Sweet Dreams Care Home

Type of visit: POC

Licensing Program Analyst Steve Chang conducted a POC case management visit to clear deficiencies cited on 07/31/2026, during the case management visit. LPA met with staff Lizzle Moldero (S1). LPA explained the purpose of the visit to S1. The Facility was cited the following Type A deficiencies on 07/31/2026. 87465 Incidental Medical and Dental Care (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. LPA received the plan of correction. LPA checked room #3 and the bathroom inside Room #3. LPA did not observe any medication is accessible to resident. The deficiency was fixed. 87309 Storage Space and Access (a)the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. LPA received the plan of correction. LPA checked room #3 and the bathroom inside, LPA did not see or chemicals were accessible to resident. The deficiency was fixed. Continue on LIC809-C. 87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. LPA received the Plan of correction. LPA only observed the doctor orders of R2 to use full bed rails, Administrator stated he/she has doctor order of R3 to use full bed rails. But LPA and S1 were unable to find in R3's files. ADM sent R3's doctor order to use full rail to S1's cell phone. ADM stated he/she will send to LPA's email address. The deficiency is fixed. 87608 Postural Supports (a)(5)(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. LPA received the plan of correction. LPA observed the doctor order of R4 to use half bed rail. LPA and S1 were unable to find the doctor order in R5's file. ADM stated he/she has R5's doctor order. S1 received R5's doctor order to use half bed rail from ADM. ADM stated he/she will send R5's doctor order to LPA's email address. The deficiency is fixed. 87608 Postural Supports (a) (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional LPA received the plan of correction. LPA did not observe R2 using the seat belt during LPA's visit. LPA did not find the doctor order for R2 to use seat belt. LPA did not observe R2's wheel chair with seat belt. ADM stated he/she will get doctor order for R5 to use seat belt while R2 on wheel chair. Exit interview was conducted with S1. The report was provided to S1 for review and signature.the state’s words, verbatim · CDSS document, Aug 28, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Steve Chang and Licensing Program Manager (LPM) Romeo Manazano conducted an unannounced case management visit and met with Administrator (ADM) Divina Fernandez. During inspection of resident's (R1) bedroom (#3 as specified in facility floor plan), and bathroom, a box of prescribed medication was found inside the bathroom cabinet unlocked. According to R1's physician report 9/12/2025, R1 is able to store and administer medication, however, R1 has neurological disorder. ADM stated that they will contact R1's physician and/or responsible party to clarify. ADM also added that R1 will not be able to determine when and what to take. Also, LPA/LPM observed a can of comet (cleaning solution) on top of sink counter accessible. R1 lacks awareness and unable to access toxic materials. During inspection of the facility bedrooms, LPA/LPM observed that full bed rails for two residents R2 and R3, while the rest of the residents, R4 to R6 has half bed rails. R2 has a medical note for the hospital bed but the rest of the residents does not have medical notes. ADM stated that they are both utilizing bed rails for mobility and safety. In addition, R2 was observed utilizing a wheelchair with a seat belt. R2 stated that he/she need it for his/her safety. R2 stated that his/her son who works for an airline, so he/she is aware of wearing a buckle seat belt for his/her safety. R2 is alert and oriented but when asked if he/she is able to release seat belt, he/she said he/she unable to unbuckle due to weakness. ADM stated that there is no medical note for the seat belt. Page 1 of 2, See continuation on LIC809-C LPA/LPM also inspected the staff bedroom across bedroom #5. The back exit door can be access through staff bedroom, bedroom #6 and between staff and bedroom #6 [Note: back exit is located in staff bedroom with ramp outside]. Since staff bedroom is the main exit leading to the back exit, LPA/LPM informed ADM that staff bedroom cannot be locked and the back exit door shall have one single door knob mechanism. LPA/LPM also reminded ADM to ensure that staff medications and toxins must be locked at all times. ADM provided a copy of an updated facility sketch which specifies the facility exits. It was also noted that bedroom#4's cabinet door is loose or not in good repair [not closing properly]. ADM stated that it will be fixed this weekend. Deficiencies were issued during today's visit, SEE LIC809-D. Exit interview was conducted with ADM. Appeal Rights information was provided.the state’s words, verbatim · CDSS document, Jul 31, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Aug 1, 2026

87465 Incidental Medical and Dental Care (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. During inspection visit, resident's(R1) During the visit, medication was found in the his/her bathroom in bedroom #3 accessible. Although R1 states he/she is able to administer and store his/her own medication, it was not locked which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 31, 2026

Plan of correction: Administrator agrees to provide a plan of correction by the POC due date (08/01/2026) to CCL office and provides the staff training log to CCL office. ADminstrtor stated the facility will instruct all staff to check each resident room every 4 hours and keep a checking log.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Aug 1, 2026

87309 Storage Space and Access the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. During the visit, LPA/LPM observed a can of comet accessible in bedroom#3's bathroom. toxins which could pose a danger to residents are in not locked storage and are not left unattended orage.disinfectant was found in the of resident room #3 and was accessible to resident which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 31, 2026

Plan of correction: Administrator agrees to provide a plan of correction by the POC due date (08/01/2026) to CCL office and provides the staff training log to CCL office.Administrator stated the facility will instruct all staff to check each resident room regualrly to make sure there is no toxic measterial left in the resident rooms. Adminstrator stated will provide a log for the checking for every 4 hours.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Aug 1, 2026

87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. During inspection visit, there are two residents utilizing full bed rails (R2 and R3) due to safety concerns and are at risk of falling. Although, R2 has MD order but it does not specify the need for it which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 31, 2026

Plan of correction: Administrator agrees to provide a plan of correction by the POC due date (08/01/2026) to CCL office and to read Title 22 to understand the regulations. Adminstrator stated the facility will contact residents' doctor to obtain the medical order which justify residents' condtion and needs for full bedrial and will be ready in one week.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87608(a)(5)(A) · Plan of correction due date: Aug 1, 2026

87608 Postural Supports (a)(5)(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. During inspection, R4 to R6 are utilizing 1/2 bedrails for both safety and mobility with no medical order which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 31, 2026

Plan of correction: Administrator agrees to provide a plan of correction by the POC due date (08/01/2026) to CCL office and to read Title 22 to understand the regulations. Administrator stated the faciity will contact residents' doctors to obtain medical order to use heal bedrail for mobility. It will be ready in one week.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Aug 1, 2026

87608 Postural Supports (a) (3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. During inspection visit, R2 was observed utilizing a wheelchair with seat belt. ADM stated there is no medical note for it. R2 is alert and oriented who stated he/she likes to have it for his/her safety but when asked if he/she can unbuckled, he/she unable due to weakness. which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 31, 2026

