Valerio RCFE

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced case management visit to conduct a final inspection of the facility to confirm the closure of the facility. LPA Yee met with Michael Custodio, Administrative Designee. The reason for today's visit was provided. LPA Yee conducted a tour of the entire facility, inside and outside, and observed the following: 2 of the 3 designated live-in staff bedrooms were observed to be vacant and all personal belongings were removed. The third bedroom is still occupied by a Michael Custodio. Per information provided, he anticipates that he will be at the facility possibly until the end of the month or for a few more weeks pending notification by the Licensee. Per tour of the 6 resident bedrooms, no residents were observed and no personal belongings observed in all 6 bedrooms. The only items observed in all the rooms were the facility furniture. The living room, dining room and kitchen were still furnished with the sofas, dining table, chairs and the kitchen equipment that was in place when the facility was still operating. It is unknown at this time as to when the furniture will be removed and the home vacated. Per observation of the back house, through the side window, the back house was observed with a twin bed but no personal belongings were observed. Per the tour of the outside areas, there were no residents present. The only other person present on the premises was a family member of Michael Custodio The posted copy of the license was returned to LPA Yee during today's visit and the return of the original license was requested from Francis Martir, via email correspondence on 6/16/26. Page 2. Resident and Staff files are still currently stored in the facility. Michael Custodio was reminded that all facility files must be kept for 3 years for Department review if needed. Prior to conducting the visit today, LPA Yee was provided with the relocation sites of the 4 residents by the Licensee and the relocation information was verified via phone As of today's visit, it was confirmed that the facility has ceased operations. If the Licensee decides to re-open the home, a new license must be obtained prior to providing any care and supervision at this location. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 19, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Jessica Leano, Staff. Today's visit was conducted with Michael Custodio, Francis Martir, Administrator did not participate in today's visit due to a prior commitment. The reason for today's visit was provided. The facility is a single storey building consisting of a kitchen, dining room, living room, 9 bedrooms of which 3 bedrooms located in the front are used for live-in staff, an attached garage and detached back house was previously rented and is currently vacant. A copy of the building permit was requested for the back house. The facility is fire-cleared for 3 AMBULATORY in bedroom #3 and bedroom #4, 2 NON-AMBULATORY in bedroom #1 and bedroom #2 and 1 BEDRIDDEN resident in bedroom #5. The home has an approved hospice waiver for 6 residents. On today's visit the only domain reviewed on the CARE Inspection Tool was the Incidental Medical and Dental domain, 4 resident files and medications for Resident #2, Resident #3 and Resident #4 were reviewed. Resident #1's medication was not reviewed as the resident retains their own medications in their own room in a locked plastic box. The following was noted: Residents #1, #2 and #4 have not received an annual medical assessment Resident #3 does not have any evidence of a TB test Resident #3 and Resident #4 are prescribed PRN medications but there were no completed PRN continued on LIC809-C Page 2. Authorization Letters observed in their files Resident #1 does not have a current Appraisal/Needs and Services(ANS). The last assessment was done April 2024. per review of Resident #2, Resident #3 and Resident #4's medications, the medications in the bubble packs do not match the medications that were dispensed. Medications noted as being dispensed on the Medication Administration Record(MAR) were still observed in the bubble pack. Evening medications noted for the evening were dispensed in the morning. Medications from the bubble pack were missing from today(2/25/26 through 2/28/26 were missing. The MAR log for Resident #1, who is hospitalized from the evening of 2/24/26 and still in the hospital as of today's visit, indicate that their medications were dispensed. Medications are dispensed once a day when the label on the bubble pack indicates it is to be dispensed twice a day. The facility does not have copies of the physician's orders for the centrally stored medications. Due to the difficulty in obtaining facility files and the issues with the medications all the other domains of the CARE Inspection Tool could not be reviewed. A return visit is needed to complete the required annual inspections. Any citations not addressed on today's visit will be addressed on the return visit. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 18. Exit interview was conducted, APPEALS RIGHTS discussed and a copy was provided.the state’s words, verbatim · CDSS document, Feb 25, 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

