The Comfort Place

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 12:29PM. The LPA met with the Administrator Omowunmi Balogun informed them of the reason for the visit. Entrance interview conducted. Beginning at 12:50PM, the LPA and 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. The following was observed: KITCHEN: The LPA observed knives and cleaning supplies stored inaccessible. Kitchen appliances were clean and in operable condition. The facility had a sufficient supply of perishable, non-perishable food, and emergency food. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. COMMON AREAS: At the time of the visit, living room/office and dining room furniture was observed to be in good condition. A fireplace was observed in the living room that was screened and inoperable. Required postings were observed in the office area. There was a secured storage room that contained extra facility supplies and emergency water. The facility maintained a comfortable temperature throughout the visit and nightlights were observed throughout the hallways. Report Continued on LIC 809-C BEDROOMS/RESTROOMS: There were eight (8) total bedrooms: six (6) private resident rooms and two (2) secured staff rooms. Each bedroom had a direct exit to the outside and the facility approved for six (6) bedridden residents. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in a hallway closet. There were three (3) total restrooms in the facility: one (1) staff and two (2) shared resident restrooms. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured between 116.2 degrees F and 118.4 degrees F which is within the required range per regulation. OUTDOOR AREA: The rear yard had a shaded area equipped with furniture in good condition for resident and visitor use. Exits and passageways were free of obstruction. There were three (3) emergency exits: two (2) self-latching gates and one (1) driveway gate. The rear yard also had a laundry room with machines in good condition and a secured shed with general storage. RECORDS: Record review began at 1:12PM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and 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 records were in order. Report Continued on LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Fire extinguishers were observed and purchased on 01/27/2026. Emergency disaster drills are conducted quarterly, with the last documented drill on 03/01/2026. Smoke and carbon monoxide detectors were tested at 1:52PM and were operational. MEDICATIONS: Medication review began at 1:58PM. Medications were centrally stored and kept inaccessible in the office area. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates and were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Mar 4, 2026

Allegation investigated: Staff do not treat resident with respect Staff did not ensure resident was safe while having a seizure Staff did not get timely medical care for resident

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced subsequent visit to deliver findings for the above allegations. The LPA arrived at 11:15AM and met with Staff Chika Anugwa. The Administrator Omowunmi “Wummy” Balogun was contacted and report delivered via telephone call. Entrance interview conducted. On 10/31/2025 between 9:30AM and 12:45PM, the LPA and Staff conducted a physical plant tour, the LPA reviewed and requested copies of pertinent documents, interviewed two (2) Residents and one (1) Staff, and attempted one (1) Resident interview. Report Continued on LIC 9099-C Unsubstantiated During today’s visit, the LPA and Staff conducted a physical plant tour at 11:27AM, and no immediate concerns were observed. The following was then determined: Allegation: “Staff do not treat resident with respect” It was reported that on 10/23/2025, Staff #1 (S1) spoke inappropriately and shouted at Resident #1 (R1). Specifically, S1 allegedly directed R1 to clean up used cigarettes in the rear yard. R1 complied and attempted to dispose of the cigarettes in the garbage bins located on the driveway outside the facility gate. During this time. S1 reportedly insulted R1; however, no specific examples of insulting language were provided. Interview with S1 revealed that S1 did not instruct R1 to clean their cigarettes but instead inquired about a pack of cigarettes left the day prior, with the intention of returning it. R1 responded that the pack did not belong to them and then proceeded to answer the rear gate for an unknown individual approaching the facility. S1 explained to R1 that visitors are not permitted entry through the rear yard and must enter through the front door. R1 then indicated they needed to access the garbage bins, at which point Resident #2 (R2) intervened. R2 confirmed that S1 did not instruct R1 to clean up and reported that no shouting or demeaning comments occurred. R2 further explained that R1 attempted to exit the rear gate to access the garbage bins, but R2 reminded R1 that a trash/ash tray was available on the patio table for cigarette disposal. Resident #3 (R3) noted that staff can sometimes be perceived as carrying themselves with a negative attitude, while R2 and Resident #4 (R4) described staff as respectful. R1 also acknowledged that two (2) out of three (3) staff are respectful. Observations of staff interactions did not reveal yelling or mistreatment of residents. S1 acknowledged the importance of their role and expressed a commitment to ensure they speak to residents calmly and