Plan of correction: Administrator agrees to provide a plan of correction by the POC due date (08/01/2026) to CCL office and to read Title 22 to understand the regulations. Adminstrator stated the facility will contact resident's doctor to get medical order. It will be ready in 7 days. Administrator stated the facility will make sure the resident is able to realese the seatbelt.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with designed Administrator Steve Comtiag (DADM). The purpose of today's visit is to physically inspect the facility after the completion of the facility fire clearance inspection with the fire department. LPA toured the facility inside out with DADM. Living room, kitchen, family room, dining room, 6 resident rooms, 2 resident restrooms, a staff room with a bathroom inside, and a medication room and office with a restroom that converted from a garage were observed. 3 storage rooms were observed locked in the back yard. LPA interviewed Administrator (ADM) Divina Fernadez (ADM) on the phone. ADM stated fire department inspector toured the facility inside out including the back yard. ADM stated he/she showed the inspector the staff room, the medication room, office with the restroom in garage. ADM stated he/she showed the backyard to the inspector. ADM stated at end of the fire clearance inspection, the inspector told him/her the fire clearance inspection passed. ADM agreed that it is fine to have another fire clearance inspection for the medication room and office with restroom in the garage. DADM provided a fire clearance inspection form with the result of passed. Exit interview was conducted with DADM. The report was provided to DADM for review and signature. A copy of the report was provided to DADM.the state’s words, verbatim · CDSS document, May 28, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Divina Fernandez. LPA observed 6 residents and 2 staff in the facility. LPA interviewed Administrator (ADM) Divina Fernandez and 2 staff (S1, S2). S1 stated he/she lives in the staff room since January 2026 and S2 stated he/she lives in the staff room since March 2026. ADM stated the facility already schedule the fire clearance with fire department on 05/15/2026. ADM stated he/she knows S1 and S2 live in the new room since January and March 2026. LPA toured the staff room. LPA observed the staff room was occupied by two staff. The facility builds an bedroom in the facility as staff room. The facility allows staff live in the bedroom before the facility obtaining the fire clearance inspection report. Deficiencies noted today. Please LIC809-D. Exit interview was conducted with ADM. The report was provided to ADM for review and for signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, May 1, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 8, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above in that the facility does not obtain fire clearance document and allows staff to occupied the new bedroom and staff admitted they live in the bedroom since January and March 2026 which poses/posed a potential safety or personal rights risk.the state’s words, verbatim · CDSS document, May 1, 2026

Plan of correction: Administrator stated he/she will read the regulation and will submit a plan of correction by 5/8/2026 to CCL office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Divina Fernandez. LPA observed 6 residents and 2 staff in the facility. The purpose of today's visit is to check status of the facility fire clearance inspection. LPA toured the facility with ADM. Living room, kitchen, family room, dining room, 3 restrooms, 6 resident rooms, a staff room, and Medication room were observed. One big storage room and two small storage rooms were observed at backyard. ADM stated he/she is working with the fire department. ADM stated he/she will the fee and schedule the date with fire department for fire clearance inspection. LPA notified ADM that the fire department did not receive the fee from the facility. ADM stated he/she will update CCL office of the status of fire clearance inspection. No citation noted today. Exit interview was conducted with ADM. The report was provided to ADM for review and signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Apr 10, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Divina Fernandez. LPA toured the facility inside and out with ADM. License, Administrator Certificate, and personal rights posters were observed in the facility. 6 residents and 3 staff were observed in the facility. LPA reviewed 3 resident file and 3 staff files. ADM cannot provide the document for the facility liability insurance. Living room, kitchen, dining room, restrooms, 6 resident rooms, and garage were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet were observed locked. Dish washing solution bottle was observed on the kitchen sink counter, ADM locked it immediately. Room temperature was at 73 degree F, and hot water temperature was at 106 degree F in facility. The temperature of the refrigerator was at 38 degree F, and the temperature of the freezer was at 0 degree F. Fire extinguisher was serviced on 07/18/2025. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detectors were tested by ADM, and were working. First aid box, night lights, and flash lights were observed in the facility. Front yard and backyard were inspected. There was no obstruction to block the walkways. There are 2 storage rooms at the backyard. There has no log for the emergency drill or fire alarm drill. ADM stated he/she does not remember when was the last time the facility conducted the emergency drill or fire alarm drill. Deficiency noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Jan 21, 2026

Allegation investigated: Resident was unlawfully evicted. Administrator did not safeguard resident's personal belongings. Staff used resident's personal belongings for other residents to use. Administrator did not communicate with responsible party regarding resident's care needs.