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:15 A.M. LPA met with Administrator Designee (AD) Michael Custodio. At 9:25 A.M. AD, contacted the Administrator by phone. At 9:32 A.M. LPA contacted administrator via phone and left a voicemail. At 9:38 A.M. Administrator, Francis Martit called LPA back stating that she won’t be able to join today’s visit and authorize AD to conduct today’s visit and sign reports. At 2:20 P.M. AD had to leave the facility authorizing caregiver, Jessica Leano to sign today’s report. Entrance interview conducted. Beginning at 10:00 A.M. the LPA, along with AD toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers are fully charged and purchased on 04/08/2024. Hardwired smoke detectors and Carbon Monoxide detector were tested at 2:39 P.M. and all were functional at the time of the visit. No fire clearance concerns were observed. KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. LPA conducted a review of expiration dates on product labels. Cleaning supplies are locked and inaccessible to residents in care. Sharps are located in the medication locked cabinet. At 10:50 A.M. hot water measured 127.5 degrees Fahrenheit. AD stated that staff does not have access to a thermometer for measuring hot water. Instead, staff currently rely on using their hands to gauge the water’s heat. LPA explained that this practice does not provide an accurate reading and it is a safety risk to residents in care. Continued on LIC 809-C Continued from LIC 809-C COMMON AREAS: This includes the living room and dining room areas. LPA observed common areas to be clean and properly furnished at the time of the visit. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. BATHROOMS: There are two (2) shared bathrooms for resident use, one (1) for visitors and one (1) for staff use only. Resident's restrooms were observed to be equipped with slip resistant surfaces and contain slip resistant mats. Grab bars were observed in the bathrooms. Between 10:36 A.M and 10:45 A.M., the hot water temperature was measured in both shared resident bathroom and measured 121.2- and 127.1-degrees Fahrenheit. BEDROOMS: There are nine (9) bedrooms in total. Including three (3) staff room and six (6) private resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. LPA observed full medication containers belonging to former and current residents inside staff room #1 (S1). AD stated that some residents had changed pharmacies and confirmed that discontinued medication should have been disposed of. OUTDOOR SPACE: The perimeter of the facility is fenced. The front yard is free of obstructions. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises at the time of the visit. LPA observed a back house. AD stated that property is part of the facility and being rented to a Private Individual (PI). A Guardian system check for criminal background clearance was conducted on PI and they are fingerprinted and associated to the facility. GARAGE: Garage is attached to the main house and inaccessible to the residents in care. Garage contained extra beds, extra mobility devices, PPE and incontinence supplies, and emergency food and water. Continued on LIC 809-C Continued from LIC 809-C RECORD REVIEW: Between 11:37 A.M. and 1:05 P.M. staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Five (5) resident files were reviewed. LPA observed that Resident #1 (R1) is unwilling to provide her personal information including date of birth and refuse to sign all documentation provided by the facility. Six employee (6) files were reviewed, five (5) staff files and one (1) private individual living in the back hose. All files were observed to contain all required documents. MEDICATION REVIEW: Per AD, no resident are refusing medication. Medications review began at 1:15 P.M. Medications for four (4) residents were observed. Medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are documented on the centrally stored medications and destruction record for all five (5) residents. The following was observed: LPA observed a piece of tape on Resident #1’s (R1s) Banophen 25 MG (take 1 tablet at bedtime) cap. On it “PRN” was written by staff. AD stated that physician had discontinued this medication, however, they were unable to provide documentation from the resident’s primary physician confirming the discontinuation. Resident #2 stores their own medication in a locked box inside their private room (Room #1). The LPA reviewed R2’s physician’s report to verify that they are able to self-administer their medication. After confirming this information, the LPA did not assess medication compliance for R2 during today’s visit. Furthermore, Resident #3s’ (R3s) Olanzappine and Dicalproex Sod ER 500 mg are not being given accordingly. Olanzapine (take 1 tablet at bedtime) which was opened on 02/07/2025, showed that only six (6) pills had been administered. Additionally, Divalproex Sod ER 500 mg which was opened on 02/08/2025 (take 1 tablet at bedtime), indicated that only two (2) pills had been given. Continued on LIC 809-C Continued from LIC 809-C Lastly, Resident #4 (R4) has two (2) bubble packs of montelukast SOD 10 mg (take 1 tablet daily) with fill dates of 10/01/2024 and 10/09/2024. Upon review, the LPA observed that one pack was opened on 11/01/2024 and missing 14 pills, while the second pack remained unopened. AD was unable to confirm whether the medication is still prescribed or has been discontinued, as R4 is responsible for self-administering their prescription medication. Aditionally, AD stated that R4 frequently leaves the facility without taking their medication, however, staff does not have documentation of these occurrences. Additionally, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. Emergency disaster drills are conducted quarterly, with the last drill conducted on 11/20/2024. LPA requested the following documents, Personnel Roster LIC (500), Liability Insurance, and Resident Roster. INTERVIEWS: During today's visit, LPA interviewed one (1) staff and one (5) residents. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Exit interview conducted. A copy of today's report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 12, 2025

