The Stuart House

Type of visit: Required - 1 Year

On 08/05/2026 at 2:25PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Pamela Green, Administrator and explained the purpose of the visit. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) total bedrooms which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 111.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/24/2025. First aid kit was observed to be complete. Continued on LIC809. Continued from LIC809. Three (3) residents' file were reviewed and are complete. LPA was informed by Administrator that there are no staff files available for review. LPA observed the following deficiencies: At 03:15pm, LPA observed unlocked pre-poured medication in the family room. At 03:25pm, LPA observed a drawer with tools such as screwdrivers, pliers, and 2 unlocked knives in another drawer located in the kitchen. At 3:40pm, LPA observed shovel, water hose, boxes, paint cans located on the side yard. LPA requested the following documents to be submitted to CCLD by 08/14/2026. Resident Roster LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report provided.the state’s words, verbatim · CDSS document, Aug 5, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 07/16/2025 at 12:35PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Pamela Green, Administrator and explained the purpose of the visit. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) total bedrooms which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 119.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/26/2024. First aid kit was observed to be complete. Continued on LIC809. Continued from LIC809. Three (3) residents' file were reviewed and are incomplete. LPA was informed by Administrator that there are no staff files available for review. LPA observed the following deficiencies: At 12:53pm, LPA observed unlocked laundry room door with chemicals such as awesome cleaner with bleach, laundry detergent and Lysol sanitizer. At 1:05pm, LPA observed unlocked pre poured medication sitting in the family room on a TV tray. At 1:10pm, LPA observed scissors, knives and tools such as screw drivers, box cutter. At 1:20pm, LPA observed during record review residents files incomplete. At 2:15pm, LPA was informed by Administrator that the facility dose not have staff files. At 2:47pm, LPA was informed by Administrator that the facility dose not have staff training's. At 3:22pm, LPA was informed by Administrator has not conducted a disaster drill in a while and has no record of drills conducted. LPA requested the following documents to be submitted to CCLD by 07/31/2025. Resident Roster LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report provided.the state’s words, verbatim · CDSS document, Jul 16, 2025

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Facility staff did not provide care for resident personal accommodations.

On 03/26/25 around 08:30 AM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to deliver the findings for the above allegations. LPA met with Pamela Green, Administrator and explained the purpose of the visit. LPA toured the facility, interviewed Staff (S1, S2, S3) and Residents (R1, R2, R3, R4, R5). LPA requested the facility’s Resident Roster, Personnel Report (LIC500) and the following for Residents (R1, R2, R3, R4, R5): current Physician's Report, ID/Emergency Contact information, Resident Appraisal, House Rules and Unusual Incident Reports (UIRs) from 10/2024 to 12/2024. Allegation: Facility staff did not provide care for resident personal accommodations. R1 stated that the bulb was missing from the lamp in his/her room and R1 was trying to reach for the lamp in the dark. R1 stated that he/she was fearful. LPA toured the facility and noted that the light switches in the resident’s rooms were secured by clear locked boxes, and room number (1) bedside lamp was not plugged into the wall. Continued on LIC9099C... Substantiated ...continued from LIC9099. Based on LPA’s observations, interviews and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. Deficiency is cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and a copy of this report provided to Pamela ADM. ...continued fron LIC9099A Facility staff slapped resident. R1 reported to W1 that S1 slapped him/her on the right side of the face. LPA interviewed R1 and R1 stated that he/she had been slapped by his/her sister many years ago. R1 stated that he/she was never hit by S1 or S2. On 03/18/25, LPA received a call from W1 stating that R1 wanted to retract his/her statement and that R1 was confused. R1 is diagnosed with Dementia. Facility staff yelled at resident. S1 and S2 stated that they do not yell at the residents. S3 stated that R3 and R1 yells sometimes. S3 will ask R1 to wait a few seconds. LPA asked R1 if S1 or S2 had yelled at him/her, R1 stated, “No, they are sensible people.” When asked again, S1 stated that he/she could not pinpoint that. Facility staff do not allow resident to use personal possessions without permission. LPA toured the facility, and all residents’ personal items, clothing, and shoes were unlocked and accessible to staff and residents. R1 stated that anything helpful disappears. R2 stated that S1 keeps the house clean. R3 stated that he/she doesn't have anything to bother and R5 stated he/she loves to read and that’s not a problem. W2 stated that S1 Based on LPA’s observations, interviews and records reviewed, the preponderance of evidence standard has not been met; therefore, the above allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 26, 2025 · control 15-AS-20241212151031

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(B) · Plan of correction due date: Mar 28, 2025

(a) Living accommodations...shall apply: (3)...necessary for personal care and maintenance…the licensee shall assure provision of: (B) Bedroom...for each resident, a chair, night stand, a lamp, or lights sufficient for reading... -This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above by not having the lamp plugged in which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: Administrator/Licensee agreed to review the regulation and made the correction during the visit on 12/16/24.