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Divina Fernandez On September 5, 2025 the Department received a complaint alleging Administrator did not communicated with responsible party regarding resident's care / Administrator did not follow eviction procedures. On September 11, 2025, Licensing Program Analyst Steve Chang interviewed Administrator (ADM) Divina Fernandez. ADM stated R1 cannot administer insulin by him/herself, and the facility does not have professional staff to provide the insulin injection. Page 1 Out of 6. Unsubstantiated LPA Steve Chang interviewed Staff S1 and S2. Staff S1 stated R1 needs to use insulin and can administer it him/herself. S1 stated the facility he/she communicated with R1’s Family Member (FM) when he/she visited the facility. S2 stated R1 is forgetful recently so it is difficult for R1 to do the insulin injection because he/she cannot adjust the volume of insulin. S2 stated home health also stated R1 might not be able to do insulin by him/herself. S2 stated he/she discussed with hospital social worker about R1's insulin injection problem. S2 stated the facility told R1's family that R1's family needed to come to the facility to help R1's insulin injection 3 times per day if R1 returns to the facility. On December 22, 2025, LPA Manuel Monter interviewed R1’s Family Member (FM). FM stated R1 had gone to the hospital, and they were going discharge R1, But FM was informed that the facility was concerned about R1 taking his/her insulin. FM stated she was informed by the facility that there wasn’t a person who would be able to administer the insulin. FM stated he/she was informed by the facility that R1 wasn’t administering his/her medication consistently and was having trouble. FM stated that it wasn't true that R1 could not could administer his/her own medication and believed it wasn't an issue. FM stated he/she can’t say there wasn’t communication regarding R1's eviction. FM stated they were not actively communicating with him/her. FM stated the facility didn’t help him/her with R1’s new placement. FM stated he/she wasn’t provided with an eviction letter. On December 22, 2025, LPA Manuel Monter interviewed ADM Davina Fernandez. ADM stated regarding R1; he/she was sent to the emergency room on July 28, 2025. ADM stated based on a conversation with the case manager of the hospital, R1 would require a higher level of care. ADM stated the issue at hand was R1’s ability to administer his/her insulin. ADM stated R1 needed to administer his/her own insulin 3 times a day. ADM stated R1 had days when he/she was not able to administer his/her own insulin. Furthermore, since R1’s hospitalization, R1 had become weaker and the issue of insulin administration would persist. ADM stated if R1 got sick or was unable to administer his/her own medication, the facility would not be able to administer his/her insulin. ADM stated they don’t have a licensed professional to administer the insulin. ADM stated the facility was not able to meet the needs of the R1, since he/she was not able to administer his/her own medication. ADM stated R1 was not evicted, ADM stated R1 was just needed to be moved to a facility that was a higher level of care and FM agreed and choose to move R1 to another facility. Page 2 Out of 6. ADM stated FM visits the facility once a week. ADM stated she and FM’s are in communication. Furthermore, FM was notified when R1 had been sent to the hospital. ADM stated the hospital, FM and the facility was in communication. ADM stated FM was aware of the issues that were highlighted by the facility. On December 26, 2025, LPA Manuel Monter interviewed R1. R1 stated he/she was evicted due to his/her insulin administration and the facility stating he/she was unable to administer his/her own insulin. R1 stated he/she can administer the medication him/herself. R1 stated there hasn’t been a time, when he/she needed facility staff to administer his/her insulin medication for him/her. During visit LPA observed R1 administering his/her own insulin. On January 7, 2026, LPA Manuel Monter interviewed Witness W1. W1 stated the reason why R1 was not discharged to sweet dreams due to the facility not being able to meet R1’s level of care. W1 stated he/she was informed by the facility that they don’t have any nurses and could not provide assistance with insulin administration. W1 stated when he/she received this case, there was back and forth between him/her, the ADM and R1’s FM. W1 stated FM was concerned with the monthly payments and couldn’t afford to move R1. W1 stated based on what the family told him/her, R1 was able to administer his/her insulin with help with family. W1 stated they were relying on the family to do it. W1 stated when R1 moved to the facility, FM was supposed to assist with the insulin administration. W1 stated he/she was informed by the ADM that FM wasn’t coming consistently to administer insulin. W1 stated there was a lot of going back and forth for over a year regarding medication administration. W1 stated Kaiser helped in searching for possible higher level of care homes for R1. W1 stated FM was introduced to a new facility and agreed. The Department reviewed Resident R1's Physician's Report, dated May 9, 2025. R1 is able to: administer his/her own medication, administer his/her own injections, able to perform own glucose testing. The Department reviewed Home Health Visit Report Forms regarding R1. Home Health Visit Report dated July 21, 2025 states R1 sometimes confuses the dosage of his/her insulin. Home Health Visit Report dated July 24, 2025 states R1 refused to take 3 medications. The report also states, "if R1 needs constant monitoring, this facility is not the place for him/her. " Page 3 Out of 6. The Department reviewed R1’s Physician’s Report, dated August 27, 2025. The physician’s report states, R1 is able to: administer his/her own medication, administer his/her own injections, able to perform own glucose testing. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Facility staff touched and or used resident's personal belongings / Administrator did not safeguard resident's personal belongings. On September 5, 2025 the Department received a complaint alleging Facility staff touched and or used resident's personal belongings / Administrator did not safeguard resident's personal belongings. It has also been alleged that the facility is using R1’s personal property for other residents use. On September 11, 2025, LPA Steve Chang interviewed staff S1 and S2. S1 stated R1's Family Member (FM) came to the facility 2 weeks ago to pick up R1's belongings. S1 stated R1's medication was returned R1's FM. S1 stated R1's FM sent a box of wipes to the facility after R1 was sent to hospital. S1 stated the next day R1's FM picked up the box. S1 stated sometimes R1 ordered from Amazon. S1 stated he/she gave R1 the packages when they arrived. S1 stated he/she open packages for the residents when they asked for the help, and opened the package in front of the resident. S1 stated he/she did not use R1's diapers for other residents. S2 stated the facility policy regarding packages, is for staff open the package in front of residents if residents asked to open package for them. If residents are not in the facility then staff put the packages in resident's room. S1 stated he never opened R1's package or other residents' package. On December 22, 2025, LPA Manuel Monter interviewed staff S1 and S3. S1 stated facility staff do not take the residents property. S1 stated staff do not touch or take the residents property. S1 stated if a resident’s package arrives, then the facility staff will not open the package. S1 stated the staff don’t take residents property for the use of other residents. S1 stated R1’s family member already picked up all of resident R1’s property, medications and other personal property. Page 4 Out of 6. Staff S3 stated when packages arrive, they will put the boxes in the residents room. S3 stated he/she has never seen staff take the residents property. S3 stated staff will open the residents boxes, if the residents ask for that assistance. S3 stated staff do not take the property of one resident and give it to another resident to use. LPA Manuel Monter interviewed Administrator (ADM) Divina Fernandez. ADM stated she or the facility staff do not take the residents property. ADM stated she and the facility staff do not give other residents property to other residents to use. ADM stated when a package / letter arrives, the staff will give that mail/package to the resident. ADM stated staff don’t open residents mail/packages. ADM stated if a resident requests to have a package open, then staff will open the package for them. ADM stated the other residents have their own supplies. ADM stated the facility also has its own in house supplies. ADM stated furthermore, R1’s supplies are extra large and wouldn’t fit the other residents. ADM stated R1’s Family Members already picked up R1’s things. LPA Manuel Monter interviewed residents R2-R3. Resident R2 and R3 stated they have not had any issues regarding their personal property. R2 and R3 stated staff has not taken their property and used it for themselves or given it to other residents to use. R2 and R3 stated there hasn't been any instance where staff open their packages or mail without their permission. On December 26, 2025, LPA Manuel Monter interviewed R1. R1 stated there are several things that have gone missing from the previous care home. R1 stated he/she had a package that was sent to the care home, wipes, that were opened by the care home. R1 stated when his/her family went to collect the packages, they were already open. R1 stated staff S1 took his/her property and used them for other residents. R1 stated he/she was also missing his/her medications as well. R1 stated he/she couldn’t remember which ones were missing. On January 13, 2026, LPA Manuel Monter interviewed resident R1’s family member, referred to as FM2. FM2 stated he/she went to pick up R1’s things after R1 had moved to a different facility. FM2 stated when he/she went to pick up R1’s belongings he/she signed a form. FM2 stated he/she also asked for R1’s mail / packages and medications. FM2 stated because this event was a long time ago, he/she doesn’t remember. FM2 stated not all R1’s medications were given to him/her. FM2 stated he/she doesn’t know which medications were missing. Page 5 Out of 6. FM2 stated he/she was informed by FM that R1 bought cleaning wipes thru amazon. FM2 stated he/she requested that amazon box. FM2 stated he/she was given an open box, and the cleaning wipes container was already opened. FM2 stated it was clearly used. FM2 stated he/she spoke to a staff member but doesn’t remember which staff he/she spoke to or what the conversation entailed. The Department reviewed a letter from R1’s Family member (FM), dated August 27, 2025. The letter states that he/she almost picked up most of R1’s items. The letter states that there are still additional items that need to be picked up: hospital bed, air mattress, oxygen tank, lift, power wheel chair, outdoor ramp, and medical supplies. The Department reviewed R1’s RCFE Medication Release form dated September 5, 2025. Based on a review, 7 medications were released, and the form was signed by R1’s Family member FM2. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 6 Out of 6. END OF REPORT.the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 26-AS-20250905090049