respectfully. Report Continued on LIC 9099-C The Administrator reported awareness of staff’s cultural presence, which may occasionally be perceived negatively, and confirmed that the facility conducts regular in-service training on Cultural Diversity and Effective Communication Skills, with the most recent training held on 10/25/2025. Subsequently, Resident Personal Rights training was conducted on 10/27/2025. It was additionally reported that facility staff and the Administrator badgered R1 upon receiving information about R1 relocating facilities. S1 stated they were unaware of R1’s relocation until they overheard R1 speaking with R2, at which point, R1 subsequently was transferred to the hospital the same day. Phone records indicated that R1 continuously called the facility and Administrator several times a day while they were at the hospital and Skilled Nursing Facility (SNF). The Administrator and S1 reported R1 calling to update them about their hospital visit and requesting if they could return to the facility. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. Allegations: “Staff did not ensure resident was safe while having a seizure” and “Staff did not get timely medical care for resident.” It was reported that facility staff failed to assist R1 during seizure episodes and refused to provide medical services. R1 was admitted on 08/22/2025 and initially experienced seizures approximately every two (2) weeks. On 10/15/2025, R1 reported an increase in frequency, occurring every other day to nearly daily, sometimes multiple times per day. On 10/23/2025, staff allegedly refused to contact Emergency Medical Services (EMS) despite R1 experiencing five (5) to six (6) seizures that day. R1 stated that staff observed their seizures but did not intervene or check on them afterward and further reported unwitnessed seizures to staff. Report Continued on LIC 9099-C According to R1, staff were trained to call EMS if two (2) to three (3) seizures occurred in one (1) day and to provide safety measures such as turning R1 to their side, elevating their head, and monitoring them afterward. On 10/23/2025, R1 called EMS independently and reported multiple seizures. R1’s Case Worker also recommended EMS for transfer to a Skilled Nursing Facility (SNF). EMS dispatch requested address verification, during which S1 denied that R1 had experienced seizures that day. Interview with S1 and the Administrator revealed that R1 did not consistently disclose seizures, and staff frequently inquired to monitor R1’s condition. They reported that R1 often stated they had no seizures or experienced one (1) seizure every three (3) to four (4) days. S1 stated they had observed one (1) seizure and followed protocol by removing obstructions, turning R1 to their side, and continued monitoring. Staff explained that R1’s Home Services Care Plan required EMS contact if R1 had more than three (3) seizures per day. Staff reported this threshold was not met as Staff did not observe and R1 did not report multiple seizures in a day. S1 also noted that a Physician adjusted R1’s medications which reportedly reduced R1’s seizure frequency. Interviews with other residents provided limited corroboration: R2 did not observe seizures, while R3 reported seeing one (1) episode through R1’s doorway. During this time, R1 was seen unsuccessfully attempting to call for help. Staff checked on R1 after the seizure concluded and continued monitoring. Record review included a Physician’s Report dated 08/11/2025 which documented a diagnosis that included Lennox-Gastaut Syndrome, Developmental Delay, Traumatic Brain Injury, and Bipolar/Schizoaffective Disorder. It was also noted that R1 faced forgetfulness to take their medication and with daily support R1’s seizures and mental health conditions will improve and subsequently improve their quality of life including reduction in seizures. Medication Administration Record review documented R1 received all prescribed medications. R1’s Appraisal/Needs and Services Plan and Enriched Residential Care Services Need and Tier Assessment indicated that R1 would benefit from medication management, assistance with activities of daily living during exacerbation of seizure symptoms, and overall seizure symptom management. Report Continued on LIC 9099-C In addition to providing Staff seizure precautions, Home Care Services instructed Staff to call 911 if R1’s seizures last more than five (5) minutes, R1 does not return to consciousness, if another seizure begins before R1 regains consciousness, and if R1 injured themselves after the seizure. Skilled Nursing Visit Notes on 10/08/2025 documented R1 reporting having one (1) seizure lasting five (5) seconds. Additionally, Staff were instructed to call EMS if R1 experienced three (3) seizures a day. On 10/15/2025, R1 reported zero (0) seizures and on 10/22/2025, reported two (2) episodes throughout that week. R1 reported each time they were safe, and Staff checked on them frequently and did not have any concerns. Los Angeles Fire Department (LAFD) Patient Care Report on 10/23/2025 indicated EMS arrived on scene at 12:46PM, noted R1 approached the ambulance appearing in no distress, and reported seizures on prior days but none that day. R1 requested Physician evaluation and was transferred to the hospital without complications. Based on interview and record review, R1’s statements varied and were not consistently corroborated by Staff, Residents, or EMS and Home Care Services documentation. Staff reported fewer seizures and adherence to seizure protocols, and records confirmed medication compliance and Physician oversight. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED at this time. Due to the Administrator’s unavailability, verbal confirmation was received for Staff to sign today’s report. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 29-AS-20251024090509

