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Type of visit: Required - 1 Year

On 11-13-25 at 10:08am Licensing Program Analysts (LPAs) Michael Bilger and Sommer Hayes arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Adetayo Kokumo and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a residential care facility for the elderly (RCFE) with a current census of 3. Facility has a total of 6 bedrooms and 3 bathrooms. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 2 ambulatory residents, 1 non ambulatory resident, non-ambulatory resident receives hospice services. Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 70*F. LPA observed the facility to have adequate food supply. Resident rooms had the required furniture and furnishings.. Smoke and carbon detectors were functioning adequately. Fire extinguisher was checked 1-15-25. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and accessible to staff. During this inspection 3 resident files and 3 staffing files were reviewed for regulatory compliance. All staff noted on LIC 500 contained criminal background clearances. {Cont. on LIC 809C} LPA completed 0 resident interviews as residents declined interviews, and 2 staff interviews.. Resident files reviewed revealed missing appraisal for resident3 (R3). Staff files reviewed revealed missing regulatory required 20-hour annual training. Facility’s liability insurance is current and up to date per regulatory requirements. Facility does not contain any bodies of water. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. LPA requested an updated copy of LIC 308, LIC 500, and liability insurance. Per California Code of Regulations, Title 22, deficiencies were observed during this visit and noted on LIC 809D. Exit interview was held and a report was given to Administrator Adetayo Kokumo. Appeal rights and LIC 811 provided for reference.the state’s words, verbatim · CDSS document, Nov 13, 2025

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Dec 1, 2025

87457 Pre-Admission Appraisal. (a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. This requirement was not met as evidenced by: Based on record review, licensee did not ensure competion of pre-admission appraisal for R3. This posed a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Licensee will read regulation 87457(a) and submit a signed declaration of understanding to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Dec 1, 2025

1569.625 Staff Training; legislative findings; contents.(b) (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement was not met as evidenced by: Based on record review, LIcensee did not ensure completion of 20 hours annual staff training requirement as stated above. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Case Management - Incident

On 4-30-2025 at 10:25am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue a case management previously conducted on 4-11-2025. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. During this case management investigation, LPA conducted interviews with Administrator and Staff1 (S1). Additionally, LPA reviewed facility file documentation including physician reports for resident1 (R1), R2, R3, and R4, death report dated 12-28-24, and death certificate pertaining to R1. Additionally, LPA reviewed hospital discharge paperwork. Investigation has determined that R1 passed away on 12-28-2024 with death certificate noting cause of death as acute hypoxemic respiratory failure and aspiration pneumonia. Cause of death was also revealed through hospital discharge paperwork. It was further determined through this case management investigation that staff's actions while on duty did not result in R1 at risk for the above cause of death which was deemed natural causes. Additional reviews of facility file documentation and staff interviews determined that facility currently provides care for multiple residents with dementia including R2 who is determined to be a wandering and elopement risk. During today's visit, LPA observed R2 attempting to elope from facility. It was further determined that R2 has a history of attempting to elope at various times throughout the day resulting in an on-going risk for elopement. Facility staffing review and interview determined that one staff was on duty for four clients in care including a resident with elopement risk. Additionally, it was determined through observation that facility is not utilizing a staff alert or auditory device to monitor exits on exterior doors. As a result of today's case management, citations are issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.the state’s words, verbatim · CDSS document, Apr 30, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 1, 2025

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 interviews, observation and record reviews, R2 is established as an elopement risk during the day, with one staff on duty for other residents requiring care and supervision. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 30, 2025

Plan of correction: Licensee will submit an updated staffing plan sufficient to meet the needs of residents including hours and days worked, including break times and additional coverages. Plan to be submitted to LPA by POC due date Licensee to read regulation 87411(a) and submit a signed declaration of understanding to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(d) · Plan of correction due date: May 1, 2025

87705 Care of Persons with Dementia(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement was not met as evidenced by: Based on observation and interview, Licensee did not ensure alert and monitoring devices on appropriate exterior doors and gates despite knowledge of R2 as an elopement risk. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 30, 2025

Plan of correction: Licensee to submit a plan ensuring appropriate coverage of supervision for residents to prevent elopement. Plan to be submitted to LPA by POC due date. Licensee to submit proof of purchase and plan for installation of alert and monitoring device to LPA by POC due date. Device to be installed within two weeks of citation issuance. Elopement prevention plan to continue before and after device installation.