Type of visit: POC

Licensing Program Analyst Steve Chang conducted a POC case management visit to clear deficiencies cited on 09/11/2025, during the case management visit. LPA met with Administrator (ADM) Divina Fernandez. LPA explained the purpose of the visit to ADM. The Facility was cited the following Type B deficiencies on 09/11/2025. -87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. LPA toured the facility with ADM including living room, dining room, main kitchen, dining area kitchen, 6 resident rooms, 3 bathrooms and staff break room. No medications was observed scattered unattested. Medication room was observed locked. In service staff training log with staff signature were provided by ADM. -87207 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. ADM discussed with LPA. ADM stated he/she stayed at the facility from 8:00AM to 11:00AM Monday to Friday and he/she and weekend as needed. ADM stated he/she will spend more time at the facility if needed. ADM stated he/she will provided the time sheet for staying at the facility. Continue on LIC809-C. Page 1 of 2. -87463(e)The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition, as defined in Section 87101, Definitions, to the attention of the appropriate licensed medical professional and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident's record and shall include: ADM stated he/she keeps reminding staff to closely monitoring residents. For any change in condition, report to ADM or facility nurse immediately. ADM stated he/she keeps reminding caregiver to document the progress note. -87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(1) Knowledge of the requirements for providing care and ADM stated he/she will attend more continue education on care and supervision, administrator duties, and regulations. LPA received the plan of correction from ADM prior today's visit. LPA reviewed the POC with ADM. No Deficiencies was cited during todays visit. This report was reviewed by ADM . A copy of this report was provided to ADM. Page 2 of 2.the state’s words, verbatim · CDSS document, Dec 5, 2025

Type of visit: Case Management - Incident

On 09/11/25, LPA Steve Chang and LPM Romeo Manzano conducted an unannounced Case Management Visit-Incident during a complaint investigation. On 08/08/25, the Department received a self-reported unusual incident and death reports that on 7/25/25, a resident (referred as R1) was sent to ER by home health nurse to check on R1's Foley Catheter due to R1 expressed a significant discomfort and pain level of 8/10. R1 was taken to the hospital due to infection and died on 08/02. On 09/09/25, LPA/LPM interviewed S3. S3 stated that R1 was sent to ER via ambulance on 07/25 due to Home Health Nurse (HHN) was unable to replace R1's Foley catheter during visit. S3 stated HHN came to see R1 after staff reported of possible infection. During today's inspection visit, LPA and LPM toured the facility. LPA and LPM met with resident (referred as R2) in bedroom#2. R2 was observed naked in bed wearing a undergarment. R2 noted to have long toenails on both feet. ADM stated that R1 does not have medical insurance but being visited with HHN; however, ADM did not consult a podiatrist, nor there is no appraisal about R2's feet and his/her behavior of being naked. R2's medication was also observed on R2's side table accessible, unlocked Staff (referred as S1) stated that he/she forgot to locked it after he/she administered medication. Two other medications were also observed accessible in the dining area, 2 medicines belongs to R3. Continue on LIC809-C. Page 1 of 2. At 3pm, LPA/LPA met with Administrator (ADM), LPA/LPM asked for a copy of facsimile report for R1's LIC624 wherein the Fax Call Report states an RCFE facility. ADM stated that she works at this RCFE facility since 2008 M to F, 8-5pm. According to LIC500 Personnel Summary report, ADM works at the facility M to F, 20 hours a week (8am-11am). ADM states she is available on the weekends and after 5pm. ADM stated that she will adjust her work hours and make herself available in the facility 20 hours a week. LPA/LPM found out that staff who are scheduled to work 7pm to 7am sleeps in the facility living room. Facility does not have a designated staff bedroom in the facility. ADM stated that they will utilize the two vacant bedrooms temporarily. LPM/LPA called licensee over the phone. LPA/LPM spoke to licensee to informed them about today's inspection visit. We discussed about the availability of the ADM and explained to them that ADM must be available during business hours, M to F 8-5pm. Licensee stated that they are in out of the country. LPA/LPM spoke to licensee's son, Ganty, to explain the purpose of visit and deficiencies. Deficiencies cited during today's visit. See LIC809-D. Exit interview was conducted with ADM. The report was provided to ADM for review. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Sep 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: Sep 18, 2025

87465 Incidental Medical and Dental Care(h)(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: On 09/11/25, During inspection, R1 to R3's prescribed medications were observed accessible/unlocked. Staff S1 and S2 had forgotten to locked it in the centrally stored cabinet after residents' administration. this poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: Administrator (ADM) stated he/she will provide staff in service training on medication ensuring that medicines are always locked at all times. ADM stated he/she will submit a copy of staff in service training to CCL by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87207 · Plan of correction due date: Sep 18, 2025

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 is not met as evidenced by: Licensee and Administrator provided false or misleading statement regarding the facility and the service, The licensee and administrator stated that administrator will stay at the facility at 20 hours during business hours, but administrator is unable to be at the facility from 8:00AM - 5:00PM on Monday - Friday, this poses an potential health, safety or personal rights risk to persons in care..the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: Administrator stated he/she will provide a written statement that he/she will not make any false claims and that he/she will comply with his/her working hours and also, licensee's son will be the back ADM who will submit his qualifications. ADM stated he/she will submit a copy of a signed written statement to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(e) · Plan of correction due date: Sep 18, 2025

87463 Reappraisals. (e)The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition, as defined in Section 87101, Definitions, to the attention of the appropriate licensed medical professional and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident's record and shall include: This requirement is not met as evidenced by: Administrator did not observed the resident R1's change in condition and did not update R1's care plan, this poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: Administrator stated the facility staff will provide care and supervision and to observe residents for any change in condition. The facility will update resident's care plan immediately and as necessary by submitting a written statement by ADM that care plan will be completed and adhered to by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(1) · Plan of correction due date: Sep 18, 2025

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by: Based on overall deficiencies cited, ADM made false statement, ADM did not assess resident's care needs, medication accessibility and not spending 20 hours in the facility. This poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: Administrator stated he/she will review his/her duties and responsibility as the ADM and to make to apply properly by submitting self certification to CCL by POC date.

