Teesdale Villa RCFE

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:14 AM. LPA met with facility staff and contacted the Administrator Jose Guevarra Jr. The Administrator arrived to the facility at 10:56 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:31 AM, the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer which contained knives and other sharp objects. LPA observed a fire extinguisher to be fully charged and last serviced on 01/05/2026. LPA observed adequate emergency food and water supplies stored in the kitchen. BEDROOMS: There are six (6) bedrooms in the facility; two (2) are dual occupancy resident rooms, one (1) is a single occupancy resident room, and three (3) are staff rooms. LPA toured all six (6) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #4 and #5 were observed to contain direct exits to the outside of the facility. Bedroom #3 is a staff room that was observed to be unlocked and contained an unsecured bottle of disinfectant spray. CONTINUED ON LIC 809C. COMMON AREAS: This included the living room, hallway, laundry room, and dining area. LPA observed the living room to be clean and in good repair. The living room contained adequate activities and adequate seating for resident use. LPA observed the living room to contain an adequately screened fireplace. LPA observed the hallway to contain an appropriately secured closet which contained the facility’s complete first aid kit, resident medications, and facility files. LPA observed an additional hallway closet which contained resident clothing/linens. LPA observed the laundry room to be locked and inaccessible to clients in care. The laundry room contained a washer and dryer, laundry chemicals, cleaning chemicals, and extra linens. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contained a dining table with adequate seating for resident use. LPA observed cameras located throughout the common areas of the facility, LPA confirmed with the facility Administrator that audio is not recorded. The facility’s combination fire and carbon monoxide alarms were tested at 01:00 PM and were functional at the time of the visit. BATHROOMS: There are three (3) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and two (2) bathrooms are designated as shared resident bathrooms. All resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 115.6 and 116.6 degrees Fahrenheit, which is within the range required by regulation. LPA observed a hallway bathroom to contain unsecured grooming supplies. OUTDOOR SPACE: The facility has two (2) emergency exit gates. One (1) is located in the front yard and one (1) is located on the side of the home; LPA observed clear passageways for emergency exit use. The gate on the north side of the facility’s backyard is not an emergency exit gate and leads to the yard of an attached ADU. The facility had adequate shaded seating outdoors for resident use. LPA observed one (1) storage shed in the backyard of the facility. LPA observed the storage shed to contain unsecured cleaning supplies, pesticides, and gardening tools. LPA informed the Administrator 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. The Administrator expressed understanding and secured the items at the time of the visit. CONTINUED ON LIC 809C. RECORD REVIEW: Record review began at 10:58 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. three (3) staff files were reviewed. One (1) staff file was observed to be missing documentation of their initial 40-hours of training. Four (4) resident files were reviewed. LPA observed four (4) resident files contained Appraisal Needs and Services Plans that were last updated more than twelve (12) months prior. LPA informed the Administrator that appraisals shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first. The Administrator expressed understanding and agreed to complete an updated appraisal for each resident and to send proof of the completed appraisal to Community Care Licensing Division. MEDICATION REVIEW: Medication review began at 12:42 PM. Medications for four (4) of four (4) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 12/05/2025 which is outside of the required timeframe. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. INTERVIEWS: LPA attempted to interview two (2) residents. The residents did not express any concerns with the facility. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their role and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s emergency disaster plan, LIC 500, resident roster, and liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 23, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:06 AM. LPA met with facility Administrator Jose Guevarra Jr. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:10 AM, the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. LPA observed two (2) fire extinguishers located in the kitchen. One (1) was observed to be empty and one (1) was observed to be full and purchased on 10/10/2024. LPA observed adequate emergency food and water supplies stored in the kitchen. Continued on LIC 809C. COMMON AREAS: This includes the living room, hallway, laundry room, and dining area. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contains a dining table with adequate seating for resident use. The living room was observed to be clean and in good repair. The living room contained activities and adequate seating for resident use. LPA observed the living room to contain an adequately screened fireplace. LPA observed a properly secured hallway closet to contain the facility’s complete first aid kit, resident medications, and facility files. An additional hallway closet was observed to contain resident clothing. LPA observed the laundry room to be locked and inaccessible to clients in care. The laundry room contained a washer and dryer, laundry chemicals, cleaning chemicals, and extra linens. LPA observed cameras located throughout the common areas of the facility, LPA confirmed with the facility Administrator that audio is not recorded. The facility’s combination fire and carbon monoxide alarms were tested at 02:56 PM and were functional at the time of the visit. BEDROOMS: There are six (6) bedrooms in the facility; two (2) are dual occupancy resident rooms, one (1) is a single occupancy resident room, and three (3) are staff rooms. LPA toured all six (6) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #4 and #5 were observed to contain direct exits to the outside of the facility. BATHROOMS: There are three (3) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and two (2) bathrooms are designated as shared resident bathrooms. All resident bathrooms were observed to be relatively clean and in relatively good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 136.8 and 143.4 degrees Fahrenheit, which is outside of the range required by regulation. At 09:31 AM LPA observed the private resident bathroom attached to bedroom #5 to contain a moldy shower curtain. OUTDOOR SPACE: The facility has two (2) emergency exit gates. One (1) is located in the front yard and one (1) is located in the backyard; LPA observed clear passageways for emergency exit use. The gate on the north side of the facility’s backyard is not an emergency exit gate and leads to the yard of an attached ADU. The facility has adequate shaded seating outdoors for resident use. LPA observed one (1) secured storage shed in the backyard of the facility. At 09:34 AM LPA observed an unsecured gardening trowel/hoe combination tool unsecured in the backyard. Continued on LIC 809C. RECORD REVIEW: Record review began at 10:05 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. three (3) staff files were reviewed. One (1) staff file for a staff member currently at the facility was observed to be missing from the facility’s records. One (1) additional staff file was observed to be missing their LIC 503 – Health screening form, a negative TB test, and up to date trainings. Four (4) resident files were reviewed. Two (2) resident files were observed to be missing a negative Tuberculosis (TB) test. MEDICATION REVIEW: Medication review began at 11:55 AM. Medications for four (4) of four (4) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 03/14/2024 which is outside of the required timeframe. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. INTERVIEWS: LPA interviewed two (2) residents. One (1) resident stated that they wish the facility showered residents more frequently than once a week. Both resident’s interviewed stated that activities are not currently offered at the facility. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their role and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. The staff member interviewed stated that they last received their annual trainings between two (2) to three (3) years ago. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 26, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by staff and informed them of the reason for the visit. Staff contacted the Administrator and they arrived shortly thereafter. LPA met with Corazon Guevarra and explained the reason for the visit. The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 71 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. One fire extinguisher was purchases on 03/11/2024. The LPA observed required postings throughout the common space. The Administrator was informed to post their current Administrator’s Certificate. BEDROOMS: Bedrooms were furnished appropriately with linens, appropriate furnishings and sufficient lighting. There are three designated client rooms and two staff rooms. There was a linen closet in the hallway with extra towels and linens. Continues on LIC 809 C... BATHROOMS: Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. Paper towels and soap were observed at the time of the inspection. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water were noted. The washer and dryer are found in the laundry room, with cleaning supplies and disinfectants. RECORDS: Records review began at 1:03 pm. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 2:15 p.m. Medications are centrally stored and locked in a locked closet in the hallway; medications are labeled and checked for expiration dates. No errors observed during the medication review. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 11, 2024