Allegation investigated: Staff do not keep the facility free of pest. Staff do not provide adequate food service. Staff do not ensure that sharp objects are inaccesible to residents in care.

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to the above facility. On today's visit at 2:30 p.m. LPA Mosley was greeted by staff and Administrator Designee and informed them of the visit. LPA met with Administrator Designee, Michael Custodio and explained the reason for the visit. The purpose of today’s visit is to deliver findings for the above allegations. Entrance interview. On 11/26/2024, the Department received a complaint regarding the following allegations, Staff do not keep the facility free of pest, Staff do not provide adequate food service, and Staff do not ensure that sharp objects are inaccessible to residents in care. (Report Continued on LIC 9099C...)(PAGE 1) Substantiated (Report Continued from LIC 9099...)(PAGE 2) During the initial visit on 12/04/2024, visit LPA Mosley conducted a physical plant tour at 9:45 a.m. to ensure there were no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. At 10:04 a.m., LPA and Administrator Designee inspected food items in the two (2) refrigerators and two (2) freezers in the kitchen area to check for proper labels and expiration dates. LPA also interviewed five (5) out of six (6) residents, interviewed two (2) staff including the Administrator Designee and reviewed relevant documents pertaining to the investigation. During today’s visit, LPA Mosley conducted a physical plant tour at 2:35 p.m. to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. On the allegation Staff do not keep the facility free of pest it is the concern of the Reporting Party (RP) that pests are present in the kitchen. To investigate this complaint, LPA conducted a physical plant tour on 12/04/2024 and inspected the kitchen and food area. During the inspection the LPA did not actively observe any pests in the kitchen area, however witnessed one (1) cockroach walking along the floor adjacent to the dining table area in the kitchen area. Interviews with resident’s support that the facility has active cockroach activity, however pest control services are performed on a weekly, or biweekly basis. Interview with the Administrator Designee support that the facility has an active cockroach activity and are working with a pest control to address the issue. The Administrator Designee provided LPA with the recent report issued by the pest control company on the visit 11/23/2024 and have upcoming scheduled visits. Visits are scheduled on an as need basis where the facility schedules when they would like to be serviced. Based on the information obtained and interviews there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not keep the facility free of pest is deemed substantiated at this time. On the allegation Staff do not provide adequate food service it is the concern of the Reporting Party (RP) that the facility is not properly dating food and food is expired. To investigate this complaint, LPA conducted a physical plant tour on 12/04/2024 and inspected the two (2) refrigerators and two (2) freezers in the kitchen area for proper labels and expiration dates. Inspection of the two (2) refrigerators and freezers revealed that there were a variety of items including two (2) undated, cooked bacon bits in a container, two (2) undated, cooked leftover meat in containers, and undated, cheese wrapped in foil paper. Furthermore, inspection revealed that food was not properly dated, stored or labeled posing an immediate health, safety or personal rights risk to persons in care. (Report Continued on LIC 9099C PAGE 3...) (Report Continued from LIC 9099C PAGE 2...) (PAGE 3) LPA spoke to Administrator Designee about the importance of properly labeling and storing food. Administrator threw out the food that was not properly dated at the time of the visit. Based on LPA observation there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not provide adequate food service is deemed substantiated at this time. On the allegation Staff do not ensure that sharp objects are inaccessible to residents in care it is the concern of the Reporting Party (RP) that the facility is not properly storing knives leaving them unattended and not locked. To investigate this complaint, LPA conducted a physical plant tour on 12/04/2024 and inspected the kitchen area and where the knives are located. Physical plant tour revealed that at 10:14 a.m. there was a knife unattended in the drying rack. At the time of the visit the LPA pointed out the knife to staff and it was immediately put away. LPA spoke to the Administrator Designee of the importance of keeping knives locked and inaccessible to persons in care. Based on LPA observation there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not ensure that sharp objects are inaccessible to residents in care is deemed substantiated at this time. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 21, 2025 · control 29-AS-20241126125851