Type of visit: Office

Licensing Program Manager (LPM) Maria Partoza and Licensing Program Analyst (LPA) Marcella Tarin conducted an announced office meeting requested by Licensee Gano Fici. Licensee states the purpose of the visit is to update the Change of Administrator documentation and withdrawal of Sultana Peku from the LLC. The purpose of this meeting is to clarify the Board Members of Sweet Dreams Care Home LLC. Mr.Fici states that Ms. Peku's is no longer a member of the LLC's Operating Agreement based on the submitted signed document LLC Member Withdrawal & Transfer Package effective 6/19/2025.. Licensee stated Sultana Peku has not been the Administrator since 10/26/2012. However, Ms. Peku continued her employment as an employee until 07/16/2016. Currently, licensee Gano Fici and Agime Fici are the administrators of the facility. Licensee submitted an amended LLC operating agreement, removing Sultana Peku as the Administrator and 50 percent ownership of the LLC as of 6/19/2025, rendering Licensee Gano Fici as the Sole Member of the LLC ,at 100% ownership of the membership interest. Licensee Gano Fici will manage and operate the business and affairs of the LLC. Licensee stated that he is assigning Divina Fernandez and Steve Comtiag as Facility Administrators as of 6/20/2025. Licensee needs to submit the following documentation: updated LIC 200 Application for a Community Care Facility or Residential Care Facility for the Elderly License, LIC 501 Personnel Record for Steve Comtiag. Licensee will submit a signed Board of Resolutions appointing new Administrators before end of day 6/20/2025. Licensee stated plans to convert laundry room to staff room are on hold until further notice.the state’s words, verbatim · CDSS document, Jun 20, 2025

Type of visit: Office

Licensing Program Analyst (LPA) Steve Chang and Licensing Program Manager (LPM) Romeo Manzano conducted an office meeting requested by the Licensee Gano Fici (GF) and Ms. Sultana Peku (SP), who is the former Administrator of the facility. . The purpose of this meeting is to clarify the Board Members of Sweet Dreams Care Home LLC. Mr. Fici that Ms. Peku's name still is under the LLC's Operating Agreement. Ms. Peku stated she is no longer the Administrator since 10/26/2012 not March 1, 2014. However, Ms. Peku continued her employment as an employee until 07/16/2016. LPA requested the facility to submit an updated or amended LLC operating agreement to CCLD 6/30/2025. Ms. Peku informed the Department that she is no longer a member of the Board and requested Mr. Fici to remove her name completely from Sweet Dreams Care Home, LLC. Mr. Fici also stated that the current Administrator Jean Jose's last day of work is today, 6/10/2025. Mr. Fici stated and his wife will the Administrators of the facility. Mr. Fici will submit a written and signed Board Resolution appointing themselves as the new Administrator, copies of their RCFE Administrator Certification and an updated LIC500 Personnel Summary and LIC308. Mr. Fici also inquired if the facility can convert a laundry room to be a staff break room. Mr. Fici stated that it will not be utilize as a sleeping or living space for staff and/or resident. Mr. Fici to submit a new floor plan indicating the change of facility use (laundry to staff break room), LIC200 and written request to CCLD. Once all requested documents, CCLD will request a Fire Clearance inspection if laundry area can be utilized as a break room. Mr. Fici was informed that if he decides to add additional bedroom and/or major construction, he and his wife have to obtain proper building permits before a construction starts and to inform CCLD/LPA. Mr. Fici agreed and understood. Exit interview was conducted with Mr. Fici. The report was provided to Mr. Fici for review and signature. A copy of the report was provided to Mr. Fici. No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Jun 10, 2025

Type of visit: Office

Licensing Program Analyst (LPA) Steve Chang and Licensing Program Manager (LPM) Romeo Manzano conducted an office meeting with Licensee Gano Fici, son of licensee Genti Fici and Administrator (ADM) Jean Jose. The purpose of this meeting is to address the incident report the Department received on 4/9/2025 regarding resident R1 who almost choke from consuming 'pork grind' given by R1's responsible party (RP). Facility summoned 911. R1 is currently at the hospital, R1 did not choke due cough and history of stroke. During today's office visit, LPA informed licensee and ADM the importance of documentation, and assessment of resident prior to admission to the facility, and the duties and responsibilities of the ADM including higher level of care and rental increase. According to licensee effective 4/11/2025, ADM Jean Jose will be a full time Administrator at the facility Monday to Friday. Administrator may provide assist with care and supervision. No deficiency noted today. Exit interview was conducted with ADM. The report was provided to ADM for review and signature. A copy of the report was provided to ADMthe state’s words, verbatim · CDSS document, Apr 10, 2025

Type of visit: Office

On 3/18/2025 Licensing Program Manager Romeo Manzano and Licensing Program Analyst (LPA) Marcella Tarin met with Licensee Gano Fici and son Ganti Fici regarding temporary non-operation of facility Sweet Dreams Care Home LLC (License # 435294351). Licensee requested a meeting regarding temporary non-operation of facility due staffing issues and facility renovation. Licensee to inform Department of updated fire clearance and provide updated facility sketch. Licensee provided copies of LIC9020, and Copies of letters to residents and facility plan of action for review. LPM advised facility to provide an action plan for the facility as they plan to become non-operational/inactive. LPM advised that the facility is not exempt from reporting to the Department, or exempt from regulations due to being non-operational/inactive. Facility is still obligated to continue required training, and meeting administrator requirements. The facility is still required to inform the Department of the status of the facility's residents and if the families have been informed. LPM advised Licensee cannot rent the facility out during non-operational/inactive, doing so would result in forfeiture of facility license. LPM advised Licensee to inform Department when the facility decides to become operational again. LPM advised Licensee to updated LTCO regarding change in operation. LPM advised Licensee that Board Members have to elect a new member if Licensee steps down. Licensee agreed to submit an updated plan of action in terms of staffing for facility to become non-operational/inactive and to submit an LIC500 (Personnel Roster), an updated 60 day letter with signature from Licensee and to keep the Department updated on the residents and their relocation. A copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, Mar 18, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit to deliver an amended LIC9099-D and met with Administrator (ADM) Jean Jose. The purpose of today's visit is to deliver an amended investigation report LIC9099-D issued to ADM on 02/19/2025. . On 02/19/2025, an investigation report LIC9099 and LIC9099-D were issued to ADM for complaint number 26-AS-20240621154956. The Department amended the investigation report LIC-9099-D. No citation were cited during todays visit. Exit interview was conducted with ADM. This report were provided to ADM for signature. A copy of this report was provided to ADM.the state’s words, verbatim · CDSS document, Mar 11, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst Marcela Yanez conducted an unannounced Case Management deficiency visit for deficiencies cited on 01/23/2025. LPA announced the purpose of the visit and met with Jean Jose Administrator. LPA observed 1 staff and 5 residents. On 01/23/2025 LPA Yanez did an unannounced annual inspection and cited a deficiency for toxics in an unlocked shed and being accessible to residents in care. The following regulation was cited 87309 (a) the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. During todays visit LPA observed the locked storage shed and toxics were inaccessible to residents in care. During todays visit POC was cleared and a Letter of Deficiency Citations Cleared was provided. This report was reviewed with Jean Jose, Administrator and a copy of he report was provided.the state’s words, verbatim · CDSS document, Mar 7, 2025