Allegation investigated: Staff are not following resident's physician order for a special diet

Licensing Program Analysts (LPAs) Erica Mosley and Quoc Huynh conducted an unannounced subsequent complaint visit to investigate the above allegation. The purpose of this visit is to deliver findings for the above allegation. Upon arrival at 9:51 a.m., LPA Mosley and Huynh were greeted by Staff who called the Administrator. The Administrator arrived during the visit. The LPAs met with Administrator, Omowunmi Balogun and explained the reason for the visit. The Administrator had to leave prior to deliver findings and designated staff Chika Anugwu to sign the report. On 04/10/2025 the Department received a complaint regarding the following allegation Staff are not following resident's physician order for a special diet. On 04/10/2025 LPA Mosley conducted the initial 10-day complaint visit. Strating at 9:48 a.m., LPA conducted a brief physical plant tour to ensure there were no immediate health and safety concerns, conducted an in-person interview with the Administrator, conducted a file review and obtained copies of pertinent documents relevant to the investigation. Report continued on LIC 9099-C PAGE 2... Unsubstantiated (Page 2) Report continued from LIC 9099... During today’s visit, starting at 9:51 a.m. LPAs conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations. Starting at 9:59 a.m. LPAs conducted an in-person interview with one (1) staff, a telephonic interview with one (1) staff and R1’s California Department of Health Care Services Case worker (CDHCS CW), in person interview with Resident #1 (R1), inspected the kitchen and food service area, a file review and obtained copies of pertinent documents relevant to the investigation. On the allegation Staff are not following resident's physician order for a special diet it is the concern of the reporting party (RP) that the facility is not providing accommodations for R1’s special diet. To investigate this complaint, LPAs conducted in person interviews with one (1) staff and the Administrator, telephonic interviews with one (1) staff and CDHCS CW, inspected the kitchen and food service area and reviewed documents relevant to the investigation. Interview with R1 revealed that the food provided at the facility is not to their liking and would prefer to have food that is aligned to their culture. R1 stated that the facility does not provide accommodations for the special diet. Interviews with staff revealed that the facility provides R1 with accommodations for a special diet however R1 refuses to accept the accommodations. Staff #1 (S1) revealed that they prepare the meals at the facility and always provide accommodations for R1’s special diet. R1 will refuse the food that goes along with the special diet and request substitutions that do not follow the special diet. Interview with Staff #2 (S2) revealed that the facility provides the proper accommodations for R1 however R1 refuses. S2 states that R1 has stated multiple times that the food that is provided is not to their liking. R1 would prefer to have food that is aligned to their culture however it is not aligned to the special diet. Interview with the Administrator revealed that R1 refuses meals that go along with the special diet. The facility provides accommodations to all meals for R1 however R1 refuses. Inspection of the kitchen and food service area revealed that the facility has information posted with food choices/ suggestions for R1’s special diet. Refrigerator and food pantry were inspected for special diet products. Report continued on LIC 9099-C PAGE 3... (Page 3) Report continued from LIC 9099C... The facility had multiple items listed on the special diet food choices such as unsweetened almond milk, plain yogurt, brown rice, whole grain pasta, corn, bell peppers, cucumbers, lettuce, apples, grapes and unsweetened tea. Documents reviewed revealed that the facility has accommodations and substitutions on the menu. R1 has refused recommendations from the staff to follow the special diet on multiple occasions dating back to when R1 was first admitted. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff are not following resident's physician order for a special diet is deemed unsubstantiated at this time. No deficiencies were observed during today’s inspection. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 29-AS-20250410144752

Allegation investigated: Staff are stealing a resident's personal documents Staff are financially abusing a resident