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(27) · Plan of correction due date: Jan 24, 2025

General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on LPA observation, the Licensee did not comply in the section cited above in that vermin was observed in the kitchen / dining room area on 12/04/2024 visit. This posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 21, 2025

Plan of correction: Administrator agrees to have pet control conduct weekly treatments to reduce / remove pest activity and send proof to CCLD that treatments are scheduled and conducted.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(9)(27) · Plan of correction due date: Jan 31, 2025

General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. Based on LPA observation, the Licensee did not comply in the section cited above in that multiple food items in the kitchen did not have proper dates and lables. This posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 21, 2025

Plan of correction: Administrator will conduct a full refrigerator and freeze audit and dispose anything that is expired or not dated by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309 · Plan of correction due date: Jan 24, 2025

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. Based on LPA observation, the Licensee did not comply in the section cited above in that a knife was left out in the kitchen area accessible to residents in care. This posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 21, 2025

Plan of correction: Administrator will review the regulation cited and conduct a training with all staff and send proof to CCLD by POC due date.

Allegation investigated: Staff is mismanaging resident's medications. Staff do not properly store and dispose facility food. Facility roof is in disrepair. Facility floor is in disrepair.

Licensing Program Analyst (LPA), Erica Mosley conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 08/11/2023 by LPA Christine Yee. On today's visit at 9:40 a.m., LPA Mosley was greeted by staff and Administrator Designee and informed them of the visit. LPA met with Administrator Designee, Michael Custodio and explained the reason for the visit. Entrance interview. Report Continued on LIC 9099C PAGE 2... Substantiated (PAGE 2) Report Continued from LIC9099.... On todays visit LPA Mosley conducted a physical plant tour at 9:45 a.m. to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. At 10:04 a.m. LPA and Administrator Designee inspected food items in the two (2) refrigerators and two (2) freezers in the kitchen area to check for proper labels and expiration dates, at 10:44 a.m. conducted a medication audit on all six (6) residents, At 11:30 a.m. conducted an audit on facilities P&I records of the four (4) residents receiving P&I funds, from 11:49 a.m. – 1:15 p.m. Interviewed five (5) out of six (6) residents, from 1:20 p.m. – 2:00 p.m. interviewed two (2) staff including the Administrator Designee and reviewed relevant documents pertaining to the investigation. On the allegation Staff is mismanaging resident's medications it is the concern of the Reporting Party (RP) that the facility staff are mismanaging residents’ medication including Resident #1 and Resident #6. To investigate this complaint, LPA conducted a medication audit on all six (6) residents. Medication audit revealed that medications are centrally stored and locked inaccessible to residents in care in a kitchen cabinet. The audit revealed that the facility was not accurately documenting the medication start dates on the Centrally Stored and Medication Record for six (6) out of six (6) residents which poses a potential health and safety risk to residents in care. LPA and Designee discussed the importance of record keeping and the potential health and safety risk in not adding accurate start dates. Based on information obtained, and medication audit there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff is mismanaging resident's medications is deemed substantiated at this time. On the allegation Staff do not properly store and dispose facility food it is the concern of the Reporting Party (RP) that the facility staff are not properly storing and disposing facility food including not labeling food properly. To investigate this complaint, LPA inspected food items in the two (2) refrigerators and two (2) freezers in the kitchen area to check for proper labels and expiration dates. Inspection revealed that the facility had multiple items that were not properly dated including two (2) containers of left over food, two (2) containers of cooked bacon, along with cheese wrapped up in foil paper and various frozen vegetables in bags which poses a potential health and safety risk to residents in care. LPA and Administrator Designee spoke about the importance of proper documentation when putting items in the refrigerator and freezer. Based on information obtained, and food inspection there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not properly store and dispose facility food is deemed substantiated at this time. Report Continued on LIC 9099C PAGE 3... (PAGE 3) Report Continued from LIC9099.... On the allegation Facility roof is in disrepair it is the concern of the Reporting Party (RP) that the right side of the facility roof is in disrepair causing a potential hazard to residents in care. To investigate this complaint, LPA conducted a physical plant tour to ensure the safety of residents in care. Plant tour revealed that the right side of the facility’s roof awning has an open area at the end that is not covered however, the beams are intact along with the rest of the roof. The awning is cosmetic and does not hinder the safety of the residents. Interview with the Administrator Designee revealed that they did have a piece of the of the roofs awning that was used for shade but was removed for safety. It was noted that the roof itself is not in disrepair, but the awning has a piece that was removed for safety. LPA did not observe any potential hazards with the roof or the awning at the time of the visit. However, based on interview with the Administrator designee confirm that last year the roof awning was in