Allegation investigated: Staff is unable to comprehend resident's request and needs in English.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Administrator (ADM) Jean Jose. On 6/21/2024, the Department received a complaint with the allegation that a facility staff is unable to comprehend resident's request and staff's instruction in English to provide care to residents. On 6/28/2024, the Department conducted an initial investigation visit. LPA interviewed ADM, a staff (S1), and 6 residents. LPA request resident roster and LIC 500 Personnel Report, and a copy of S1's profile documents. Continue on LIC9099-C. Page 1 of 2. Substantiated On 6/28/2024, LPA met and interviewed staff S1. LPA asked questions such as but not limited to "What is your name?" "How long do you work for the facility?" S1 was unable to answer the questions rather he/she used hand gesture to be suggested the use of "google translator" to communicate on his/her cell phone. LPA and S1 used google translator software on S1's cell phone to communicate. S1 stated he/she cooks the meals for residents and cleans the facility including resident rooms. S1 feeds residents and helps residents for showers. S1 stated that he/she uses body language/gesture to communicate with residents. On 6/28/2024, LPA interviewed witnesses (W1 to W7). W1 to W7 except W4 and W5, shared same sentiments about S1’s inability to communicate in English wherein they had to use body language/gestures to communicate and had concerns in particularly during emergency situations. W4 and W5 were not able to respond due to neurocognitive disorder. The Department has investigated the above allegation. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Citations was noted today. Please see LIC9099-D. Appeal right was provided. Exit interview was conducted with ADM. A copy of the report was provided to ADM. Page 2 of 2.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 26-AS-20240621154956

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 26, 2025

87411 - Personnel Requirements - (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interview with witnesses, staff S1 is unable to comprehend English, and inability to communicate in English wherein they had to use body language/gestures to communicate.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Administrator agreed to send plan of correction by the POC due date to ensure the facility to hire competent staff to provide care and service to residents in care. The facility already sent the plan of correction on 2/20/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcela Yanez & Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Jean Jose. During the visit, LPA observed 4 residents and 2 staff. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. The front yard and backyard were inspected. LPA toured the facility garage, which is being used as a storage area. There was no obstruction to block the walkways. While touring the backyard, LPA's observed several sheds in the backyard. LPA observed a shed in front of the storage shed in the backyard. Both of these sheds were not locked and contained tools and other toxic materials such as; WD-40 and a paint can.(Photographs were taken.) While, touring the side of the home next to the garage/office, LPA observed a gallon of windshield washer fluid and accessible. (Photographs were taken.) LPA's also observed a shovel next to the exit to the front yard, directly next to the garage/office. ADM locked both storage sheds and secured the windshield washer fluid during visit. While touring the home, Licensee arrived to drop off supplies. LPA's advised Licensee regarding some of the clutter around the facility. LPA's advised Licensee that he/she must maintain the facility clean and in good repair. LPA's noted some of the clutter LPA's observed in the laundry room area and in the backyard. Licensee stated he/she is in the process of de-cluttering. Licensee stated he agreed and understood LPA's observation regarding the clutter. Page 1 of 2 Page 2 of 2 Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 108 degrees F in resident bathrooms. Fire extinguisher was serviced November 28, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on December 15, 2024. LPA reviewed facility records for 3 staff and 4 residents. LPA reviewed 4 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 3 residents. LPA provided ADM with CDSS Flyer, "Important updates to Dementia Care and Miscellaneous Changes, effective January 1, 2025." A deficiency and technical violation is being cited during today's visit. This report was reviewed with Administrator Jean Jose and a copy of the signed report and appeals rights was provided.the state’s words, verbatim · CDSS document, Jan 23, 2025

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

Type of visit: Case Management - Other

Licensing Program Analyst Manuel Monter conducted an unannounced case management -other, regarding an eviction for resident referred to as R1. LPA met with Administrator Jean Jose and explained the purpose of the visit. On November 16, 2024, the facility provided an eviction letter to R1; stating the reason for the eviction was due to the change in R1's status from non-ambulatory to bedridden. On December 16, 2024, LPA Manuel Monter conducted an unannounced case management visit. LPA observed resident R1 in his/her bedroom. LPA observed R1 was able to make slight repositioning from left to right. LPA observed when ADM was assisting R1 with repositioning, R1 was holding on to trapeze bar above his/her bed to help in repositioning him/herself. LPA interviewed R1. R1 stated he/she can move him/herself slightly to the left and right. R1 stated he/she also uses the trapeze bar above his/her bed to reposition him/herself slightly. ADM stated she was informed that R1 had become bedridden around November 12, 2024. ADM stated she accepted R1 back to the facility, knowing the bedroom which has been cleared for bedridden use is already occupied by a non-ambulatory resident in his/her care. LPA requested to review R1's Preplacement appraisal. ADM stated she does not have one for R1. ADM stated R1 was seen before he/she moved in but they did not document the actual pre-placement appraisal. ADM stated she will be notifying the local fire department regarding the bedridden residents who are currently under their care. Deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Jose & a copy of the signed report was provided. Appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 16, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c) · Plan of correction due date: Dec 23, 2024

87457 Pre-admission Appraisal - General (c)Prior to admission... resident's suitability for admission shall be completed... an appraisal of his/her individual service needs ... This requirement was not met as evidenced by; Based on interview and record review, ADM stated the facility did not document the pre-admission apprisal for resident R1. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: ADM stated she will send a written letter of understanding regarding the regulation. ADM stated she will send this letter of understanding to LPA, by POC date, December 23, 2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87202(a) · Plan of correction due date: Dec 23, 2024

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved ... Prior to accepting or retaining any of the following types of persons,... obtain an appropriate fire clearance approved ... the State Fire Marshal. This requirement was not met as evidenced by Based on interviews and records reviewed, resident R1 is a bedridden resident who resides in bedroom #6. Based on a review of the facility's fire cleareance, bedroom #6 is not cleared for the use of a bedriddent resident. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: ADM stated she will send a written letter of understanding regarding the regulation. ADM stated she will send this letter of understanding to LPA, by POC date, December 23, 2024.