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above allegations. The purpose of this visit is to deliver findings for the above allegations. Upon arrival at 9:45 a.m., LPA Mosley was greeted by Staff and Administrator / (Licensee representative). The LPA met with Administrator, Omowunmi Balogun and explained the reason for the visit. On 07/22/2024 the Department received a complaint regarding the following allegations, Staff are stealing a resident's personal documents, and Staff are financially abusing a resident. On 07/31/2024 LPA, Esther Cortez conducted an unannounced initial 10-day complaint visit. Between 01:15 p.m. and 2:30 p.m. LPA toured the facility with the administrator, interviewed the Administrator, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. Report continued on LIC 9099-C PAGE 2... Unsubstantiated (PAGE 2) REPORT CONTINUED FROM LIC 9099... On 04/09/2025 LPA, Mosley conducted an unannounced subsequent complaint visit. From 12:46p.m.- 2:20p.m. LPA conducted a brief physical plant tour, conducted in person interviews with the Administrator, two (2) staff, two (2) residents, a file review and obtained copies of pertinent documents relevant to the investigation. During today’s visit, at 9:48 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations. From 9:02 a.m.- 1:15p.m LPA conducted three (3) telephonic interviews with Resident # 1(R1) emergency contact (E.C) #1, R1’s E.C #2, R1’s California Department of Health Care Services (DHCS) Case worker (CW), an in-person interview with the Administrator, brief file review, and obtained copies of pertinent documents relevant to the investigation. On the allegation Staff are stealing a resident's personal documents it is the concern of the reporting party (RP) that the facility Licensee representative is stealing R1’s personal documents including ID card. To investigate this complaint, LPA conducted in person interviews with two (2) staff members, Administrator / Licensee representative, two (2) residents including R1, telephonic interviews with R1’s E.C #1, R1 E.C #2, R1 DHCS case worker, and a file review. Interviews with the staff revealed that they do not enter R1’s room without permission and without R1 being present. Interviews revealed R1 has a tendency to misplace things and blame the staff for things going missing. Later R1 will apologize to the staff and state that the items were found. Since misplacing things is a reoccurring thing for R1 the staff and R1 had made a written and verbal agreement in March 2024 that staff will only enter R1’s room when R1 is present. Staff state that they have not taken or stolen any personal documents including R1’s ID card. Interview with the Administrator / Licensee representative revealed that R1 has made allegations in the past that personal belongings have gone missing, and that staff are stealing personal belongings. Administrator / Licensee representative stated that R1 will later apologize to the staff and state that the items were found. Since misplacing things is a reoccurring thing for R1 In March 2024 that Administrator / Licensee representative made a written and verbal agreement with R1 that staff will only enter R1’s room when R1 is present to try and give R1 more confidence in the staff. Report continued on LIC 9099-C PAGE 3... (PAGE 3) REPORT CONTINUED FROM LIC 9099-C PAGE 2... Administrator / Licensee representative stated that she has not taken or stolen any personal documents including R1’s ID card. Interviews with R1’s E.C #1 revealed that R1 was willingly placed at the facility with assistance from E.C #2. E.C #1 stated that R1 did not have any possession of any personal documents including ID card as E.C #2 has possession of all legal documentation for safeguarding. R1 has a copy of the ID card. Interview with CDHS CW revealed that R1 has reoccurring behaviors that include confrontation with staff and making accusations about the staff. CDHS CW states that the facility staff did not take her personal documents including ID card. File review revealed that on R1’s LIC 621 Residents personal property and valuables record sheet, ID card was not listed. Interview with R1 revealed that they have a copy of their ID but have had difficulty obtaining a physical copy. R1 stated that they are unsure what happened to their ID card. LPA educated R1 on the procedures and resources on how to obtain a physical ID card. R1 stated that at times they misplace things, but the items are typically found at a later time. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff are stealing a resident's personal documents is deemed unsubstantiated at this time. On the allegation Staff are financially abusing a resident it is the concern of the reporting party (RP) that the facility Licensee representative is stealing R1’s personal assets, including assets in another state and R1’s identity. To investigate this complaint, LPA conducted an in person interviews the Administrator / Licensee representative, R1, telephonic interviews with R1’s E.C #1, R1 E.C #2, R1 DHCS case worker, and a file review. Interviews with the Administrator / Licensee representative revealed that R1 was willing admitted to the facility with R1’s E.C #2. All R1’s family is involved and cooperative with the facility and R1’s wellbeing. Administrator / Licensee representative states that they are unaware of any of R1’s assets or finances as they do not handle or store any of R1’s finances or personal belongings. All the residents at the facility handle their own finances as the facility does not safeguard money for the residents. Administrator / Licensee representative stated they have not and do not plan to steal R1’ s personal assets or identity. Report continued on LIC 9099-C PAGE 4... (PAGE 4) REPORT CONTINUED FROM LIC 9099-C PAGE 3... Interview with R1’s E.C #1 revealed that R1 does not have any personal assets, and nothing has been stolen. Interview with CDHS CW revealed that R1 does not have any personal assets. R1 struggles with their mental health. R1 has reoccurring behaviors that include confrontation with staff and making accusations about the staff. CDHS CW was not aware of the facility stealing any assets or R1’s identity. Interviews with R1 revealed that they handle all of their own finances and have no issues or concerns with their personal finances. R1 stated they have no problem with the facility staff and the staff do not handle any of their personal finances or personal belongings. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff are financially abusing a resident is deemed unsubstantiated at this time. No deficiencies were observed during today’s inspection. Exit interview conducted. Report was reviewed and a copy was provided. A copy and appeal rights were issued.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 29-AS-20240722215837

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Erica Mosley conducted a Case Management - Incident visit to follow up on a self-reported incident which took place on 04/03/2025. At 9:45 a.m. LPA Mosley was greeted by staff and Administrator, Omowunmi Balogun and the reason for the visit was explained. Entrance interview. On 04/02/2025, it was reported that Resident 1 (R1) made the accusation to the Administrator that there are no staff at nighttime, R1 had an altercation with Staff #1 (S1) where S1 attacked R1 and staff serve the same meal every day. During today's visit, from 9:45 a.m. LPA conducted a physical plant tour to ensure there were no immediate health and safety concerns. On 04/09/2024 from 12:46p.m.- 2:20p.m. LPA conducted a brief physical plant tour, conducted in person interviews with the Administrator, two (2) staff including S1, three (3) residents including R1, a file review and obtained copies of pertinent documents relevant to the incident. On the accusation that there are no staff at nighttime the LPA conducted interviews with the Administrator, two (2) staff, and three (3) residents including R1. Interviews with the staff revealed that they always have staff at night. They have two (2) live in staff who are readily available. Staff state they regularly have two (2) staff scheduled throughout the day and night. There are always staff available. They have never left the residents alone at night. Interviews with residents revealed that they always have staff at night. They have not been left alone without any staff. Interview with R1 revealed that one morning, day unknown at 5:00 a.m. staff took longer than normal to assist and was upset that the staff took longer than usual. R1 stated that they do have staff at night. R1 stated that S2 is available at night and helps regularly. R1 stated that they were upset with the staff and told the Administrator that no one was here. Report continued on LIC 809-C PAGE 2... (PAGE 2) REPORT CONTINUED FROM LIC 809... Interview with the Administrator revealed that they have staff regularly scheduled and always have staff at night. R1’s California Department of Health Care Services (DHCS) Case worker (CW) was made aware of the accusation and came the next day to speak to R1 and gave the facility interventions for R1. On the accusation R1 had an altercation with S1 where S1 attacked R1 the LPA conducted interviews with the Administrator, two (2) staff including S1, and three (3) residents including R1. Interviews with that staff revealed that they are unaware of any altercation with R1 and S1. S1 did not attack R1. S2 stated that there has not been any altercation with R1 and S1.S1 did not attack R1. S2 stated that R1 was upset with S1 for telling R1 to not open the door to strangers and that the Staff would open the door for their safety. R1 then proceeded to yell and use profanity towards S1 and stormed off. Interview with S1 revealed that S1 did not get into any altercation with R1. R1 was upset with S1 for telling R1 to not open the door to strangers. Interview with R1 revealed that they did not have any physical altercation with S1. S1 did not push or put their hands on R1. S1 did not attack R1. Interview with the Administrator revealed since the accusation an Inservice training was conducted on 04/04/2025 with all the staff on Abuse, Abuse reporting procedures, Resident Rights, and Effective communication. On the accusation staff serve the same meal every day the LPA conducted interviews with the Administrator, two (2) staff, and three (3) residents including R1. Interview with staff revealed that they do not serve the same meal everyday and have photo proof of what is served daily. Staff follow a monthly menu that cover all nutritional guidelines. Interview with residents revealed that the same meal is not served every day, and the food is of good quality. Interview with R1 revealed that the facility does not serve the same meal everyday but that the food is not to their liking. R1 would prefer food that is culturally aligned with their culture. R1 states that the food is okay and good quality but not to their liking. Interview with the Administrator revealed that the facility has mad efforts to bring in more of R1’s culture into the food they provide. No deficiencies were observed during today’s inspection. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Apr 10, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:45 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator, Kemi Oluwole arrived shortly after and the reason for the visit was explained. Entrance interview. The LPA 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. INTERVIEWS: From 9:55 a.m. – 10:38 a.m. two (2) staff and one (1) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit. KITCHEN: The LPA inspected the kitchen/food service area at 10:50 a.