disrepair is sufficient evidence to support the allegation occurred. Therefore, the allegation of Facility roof is in disrepair is deemed substantiated at this time. On the allegation Facility floor is in disrepair it is the concern of the Reporting Party (RP) that part of the floor covering in the hallway is in disrepair causing a potential hazard to residents in care. To investigate this complaint, LPA conducted a physical plant tour to ensure the safety of residents in care. Plant tour revealed that the hallway has an area that has visibly had wood tiles replaced. LPA did not observe any potential hazards with the floor at the time of the visit. Interviews with staff revealed that the wood tiles were coming loose however were replaced in a timely manner. Based on interview with the Administrator Designee stating last year the floor was in disrepair is sufficient evidence to support the allegation occurred. Therefore, the allegation of Facility floor is in disrepair is deemed substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided. (PAGE 2) Report Continued from LIC9099A.... During the initial visit on 08/11/2023, LPA Yee reviewed medications at 10:40am, toured the facility, inside and outside at 12:28 pm, reviewed facility records at 12:50pm, interviewed Resident #1 at 1:25pm and ensured there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. On todays visit LPA Mosley conducted a physical plant tour at 9:45 a.m. to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. At 10:04 a.m. LPA and Administrator Designee inspected food items in the two (2) refrigerators and two (2) freezers in the kitchen area to check for proper labels and expiration dates, at 10:44 a.m. conducted a medication audit on all six (6) residents, At 11:30 a.m. conducted an audit on facilities P&I records of the four (4) residents receiving P&I funds, from 11:49 a.m. – 1:15 p.m. Interviewed five (5) out of six (6) residents, from 1:20 p.m. – 2:00 p.m. interviewed two (2) staff including the Administrator Designee and reviewed relevant documents pertaining to the investigation. On the allegation Staff do not dispose expired medications it is the concern of the Reporting Party (RP) that the facility staff are not disposing residents expired medication. To investigate this complaint, LPA conducted a medication audit on all six (6) residents. Medication audit revealed that medications are centrally stored and locked inaccessible to residents in care in a kitchen cabinet. The audit revealed that all six (6) residents’ medications are unexpired. Staff interviews revealed that they are unaware of any medication being expired at the facility. Furthermore, staff deny ever having any medications that are expired at the facility. Record review revealed that all staff have proper training regarding medication. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not dispose expired medications is deemed unsubstantiated at this time. Report Continued on LIC 9099C PAGE 3... (PAGE 3) Report Continued from LIC9099 PAGE 2.... On the allegation Staff is not safeguarding resident's personal belongings it is the concern of the Reporting Party (RP) that the facility staff are not safeguarding residents’ personal belongings including Resident #2 (R2) personal food items. To investigate this complaint, LPA conducted interviews with five (5) residents including R2 and two (2) staff interviews. Resident interviews revealed that they have not had any issues with their personal belongings not being safeguarded by the facility. They feel the facility keeps their belongings safe and have not experienced any issues or things going missing. Interview with R2 revealed that they have not had any issues any of their personal items not being safeguarded by the facility. They have not had any of their personal belongings including food taken or gone missing at the facility. Staff interviews revealed that staff ensure resident’s personal belongings are safeguarded. Staff are unaware of any resident having issues with personal belongings going missing. Furthermore, staff deny having any knowledge or taking any personal belongings of a resident. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff is not safeguarding resident's personal belongings is deemed unsubstantiated at this time. On the allegation Staff is mismanaging resident's money it is the concern of the Reporting Party (RP) that the facility staff mismanaging residents’ money including R1 and not having accurate documentation. To investigate this complaint, LPA conducted an audit on the facilities P&I records of the four (4) residents receiving P&I funds, interviewed three (3) out of four (4) residents receiving P&I funds. The fourth (4) resident was unavailable at the time of the visit. Interviewed the Administrator Designee who handles the facilities P&I funds. The audit revealed that the facility has accurate documentation of when funds are received and distributed to the residents. The facility does not handle the residents’ funds past distributing. All four (4) residents handle their finances and do not have the facility managing or storing their funds past distribution. Interviews with three (3) out of four (4) residents revealed that the facility accurately distributes their P&I funds and documents every time funds are distributed. Residents have not had any issues with their funds being withheld or unaccounted purchases on their behalf. Interview with R1 revealed that they have not had any issues with their P&I or with staff purchasing items on their behalf. R1 stated they handle their money and spend it as they choose. R1 stated they have not experienced staff purchasing items on their behalf. Interviews with staff revealed that staff do not handle residents’ funds beyond distributing the funds when received. Staff deny and are unaware of purchasing items for any resident including R1 on their behalf. Staff do not purchase items for residents only assist if needed and requested by residents. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff is mismanaging resident's money is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 4, 2024 · control 29-AS-20230809161001