Type of visit: Case Management - Other

Licensing Program Analysts ( LPAs) Steve Chang and Mita Partoza conducted an unannounced case management inspection visit and met with Administrator (ADM) Jean Jose. ADM stated that licensee is not in the facility is out of the country approximately beginning of July, 2024 and have not returned since then. ADM stated that there are currently 6 residents in the facility. 1 Out of 6 is at the hospital and 5 out 6 are present and resting in their room. 1 out of 6 is ambulatory, 2 of 6 are under hospice care. 3 out 6 are non-ambulatory. 1 out of 6 is in the hospital. LPAs stated the purpose of the visit is to conduct a case management visit ensure that facility is compliant with California Code of Regulation (CCR) Title 22 such as the condition of the physical plant, staffing requirement, the living condition of the resident, and if the garage is being used as a room to accommodate a resident. LPA toured the facility inside and outside with ADM such as living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. 6 of 6 resident's room are sanitary, organized and has sufficient storage. One of the resident's restroom sink drawer cabinet was not closing properly and can be a tripping hazard. Bedroom #6 at the end of the hallway has a broken window glass and is missing a window screen. S1 stated that there are window air conditioner system for each room. However R1 does not want the window air conditioner. S1 stated that the screen window will be re-installed. The facility is equipped with working smoke and carbon monoxide alarm system. The front yard and backyard were inspected. LPAs observed the following, at the front yard is a vehicle that is not operational covered by a gray tarp. S1 stated that the vehicle has been parked for a number years prior to her being employed at the facility, LPAs toured the facility garage and observed a sleeper couch inside and clothing items. S1 stated that the staff use the garage as their place to rest, while the licensee is out of the country. LPAs observed a functioning bathroom with shower inside the garage used by the staff. Page 1 of 2 LPA observed backyard has multiple storage, one storage was missing a door. There was piled household items that are no longer in use, a recliner that is no longer in used, 2 grills that are not used, a bucket of standing water, piled wood planks, a non operating refrigerator by the side of the building, medical equipment that are no longer in use are stored inside an open storage. The facility has emergency exit gates on both sides. on the right side the gate is not attached and not functional and another plank of wood was used to put weight on the half gate to prevent the gate from falling. The walkway is obstructed by garden chairs. The bank fence needs reinforcement and 3 planks are not secured properly. LPA reviewed facility record and found that the facility's last disaster training was done on 8/14/2024. Based on review of the facility file, the facility has a total of 5 staff. Based on record review there is a shortage of staff for both day and night shift. S1 stated that he/she is the day and nocturnal shift (NOC) shift and sleeps on the couch so that he/she can hear the resident when they push their pendant when assistance is needed. The LIC 500 does not reflect the true hours and days that staff are working. S1 stated that when other staff are on break he/she covers the two hour breaks between shift. LPA reviewed resident's records including but not limited to centrally stored medication and destruction record (CSMDR), physician's report and appraisal needs and services plan, and observed that 2 out of 6 are under hospice care, 4 out of 6 are complete and updated. LPA reviewed 2 staff records and observed records to be complete an updated, certificates are up to date, compliant with training current and up to date. Staff are fingerprint/criminal background cleared. Licensee did not notify the Community Care Licensing (CCL) of their absence to ensure that the facility has general supervision over the affairs, policies concerning it's operations to conform with regulations. Deficiencies are cited during today's visit based on California Code of Regulation CCR, Title 22 87303 (a) and 87411 (a). An exit interview was conducted with ADM Jean Jose and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Oct 30, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Oct 31, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation the LIC did not comply with the above by not maintaining the facility clean, sanitary and in good repair. LPAs observed piled up household items no longer in use,broken window glass, non-operating appliances, vehicle, and medical equipments and pile of woods.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: ADM stated that she will notify the licensee of the broken glass window, the piled up household items, unused medical equipement, & applicance. ADM will submit a written plan of correction on how the facility will ensure that facility is maintained and in good repair at all times by the due date con't. Which can serve as a place for rodents and other animals to breed, which pose/poses an immediate, health, safety and personal rights risks to persons in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: Oct 31, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interview and record review the LIC did not comply by not having sufficient personnel who are competent to provide necessary services. LPAs interviewed ADM/S1 and stated that he/she cover other staff breaks, and is the overnight staff. Based on review and assessment of LIC 500,the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: ADM stated that he/she will notify the LIC regarding staffing shortage. ADM will submit a written plan of correction on how the faciltiy will address staffing shortages by the due date. con't. the facility does not have a night staff and have no sufficient coverage for breaks and days off.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87205(a) · Plan of correction due date: Nov 6, 2024

87205(a) Accountability of Licensee Governing Body (a) The licensee, whether an individual or entity ...shall excercise general supervision over the affairs of the licensed facility ... policies..in confrmance with these regulations and welfare of the individuals it serves: This requirement is not met as evidenced by: Based on interview, the LIC did not notify CCL of their prolong absence leaving the facility without proper general supervision to conform with regulations and welfare of the individualls in the facilty whic pose/poses a potential health, safety and personal rightsthe state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: ADM stated that he/she will notify the LIC of the need to inform CCL of their prolonged absence due to issues that may arise at any time. ADM will submit a written plan of correction on how the facility will ensure that general supervision and conformance to regulations is followed. con't to persons in care.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management- Deficiencies visit. LPA met with Administrator (ADM) Jean Jose. LPA explained the purpose of the visit. During the visit, LPA observed 5 residents and 2 staff. The purpose of the visit is regarding to deficiencies cited on December 14, 2023 and to verify that the plan of corrections are being followed. The following are the some of the deficiencies cited that are being inspected today which included the following; 1. Fire clearance; for residents residing in the garage and not following their fire clearance. 2. Operating beyond the conditions and limitations specified on the license 3. Personal Rights; for residents residing in the garage 4. Non-skid Mats; It was observed a shower did not have the non-skid mats. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. The front yard and backyard were inspected. There was no obstruction to block the walkways. LPA toured the facility garage. LPA observed the garage being used as a storage area. No deficiencies cited during today's visit. This report was reviewed with Administrator Jean Jose and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management- Deficiencies visit. LPA met with Administrator (ADM) Jean Jose. LPA explained the purpose of the visit. During the visit, LPA observed 4 residents and 2 staff. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. . The front yard and backyard were inspected. There was no obstruction to block the walkways. LPA toured the facility garage. LPA observed the garage being used as a storage area. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. LPA reviewed facility records for 3 residents. No deficiencies cited during today's visit. This report was reviewed with Administrator Jean Jose and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Apr 26, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Steve Chang and Manuel Monter conducted an unannounced case management visit- Annual continuation visit to inspect and evaluate the resolution for the prior deficiencies. LPAs met with Administrator (ADM) Jean Jose. LPA's observed 6 residents and two staff. LPAs toured and inspected the garage, bedrooms and bathrooms. No residents were observed resides in the garage. LPAs reviewed the resident files. LPAs reviewed and discussed the Plan of Correction with Administrator (ADM). The following deficiencies and plan of corrections were reviewed and cleared during the visit. Type A, 87202 Fire Clearance (a) This deficiency was cited on December 14, 2023. During today's visit, LPA's observed the garage not being used as a bedroom for residents or staff. LPA's also received the facility's plan of correction letter, which also included the pictures of the converted garage (office). Type A, 87468.1 Personal rights of Residents in All Facilities (a)(1) This deficiency was cited on December 14, 2023. LPA received the facility's plan of correction letter. Type A, 87207 False Claims, This deficiency was cited on December 14, 2023. LPA received the facility's plan of correction letter. Type A, 87405 Administrator Qualifications and Duties (d)(1)(2) This deficiency was cited on December 14, 2023. LPA received the facility's plan of correction letter. Page 1 out of 2. Type A, 87204 Limitations Capacity and Ambulatory Status (a) This deficiency was cited on December 14, 2023. During today's visit, LPA's observed the facility had only 6 residents and the converted garage was not being used as a bedroom for staff or residents. The facility provided their plan of corrections. Type B, 87303 Maintenance and Operation(e)(5) - This deficiency was cited on December 14, 2023. During todays visit, LPA's observed the facility bathtubs and showers had non-skid mats. LPA also received the facility's plan of action, with photo showing the bathroom adjacent to the laundry room has a non-skid mat. LPA reviewed facility records for 8 residents. LPA reviewed 8 resident medications and centrally stored medication records. During a review of resident R3's records, LPA could not find R3's admission agreement. LPA's asked ADM for R3's admission agreement. ADM stated she doesn't know where it is and does not have a copy. A deficiency is being cited during today's visit. This report was reviewed with ADM Jean Jose and a copy of the signed report was provided. Appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 4, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(d) · Plan of correction due date: Jan 11, 2024