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 110.1 degrees Fahrenheit at 10:52 a.m. Cleaning supplies and other chemicals are kept in a locked closet / cabinet inaccessible to residents in care. LPA observed an adequate amount of emergency food. BEDROOMS: There are eight (8) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms and two (2) staff rooms. The staff rooms are kept locked at all times. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Report Continued on LIC 809C... Report Continued from LIC 809C... RESTROOMS: There are three (3) restrooms. Two (2) are designated as shared / common restrooms and one (1) is designated as a staff restroom. Resident restrooms were observed to be equipped with a slip resistant surface. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured all resident restrooms and ranged between 110.6-116.1 degrees Fahrenheit, all within the required range. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 11:17 a.m., hardwire combination of smoke / carbon monoxide detector and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 02/17/2025. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 12/01/2024 and are conducted quarterly with the next one scheduled in March. The facility had the annual automatic sprinkler system checked and passed on 09/30/2024. Activities were observed in the common areas. The fireplace in the living room was adequately screened. LPA observed a locked storage closet adjacent to the entrance with an adequate amount of incontinent supplies, PPE, and emergency water. LPA observed a deep freezer that was checked for proper labels and expiration dates. There is a functioning telephone on the premises. Adjacent to the dining room is an open office where locked files and locked medication cart is located. BACKYARD: The entire property is fenced. There is a laundry area, with a washer and dryer. Laundry detergent was observed in a locked cabinet. The backyard has a portable umbrella for shade with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed two (2) self-latching gates. There were no bodies of water noted at the time of the visit. There is a locked storage shed in the back yard inaccessible to residents. Infection Control / Emergency disaster planning: At 11:08 a.m. LPA Mosley reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control are adequate. Report Continued on LIC 809C... Report Continued from LIC 809C... RECORDS: Record review began at approx. 11:08 am. Resident Records were reviewed beginning at 11:13 a.m. and Personnel Records at 12:43 p.m. Five (5) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Four (4) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. MEDICATIONS: Medications review began at approximately 2:08 p.m. The medications are in a locked medication cart adjacent to the kitchen. Medications for four (4) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed. LPA obtained the following documents - Resident roster - LIC 9020, Staff roster - LIC 500, a copy of the Limited Liability insurance, and an updated facility sketch. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of the report provided.the state’s words, verbatim · CDSS document, Mar 5, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced at 9:00 AM for a Case Management – Annual Continuation inspection. The LPA met with facility supervisor Omowunmi Balogun and explained the reason for the visit. During the Required 1-Year on 03/15/2024, the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility compliance of Title 22 Regulations. Physical plant tour was conducted during the Annual visit. Today, 05/22/2024 a brief tour was conducted. No health and safety concerns were identified during today's tour. Facility has a sprinkler system in place, last inspection report was conducted on 12/08/2022 with an expiration date of 09/30/2024. Test result “Pass”. RECORD REVIEW: Began at 10:12 AM, staff and resident records were reviewed for documents including, but not limited to; admission agreement, health screening, TB test result, resident physician's report, needs and service appraisal, and personal rights. Five (5) out of five (5) resident records reviewed were missing consent forms and need and service plan. During the visit, the supervisor was able to complete all five (5) needs and service plan without resident’s signatures. Supervisor agreed to submit all completed and signed forms to LPA once each resident signs it. LPA reviewed five (5) staff files for documents including but not limited to staff training records, fingerprint clearance, health screening and TB test result. Record review and interview conducted revealed Staff #1 (S1) was employed by the company in March of 2023. S1 is working for this facility at least 20 hrs. per week. LPA reviewed the facility guardian roster and discovered that S1 does have fingerprint background clearance but is not associated to this facility. Continued on LIC 809-C Continued from LIC 809 MEDICATION REVIEW: LPA conducted a medication review for five (5) residents with the facility supervisor between 12:25PM and 1:28PM. LPA observed the following three (3) medication discrepancies were noted. For Resident #1 (R1) LPA observed five (5) pills of Levothyroxine, in a bottle labeled