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(H)(6)a-e · Plan of correction due date: Dec 25, 2024

(h)The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes.... Based on records review, and medication audit the licensee did not comply with section cited above as in six (6) out of six (6) residents did not have the start dates documented on the centrally stored log.the state’s words, verbatim · CDSS document, Dec 4, 2024

Plan of correction: Licensee will request training from a professional entity to provide medication training and conduct a medication audit on all medications. Licensee will update centrally stored medication log and submit paperwork as proof to CCL/LPA indicating the training, audit and updated centrally stored was completed.Submit proof to LPA/ CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9) · Plan of correction due date: Dec 25, 2024

General Food Service Requirements. Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. Based on observation the licensee did not comply with section cited above as Food items observed in refrigerator were in containers and bags with no lable or date to esure the nutritive values of food.the state’s words, verbatim · CDSS document, Dec 4, 2024

Plan of correction: Licensee/Administrator agreed to provide in-service training to staff regarding food storage (labeling and dating). Submit written self certification that in-service was completed and ensure proper food storage procedures are followed. Licensee agreed to go through both refrigerators and ensure all items are dated and labeled by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 4, 2024

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: facility roof awning was in disrepair. The Facility floor was in disrepair.the state’s words, verbatim · CDSS document, Dec 4, 2024

Plan of correction: The facility has corrected / fixed the roof. The facility has corrected / fixed the floor.

Allegation investigated: Staff did not ensure the kitchen was free of pests.

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above at 09:32AM. LPA met with staff and Administrator Designee (AD) Michael Custodio and explained the reason for the visit. During today's visit, LPA conducted a physical plant tour at 09:35AM, conducted interviews with residents, staff, and AD around 10:15AM, and reviewed and obtained copies of pertinent documents. At approximately 10:25AM, LPA discussed allegation with AD. Report Continued on LIC 9099-C Substantiated It was alleged that staff do not ensure the kitchen was free of pests. Additional information received by a credible witness reported that the facility has been attempting to treat the infestation on their own for months with no success. During the plant tour, between 09:40AM-10:00AM, the LPA observed dead and alive roaches and flies in the kitchen pantry and refrigerator. During the visit, staff informed LPA that the infestation has been happening for a few months. The facility has extermination service every month but for outside areas only. Facility staff have been spraying Raid bug spray and setting roach traps to treat the issue on their own, however, efforts have been unsuccessful. Based on LPA observation and evidence provided by a credible witness, the allegation of “staff do not ensure kitchen was free of pests” is deemed Substantiated at this time. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 20, 2024 · control 29-AS-20240816081953

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Sep 3, 2024

General Food Service Requirements (b)The following food service requirements shall apply: (27)All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on LPA/credible witness observation and pictures obtained, the licensee did not comply with the section cited above as roaches and flies were observed in kitchen areas. This poses a potentail health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2024