87507 Admission Agreements (d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This requirement was not met as evidenced by; Based on record review, the facility did not have a copy of R3's admission agreement. LPA's asked ADM if she had the R3's admission agreement, and ADM stated she did not have a copy and cannot find it. This poses a potential heath, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 4, 2024

Plan of correction: The administrator stated she will send a plan of action on how the facility will retain residents's admission agreements. Administrator stated she will send plan to LPA by POC date, Janurary 11, 2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Administrator (ADM) Jean Jose and Licensee (LCN) Gano Fici. LPA reviewed 5 residents files and 5 staff files.LPA toured the facility inside out with ADM. Licensee, Personal Rights posters and Administrator Certificate were observed at the main entrance. Living room, family room, dining room, kitchen, 6 resident bedroom rooms, 3 restrooms, and laundry room were inspected. 2 staff and 6 residents were observed in the facility. Two day perishable food supplies and Seven day nonperishable food supplies were observed sufficient. Room temperature was observed at 71 degree F. Hot water temperature was observed at 115 degree F. Refrigerator temperature was observed at 40 degree F. Freezer temperature was observed at 0 degree F. All of the bedrooms were observed with window screens and in good repair. Fire extinguisher was serviced on 11/28/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by ADM, and were working fine. Medications closet was observed locked. Knives closet and detergent closet were observed locked. One of the bathroom was observed without nonskid pad. The bedroom with resident using Oxygen administration was observed with the warning sign. First aid box was observed in the facility. Night lights were observed at the hallway. LPA toured the backyard with ADM. There were no obstacles blocked the exit. The facility last fire and emergency drill was conducted on 10/7/2023. Continue on LIC9099-C. Page 1 of 3. During LPAs visit, LPA met with ADM Jean Jose and Licensee, Gano Fici. While conducting inspection with ADM, R1 asked ADM why he/she couldn’t go back to his/her bedroom wherein it was locked. ADM stated that the bedroom (garage converted into an office) has inverted doorknob. ADM stated that when LPA arrived at the facility, it was open. LPA asked to ADM and L1 to unlocked doorknob wherein both stated they did not have the key. Subsequently, L1 unlocked the door. LPA ask the ADM to unlocked the door. L1 stated his/her spouse has the key, L2. L2 was not in the facility. Licensee was aware that the converted garage has been denied as a living quarter for staff or any individuals and can only be used as an office space by the Milpitas Fire Department. On April 2, 2013 the facility was cited for over capacity. On February 16, 2016 Licensee was informed that the garage could only be used an office and not a living space for residents or staff. In addition, during a Non-Compliance Conference Meeting on 12/2/2015 wherein the garage cannot be used as a living space. Licensee and Administrator must submit a plan of action to relocate R1 and R2 by end of business, 12/15/23. LPAs interviewed ADM Jose Jean and staff (S1) who admitted that residents (R1 and R2) are sleeping in the office (converted garage) on 12/5/2023. During LPAs interview with Mr. Fici (licensee). Mr. Fici was asked if he admitted 2 residents beyond the allowed licensed capacity. Mr. Fici stated that there were no residents occupying the converted garage rather it is a storage for unused beds. LPAs inspected the converted garage wherein R1 and R2’s beds and personal belongings for R1 and R2, confirmed by ADM. Prior to 4:52 PM, LPA Chang called Licensing Program Manager (LPM) Manzano to consult about over capacity. LPM requested to speak with the ADM. While LPM was on the phone with ADM Jean Jose about the over capacity, during the phone conversation, LPM overheard Mr. Fici stating, “tell we have 6.” ADM stated Mr. Fici said, ‘we have 6.’ Subsequently, ADM told the truth to LPA and LPM that on 12/5, Mr. Fici, has admitted new two elderly residents (R1 and R2) in the converted garage. During interview with ADM and S1, LPAs also found out that ADM and S1 are sleeping in the couch and at the back of the house near the laundry area, based on their admissions. The facility does not have staff bedroom, therefore, the facility must have a awake night staff. On 2/16/2016, The facility licensee and ADM stated the noc shift staff are not allowed to sleep. LPA may issue more citations if more deficiencies were found. Continue on LIC809-C. Page 2 of 3. At approximately 7:30pm, Licensee L2 arrived at the facility. L2 was interviewed. L2 denied the facility admitted additional two residents beyond the approved license capacity. L2 stated the converted garage (office) is a storage room. Exit interview was conducted with ADM and LCN. LIC809-D and Appeal Rights were attached. The report was provided to ADM and LCN for signature. A copy of the report was provided to ADM and LCN. The annual required inspection will be continued at a later date. Page 3 of 3.the state’s words, verbatim · CDSS document, Dec 14, 2023