TLC Elderly Residence 1

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by caregiver. There are five residents at the facility and there are no residents receiving hospice services currently. LPA began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in storage in two spare refrigerators located in the garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the kitchen. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the bathroom. LPA measured the hot water temperature which measured 111.10 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathroom is equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked in the storage closet. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of Continued on LIC809-C obstructions. LPA observed there are shaded seating areas for residents’ enjoyment. LPA observed a swimming pool adjacent to the house with a fence around it. LPA observed the pool gate has two self-latching entry door which opens away from the pool. Both fence entries have a key lock at the gate door for inaccessibility. LPA measured the pool fence which measured 5ft from base of the floor to the top of the fence and it was observed to enclose the entire pool area. LPA observed a fire extinguisher with service date April 15, 2025, in the kitchen. Fire drills are conducted every three months. The facility is two stories and LPA observed no resident in care to reside on the second floor. Residents in care do not have access to the second story. LPA began review of records. LPA reviewed two resident records. All the required documentation was present and current in the residents’ files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 11, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of conducting a case management visit for an increase of capacity. LPA met with Masroor Batla, Administrator and LPA explained the nature of the visit. The facility was originally licensed for five non ambulatory residents of which five may be bedridden. Licensee requested a increase of capacity for six non ambulatory residents of which six may be bedridden. Licensee constructed a 6th bedroom with a private bathroom utilizing a portion of the attached garage. LPA toured the entire premises. The facility is a two story home which has 6 bedrooms, 3 bathrooms on the first floor and with the 2nd floor being occupied by licensee only. The 2nd floor is inaccessible to residents in care. There are no residents residing on the second floor of the facility. LPA verified resident in care do not have access to the second floor. Residents were observed to be having breakfast during this visit. Beds were made with appropriate linens. Furniture appeared safe and adequate. LPA inspected the 6th residents’ bedroom which has sufficient lighting to ensure the safety and comfort. Bedroom was observed to have all required components. Storage space is provided for resident in the bedroom. The bathroom is equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The fire clearance for the increase in capacity was granted on September 2, 2025. The facility appears meets the requirements for a increase of capacity from 5 non ambulatory residents of which five may be bedridden to 6 non ambulatory residents of which 6 may be bedridden residents of age 60 yrs and older, hospice waiver for 4 as of todays date. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. This report was reviewed with Administrator and a copy of this LIC809 was provided to the facility.the state’s words, verbatim · CDSS document, Sep 23, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by caregiver. LPA met with Masroor Batla, Administrator and LPA explained the nature of the visit. There are five residents at the facility and there are no residents receiving hospice services currently. LPA began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in storage in two spare refrigerators located in the garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the kitchen. LPA reviewed medication and observed medication was labeled and stored i naccessible to residents in care. LPA inspected the bathroom. LPA measured the hot water temperature which measured 110.1 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathroom is equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked in the storage closet. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there are shaded seating areas for residents’ enjoyment. LPA observed a swimming pool adjacent to the house with a fence around it. LPA observed the pool gate has two self-latching entry door which opens away from the pool. Both fence entries have a key lock at the gate door Continued on LIC809-C for inaccessibility. LPA measured the pool fence which measured 5ft from base of the floor to the top of the fence and it was observed to enclose the entire pool area. LPA observed a fire extinguisher with service date December 04, 2024, in the kitchen. Fire drills are conducted every three months. The facility is two stories and LPA observed no resident in care to reside on the second floor. Residents in care do not have access to the second story. LPA began review of records. LPA reviewed three resident records. All the required documentation was present and current in the residents’ files reviewed. LPA reviewed three employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 12, 2024

Allegation investigated: Licensee is refusing to provide copy of admission agreement to responsible person. Licensee is refusing to provide copy of billing statement to responsible person.

Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced subsequent visit for the purpose of delivering the findings into the above allegations. LPA was greeted and granted entry and explained the reason of the visit to Administrator (Admin) Masroor Batla. On September 17, 2024, LPAs Jessica Cho and Edward Kim initiated the complaint investigation and interviewed five residents and three staff. Pertinent records of Resident #1 (R1) were obtained during the visit which includes the Face Sheet, Identification and Emergency Information, Physician's Report, Admission Agreement, Notice of Termination, billing invoices paid on October 2022, and all correspondence receipts with R1's responsible person as well as the current residents' Roster, Personnel Report, Face Sheets, and Physician's Reports. Additional interviews and records of former residents were obtained on September 18, 2024. The investigation revealed the following: It is alleged that the licensee is refusing to provide copy of admission agreement and the billing statement to the responsible person. Substantiated Based on the review of records, R1 resided at the facility for 26 days from October 6, 2022 to October 31, 2022. On Tuesday, September 7, 2024, at 12:28pm, R1's Responsible Person (RP) requested a copy of the admission agreement and billing invoice for the month of October 2022. A follow-up text was sent by the RP on Tuesday, September 10, 2024 at 8:38am indicating that the copy of R1's admission agreement and billing statement was not provided. Administrator Batla responded at 11:00am that the admission records were provided to the RP to take home to sign (which had allegedly taken two weeks to complete and return). Admin requested time to search for the records as they were in storage. Per review of the email receipts, the admission agreement and the billing invoice was submitted to the RP via email on Sunday, September 15, 2024 at 2:51pm. Per Title 22 Regulation, Additional Personal Rights of Residents in Privately Operated Facilities, 87468.2, records are provided promptly within two business days, however it took the Administrator nine days to produce the records requested. Therefore, based on LPA's interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations, Licensee is refusing to provide copy of the admission agreement to responsible person and Licensee is refusing to provide copy of billing statement to responsible person, are deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. A deficiency is being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Masroor Batla, and a copy of this report and the appeal rights were provided at the end of the visit. The two remaining resident interviews were not obtained due to a language barrier and refusal. Three out of three individuals also interviewed also denied the allegation. Therefore, based on the interviews which were conducted, 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 following allegation, Caregivers hit residents, is deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Masroor Batla, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Sep 20, 2024 · control 22-AS-20240910152630

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Sep 27, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, ...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records… and…shall be provided within two (2) business days…This requirement was not met as evidenced by: Based on interviews and review of records, the administrator provided the records nine days later which poses a potential Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 20, 2024

Plan of correction: Records were provided to the family on September 15, 2024. Adminstrator stated that he will submit an Acknowledgement of Understanding of the said regulation to LPA via email by POC due date.