Type of visit: Case Management - Incident

On 4/11/2025 at 10:29am, Licensing Program Analysts (LPAs) Michael Bilger and Noel Wolf Petersen arrived unannounced to conduct a case management visit regarding a previous death of a resident. LPAs met with Administrator Adetayo Kokumo and explained the purpose of the visit. LPAs conducted interviews with administrator, Staff1 (S1), and reviewed facility file documentation including physician's report for resident1 (R1), R2, R3, R4, R5, hospital discharge paperwork, and death report dated 12-28-24. Based on interviews and record reviews it was determined that on or about 12/12/2024 at approximately 10:00pm, R1 experienced a choking episode while laying in bed eating a piece of pineapple. Staff1 (S1) on duty observed R1 initially appearing pale, coughing, and vomiting. S1 then observed R1 to be choking and called 911. Based on interview conducted, S1 notified 911 within 10 minutes of initial discovery of above symptoms. On 12/28/24, Licensee was notified that R1 passed away and submitted death report to licensing on the same date. A review of R1's death certificate and hospital discharge paperwork revealed R1 passed away due to acute hypoxemic respiratory failure and aspiration pneumonia. Based on interviews and additional documentation review, it was further revealed that R1 did not require any special diet or diet restrictions. This case management requires further review. LPA will return at a later time for completion. An exit interview was conducted with Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 11, 2025

Type of visit: Required - 1 Year

On 11-19-24 at 1:40pm Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Adetayo Kokumo and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a residential care facility for the elderly (RCFE) with a current census of 4. Facility has a total of 6 bedrooms and 3 bathrooms. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 2 ambulatory residents, 2 non ambulatory residents, 0 hospice, and 0 bedridden. The facility has an approved infection control plan in place. Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 73*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 12-27-23. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and accessible to staff. During this inspection 4 resident files and 3 staffing files were reviewed for regulatory compliance. All files contained required contents. All staff noted on LIC 500 contained criminal background clearances. {Cont. on LIC 809C} LPA completed 0 resident interviews as residents declined interviews, and 2 staff interviews.. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility’s liability insurance is current and up to date per regulatory requirements. Facility does not contain any bodies of water. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. LPA requested an updated copy of LIC 308 and LIC 500. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Adetayo Kokumothe state’s words, verbatim · CDSS document, Nov 19, 2024

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 2-21-24 at 2:23pm, Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to conduct a case management visit regarding a previous resident to resident confrontation. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. LPA reviewed incident report dated 12-25-23 and conducted brief interview with Administrator. Based on review of incident report, on 12-25-23, resident1 (R1) approached R2 stating negative verbalization towards R2. Administrator redirected R1 at that time. At a later time during the night at approximately 9:00pm on 12-25-23, R1 approached R2 and continued with this verbalization towards R2. R2 responded by pushing R1 to the ground. Based on interviews and incident report, Administrator called 911. Paramedics arrived as well as local law enforcement. According to incident report and Administrator, R1 refused to go with paramedics to the hospital, and law enforcement counseled R1 on the dangers of fighting with other residents. No injuries reported by either party. Additional record reviews of R1 and R2 indicate needs and service plans have been updated to reflect behaviors and includes other interventions in place. As a result of today's case management, no citations are issued. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Feb 21, 2024

Type of visit: Case Management - Legal/Non-compliance

On 11-16-23 at 3:45pm meeting was held via Microsoft teams to review the facility's compliance with the quarterly visits. Present at this meeting were Licensing Program Analyst (LPA) Michael Bilger, Licensing program manager (LPM) Liza King, Ombudsman Kathryn Thomas, and Licensee Adetayo Kokumo. Topics discussed in this meeting included physical plant, incident reporting, medication procedures, record keeping, resident rights, care and supervision, and staffing levels. LPA and LPM discussed with Licensee the facility’s current absence without leave (AWOL) procedures. At this time, licensee states 2 staff are on duty at all times. In addition, to ensure whereabouts of residents at all times, Licensee has initiated a checklist for staff to complete noting the location of residents in care. Previous AWOL incidents were discussed. Additionally, Licensee stated a signal system has been placed on the door to alert staff of individuals exiting and entering facility. Licensee will continue to complete all initial and on-going staff training per regulations and continue to maintain appropriate updated resident records including needs and service plans, appraisals, and medication documentation. At this time the department finds the facility to have been in compliance with the requirements for the quarterly visits and the department has no concerns regarding the facility at this time. Therefore, the quarterly visits will cease. Additionally, the Department has lifted the requirement of Administrator of Record on duty at least 40 hours per week previously imposed. Licensee was made aware that Administrator must be present in facility a sufficient number of hours to meet the needs of residents in care. An exit interview was conducted with Adetayo Kokumo and a copy of this report was emailed to Adetayo with request for return with signature.the state’s words, verbatim · CDSS document, Nov 16, 2023