Plan of correction: AD will ensure kitchen and refrigerators will be thoroughly cleaned and sanitized. AD will submit a plan for the next 3 months to ensure all regular and preventive professional treatments are taken. Administrator will submit proof to CCL by 08/30/2024.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 2 29-AS-20240816081953). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation. During the visit on 08/20/2024, LPA observed expired food items in the pantry and refrigerator and unlabeled food items stored without original packaging and labels detailing nutritive values and expiration dates between 09:40AM-10:00AM. At 10:06AM, LPA observed cleaning solutions, chemicals and hazardous items stored unlocked in visitor bathroom, which is accessible to residents in care. At 10:09AM, LPA observed surveillance cameras in common areas. Interview with AD revealed that the cameras have an audio component. At 10:20AM, LPA observed resident bedrooms to contain trash bins without tight fitted lids. During the visit, LPA observed smoke detector chirping throughout the facility. Hardwired combination smoke and carbon monoxide detector was tested at 10:33AM and was functional and operating during the time of the visit. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 20, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Aug 27, 2024

(b) The following food service requirements shall apply: (8)All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Based on LPA observation, the Licensee did not comply with the section cited above. LPA observed expired food items in pantry and refrigerator dating back to 11/17/2022. This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2024

Plan of correction: Staff discarded expired food items during time of the visit. POC is cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(9) · Plan of correction due date: Aug 27, 2024

(b) The following food service requirements shall apply: (9)Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by: Based on LPA observation, the Licensee did not comply with the section cited above. LPA observed food items stored without original packaging and labels detailing nutrtitive values and expiration dates. This poses a potental health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2024

Plan of correction: Administrator will provide general food service requirements training to staff and will submit training logs as well as a signed and dated statement of understanding of the section to CCL by 08/27/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Aug 27, 2024

Storage Space(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on LPA observation, the Licensee did not comply with the section cited above in that cleaning solutions were stored accessible in the visitor bathroom which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2024

Plan of correction: Staff stored cleaning solutions inaccessible to residents in care during the time of the visit. POC is cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(1) · Plan of correction due date: Sep 3, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on observation and interviews, the Licensee did not comply with the section cited above in that cameras in the common areas have an audio component which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2024

Plan of correction: AD will unplug the cameras until the Licensee can confirm that the cameras do not record audio and will submit a statement detailing if cameras have or do not have an audio system. AD will replace the cameras to a non-audio system if found to record audio and will submit proof to CCL .

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80088(f)(1) · Plan of correction due date: Aug 30, 2024

Solid waste shall be stored, located and disposed of in a manner that will not...provide a breeding place or food source for insects or rodents. (1)All containers, including movable bins, used for storage of solid wastes....shall have tight fitted lids... This requirement is not met as evidenced by: Based on LPA observation, the Licensee did not comply in the section cited above in that resident bedrooms were observed to contain trash bins without lids. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2024

Plan of correction: AD will either buy lids for the trash bins or replace the trash bins to be lidded. AD will submit proof to CCL by 08/30/2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Lorna Montemayor, Staff. Francis Martir, Licensee was contacted via telephone and she arrived later to conduct the visit. The reason for today's visit was provided. The facility is a single storey building consisting of a kitchen, dining room, living room, 9 bedrooms of which 3 bedrooms located in the front are used for live-in staff, an attached garage and detached back house rented by part time staff/nurse. The facility is fire-cleared for 4 AMBULATORY, 1 NON-AMBULATORY and 1 BEDRIDDEN residents. Per copy of the STD850, Bedroom #1 is the designated room for 1 bedridden or 1 non-ambulatory use only and all the other rooms are for AMBULATORY use only. On today's visit LPA Yee reviewed 6 resident and 6 staff files. Also reviewed on today's visit were the following domains: Resident Records/Incident Reports and partially reviewed the Physical Plant and Environmental Safety domain. The following were observed on today's visit: The facility did not obtain a medical assessment for Resident #5 and the ambulatory status is unknown. Resident #1, who is diagnosed per Physician's Report as non-ambulatory was observed placed in Bedroom #5 which is fire cleared for ambulatory residents only. Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Immediate CIVIL PENALTIES were assessed. Any deficiencies not cited on today's visit will be addressed on return visit. Exit interview was conducted, APPEALS RIGHTS discussed and copy was given.the state’s words, verbatim · CDSS document, Feb 26, 2024