with quantity of 90 pills, with instructions to take 1 tablet orally daily, and with a start date on documentation as 04/01/2024. Resident #2 (R2) had four (4) extra pills of Aspirin in a bottle labeled with quantity of 30 pills, with instructions to take 1 tablet orally daily, and with a start date on documentation as 05/01/2024. Resident #3 (R3’s) pill count reflected three (3) extra pills of Spironolactone in a bottle labeled with quantity of 30 pills, with instructions to take 1 tablet orally daily, and with a start date on documentation as 05/01/2024 and an additional five (5) extra pills of Spironolactone in a bottle labeled with quantity of 30 pills, with instructions to take 1 tablet orally daily, and with a start date on documentation as 05/01/2024. Staff could not provide an explanation for the discrepancy. EMERGENCY DISASTER PLAN and Quarterly Drills: During today's visit, LPA reviewed the facility's infection control plan, Emergency drills, and Emergency Disaster Plan. All facility's policies and procedures related are adequate. The facility's Emergency Disaster Plan is complete and updated annually. Emergency drills are conducted quarterly, with the last drill taking place on 03/16/2024. Staff checks smoke detectors monthly, last test was 05/04/2024. Per the California Code of Regulations, Title 22, Division 6, Chapter 8 the following deficiencies were observed and cited. Refer to the following LIC 809-D pages for list of deficiencies. Civil penalty issued in the amount of $500. Failure to correct deficiencies may result in additional civil penalties. Exit Interview Conducted. Report was reviewed with Supervisor, and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 22, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at 8:52 a.m. to conduct an unannounced annual inspection visit to the above noted facility. At 9:28 a.m. LPA met with Administrator Assistant, Omowunmi Balogun, and explained the reason for the visit. The facility is a one-story facility. At 10:15 a.m., a physical plant tour was conducted inside and out. The facility consists of a total of seven (7) private bedrooms. During today’s visit, LPA observed that resident bedroom #7 which was previously designated as a resident room to be utilized as a staff room. Additionally, the storage room was also designated as a second staff room. LPA discussed these changes with the assistant administrator and requested for an updated facility sketch to be submitted to licensing. All resident rooms have direct exits to the outside. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, a mattress and clean linen. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. All rooms were free of odors. In addition, no bedroom was used as a passageway to another room, bath, or toilet. There are two (2) bathrooms for residents in the hallway and one (1) staff bathroom next to the living/dining room for staff use. The toilet and shower have grab bars and non-skid mats. At 10:41 a.m., LPA tested the hot water temperature in bathroom #1 and read 116.2, and the hot water temperature in bathroom #2 measured at 118.7. Resident and staff records are filed in a filing cabinet which is currently located near the front desk. Medications will be centrally stored in a locked cabinet near the front desk. The first aid supplies were complete, including a current version of a first aid manual. Continued on LIC 9099C Continued from LIC9099 Kitchen knives are stored in a locked drawer in the kitchen. The supply of dishes, utensils, pots, pans and drinkware is adequate. The supply of perishable and non-perishable food is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen and house cleaning supplies are stored in a locked cabinet located in the kitchen. No flies or other insects were observed. The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace in the living room which it is screened. There are not working cameras around the common areas and doors have alarms on all exterior doors. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has central air conditioning and are a comfortable range. The facility smoke alarm system is hard wired. At 11:20 a.m. the smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. Last earthquake and fire drill was done 12/01/2023. There are four (4) fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date. The laundry area is located in the backyard, all laundry detergents are inside a cabinet inaccessible to residents. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a hallway closet. Extra PPE supplies are stored in a storage room next to the main entrance along with emergency water and food. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in common hallway. Other required postings are posted in the common hallway. Continued on LIC 9099-C Continued from LIC9099-C The exterior passageways were clean and clear of any obstructions. Patio has a portable umbrella for shade and furniture such as chairs and a table for residents to enjoy. The entire property is fenced, LPA advised Assistant Administrator to change the latch on the main front gate. There is a door with gate with a self-latching mechanism for persons to enter the front yard. There is a locked storage shed in the back yard inaccessible to residents. There no bodies of water on the premises at the present time. Medication, Staff File and Resident File Review: Not reviewed during today's visit.the state’s words, verbatim · CDSS document, Mar 15, 2024