Type of visit: Case Management - Other

On 03/26/25 around 09:00 AM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to deliver the findings for complaint 15-AS-20241212151031 received 12/12/24, and conducted a case management because of the interviews obtained. LPA met with Pamela Green, Administrator and explained the purpose of the visit. R1 stated that there’s no flexibility, he/she goes to bed from 05:30 - 6:00 PM. R5 stated that the staff comes to get the residents when it's time for bed; a little later would be nice about 7:30 PM. S2 stated, “The staff have to start early to begin getting the residents ready for bed about 05:30 PM; since it’s several of them (residents), they (staff) have to start early.” R1 and W2 stated that there could be more activities. Although a complaint was not generated, interviews revealed concerns. LPA provided educational literature to the ADM for the following regulations to be assured the facility is in compliance. - 87468.1 Personal Rights of Residents in All Facilities - 87219 Planned Activities - 87507 Admission Agreements No citation issued, exit interview conducted, and a copy of this report provided to Pamela Green, ADM.the state’s words, verbatim · CDSS document, Mar 26, 2025

Type of visit: Required - 1 Year

On 08/01/2024 at 1:00PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Pamela Green, Administrator and explained the purpose of the visit. The Administrator currently holds a certificate (#6024026740) that expires on 02/10/2025. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) total bedrooms which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 69 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 112.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/18/2023. First aid kit was observed to be complete. Continued on LIC809. Continued from LIC809. LPA reviewed three (3) staff files all are incomplete. Three (3) residents' file were reviewed and all were complete. LPA observed the following deficiencies: At 2:30pm, LPA observed during record review all three (3) staff files are incomplete. LPA requested the following documents to be submitted to CCLD by 08/08/2024. Resident Roster LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report provided.the state’s words, verbatim · CDSS document, Aug 1, 2024

Allegation investigated: Facility staff failed to timely seek medical attention to address resident's change in condition. Facility staff hit resident with a back-scratcher.

On 3/19/2024 at 1:30pm, Licensing Program Analyst (LPA), Carol Fowler arrived unannounced to open and deliver complaint findings for the allegations above. LPA met with Pamela Green and explained the reason for the visit. During the course of the investigation, the Department conducted interviews with the reporting party, S1 & S2, LPA obtained and reviewed records. Allegation: Facility staff failed to timely seek medical attention to address resident's change in condition. Investigation Finding: un-substantiated Responsible Party (RP) reported R1 didn't received medical attention in a timely manor. LPA conducted a record review and R1 had a medical assessment on 11/8/2023 before R1 moved into the facility. LPA also reviewed R1 hospice care binder and R1 was placed on hospice care on February 14, 2024 R1 had a hospice nurse visit R1 at the facility 5 days a week. Therefore the this allegation is un-substantiated. Continued on LIC9099C. Unsubstantiated Continued from LIC 9099 Allegation: Facility staff hit resident with a back scratcher. Investigation Finding: un-substantiated Responsible Party (RP) reported R1 told RP that R1 was getting hit on R1 legs with a back scratcher. LPA conducted interviews with S1 and S1 stated that the back scratcher belongs to R1 roommate and was located on the dresser. S1 stated that S1 has never hit or knows of any staff that has hit R1 with the back scratcher. LPA interviewed S2, S2 stated that S2 has never hit R1 with a back scratcher. S2 stated that due to R1 diagnoses that R1 would curse at S2 and request S2 not to touch her. S2 stated that R1 would apologize to S2 at the end of the day. Therefore the this allegation is un-substantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations Facility staff failed to timely seek medical attention to address resident's change in condition and Facility staff hit resident with a back scratcher are unsubstantiated. No deficiencies observed during visit.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 15-AS-20240311150745