting in severe injuries.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Jen Jimenez (Caregiver) and explained the purpose of the visit. Investigation consisted of the following: During the initial unannounced 10-day complaint visit conducted on 08/03/21, LPA Joe Katrdzhyan reviewed the file of Resident #1 (R1) and obtained copies of the following documents of R1 medical records along with other supporting documentation pertaining to the allegation. This Investigation was investigated by Investigator Spindola with the Investigations Branch and revealed the following: In regards to the allegation “Resident sustained unexplained fall resulting in severe injuries” it is alleged that Resident #1 (R1) had an unwitnessed fall at the care home and resident suffered severe injuries as a result of the fall. (Continued on 9099-C) Unsubstantiated Interviews conducted with facility staff, residents, and R1's family revealed that R1 had a medical condition that would cause R1 to try to ambulate on their own without asking for assistance from facility staff resulting in accidental falls. Interview with Staff #1 (S1) revealed that R1 would have delusional behaviors and although not present during R1s fall the fall was said to be the cause of R1 lowering bedrail and ambulating unassisted. Staff interviewed denied any wrongdoing. Review of medical records confirmed diagnosis of medical conditions that resulted in delusional behavior and psychosis episodes, which would cause R1 to try to ambulate without assistance. R1 was admitted to the facility on 7/13/2021, was hospitalized on 7/28/21 after R1 sustained a fall from trying to ambulate unassisted, and passed in the hospital on 8/21/21. During Investigator Spindola's investigation there was no supportive evidence that revealed facility staff neglected R1 and the injuries that R1 sustained were most likely due to the medical condition and trying to ambulate without assistance. Based on statements and interviews conducted with staff, clients, family, review of facility file records and medical records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held and a copy of this report was provided to Jen Jimenez.the state’s words, verbatim · CDSS document, Oct 3, 2023 · control 28-AS-20210729111636