Terrace Gardens

Allegation investigated: Licensee does not ensure staff have ability to communicate with clients. Staff do not ensure resident is allowed to receive phone calls at all times.

On December 15, 2025, Licensing Program Analysts (LPA) Eldin Serrano visited the facility to investigate the above mentioned allegations and deliver findings. LPA met with Administrator Dekki Mawikere to discuss the purpose of the visit. The investigation consisted of interviewing relevant parties. Allegation #1: Licensee does not ensure staff have ability to communicate with clients. – Based on information received during staff and resident interviews, 3 out of 4 staff stated that they have the ability to communicate with the residents. 2 out 2 residents stated that they can understand the staff and able to communicate with them if they need the staff to do something for them. R1 stated that R1 can understand the staff and they are able to communicate with R1. LPA was unable to corroborate the allegation. *** Continuation in LIC9099C *** Unsubstantiated Allegation #2: Staff do not ensure resident is allowed to receive phone calls at all times. - Based on interviews with residents and staff. 3 out of 4 staff stated that the facility allowed the residents to received phone calls. 2 out of 2 residents stated that they are allowed to receive phone calls either to their personal cell phone or through the facility number. R1 stated that the staff allowed her to received phone calls from her family. S3 stated that if the staff are busy and unable to pick up the call, the phone call will be forwarded to the administrators cell phone so the family can communicate with the residents. LPA was unable to corroborate the allegation. Information received during investigation LPA did not find evidence to corroborate the allegations. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 and LIC9099C were discussed and provided to Administrator Dekki Mawikerethe state’s words, verbatim · CDSS document, Dec 15, 2025 · control 56-AS-20251211161027

Type of visit: Required - 1 Year

On 12/3/2025 at 1:45PM, Licensing Program Analysts (LPAs) Eldin Serrano and Sarina Ramirez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPAs met with Administrator Dekki Mawikere At the time of the visit there were three (3) staff present, and five (5) residents present. The facility is a four (4) bedrooms, two (2) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory and three (3) hospice care and the current census is six (6) residents. LPAs were accompanied by Staff to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPAs inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathroom to be at 116 degrees Fahrenheit. The facility is equipped with operating smoke detectors. LPA observed that the facility does not have the carbon monoxide detector at the time of visit. Deficiency will be issued. Fire extinguishers were also observed at the facility. LPAs observed no updated fire drill done at the facility. Citation issued. Posters such as CCLD complaint poster, labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. The resident’s medication is locked. LPAs observed complete first aid kit and first aid book at the facility. Food Service: Seven (7) days’ supply of Non-perishable foods and two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision: The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA's reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Serrano observed resident files reviewed were complete. LPAs reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that Staff #1 (S1) does not have a health screening report on file. Deficiency will be issued. LPA observed that resident #1 (R1) does not have an updated physician's report on file. Deficiency will be issued. LPA observed that resident #1,#2, #3 (R1,R2,R3)) does not have the medication log to track the administered medication Deficiency will be issued. Based on the observations made during today’s visit, Six (6) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC809, LIC809C, LIC809D forms, and Appeal Rights were discussed and provided to Administrator Dekki Mawikere.the state’s words, verbatim · CDSS document, Dec 3, 2025

Type of visit: Required - 1 Year

On 12/26/2024 at 09:10 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA Serrano met with caregiver Margaretha Jacobus and was granted entry to the facility. Caregiver called the administrator Dekki Mawikere and the administrator arrived after 3 hours. At the time of the visit there was three (3) staff present, and six (6) residents present. The facility is a four (4) bedrooms, two (2) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory and three (3) hospice care and the current census is six (6) residents. LPA Serrano was accompanied by Staff to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. LPA Serrano inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA Serrano measured and observed the water temperatures in the bathroom to be at 116 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, labor laws, and the disaster plan were posted in a common area. LPA observed that the facility does not have the Infection Control Plan available for review at the time of visit. Deficiency will be issued. ***Continuation in LIC809C *** Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. The resident’s medication is locked. LPA Serrano observed complete first aid kit and first aid book at the facility. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision: The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA Serrano reviewed five (5) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Serrano observed resident files reviewed were complete. LPA Serrano reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that Staff #1 (S1) has an expired CPR/First Aid certification and Staff #2 (S2) does not have a CPR/First Aid certification on file. Deficiency will be issued. LPA observed that resident #2 (R2) and resident #5 (R5) does not have the physician's report on file. Deficiency will be issued. LPA observed that resident #4 (R4) does not have the admission agreement on file. Deficiency will be issued. Based on the observations made during today’s visit, Five (5) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC809, LIC809D forms, and Appeal Rights were discussed and provided to Administrator Dekki Mawikere.the state’s words, verbatim · CDSS document, Dec 26, 2024

Type of visit: Required - 1 Year

0855: Licensing Program Analyst (LPA) Amy Goldenberg arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose of the visit. LPA toured the facility inside and outside. LPAs observe the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 110.2 degrees F. Grab bars, non slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways were inspected. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility does not handle resident money. Six (6) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Resident Rights are posted in the facility and a copy is signed on file. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed two gates leading from the back yard with locking mechanisms which prevent exiting without a key. LPA observed that the key is maintained in a coded lock box on the side of a backyard shed with the key in it. LPA also observed in the garage an addition of walls and a door. Inside the addition is a bed, clothing and personal effects of caregivers. Administrator admits that they are using the space place to rest for the employees. This space is not part of the approved fire clearance as a caregiver room. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually, last done 5/24/2023 . The facility is conducting emergency disaster drills, last done on 06/03/2023. LPA observed a camera in one of four resident bedrooms. Based on the information received during this visit today, the following deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.the state’s words, verbatim · CDSS document, Nov 30, 2023