Valley Haven III

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Licensees Josephine and Jesus Arcilla, and ADM Minerva Velasco. LPA stated the purpose of the visit. The facility has two buildings (Blossom Home and Wisteria Place) and a licensed capacity of 48. LPA toured the interior and exterior of both Blossom Home and Wisteria Place with ADM and Licensee to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. LPA observed all exit and passageways were free and clear of obstruction. LPA toured the kitchen areas in Blossom Home and Wisteria Place, and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed refrigerator temperature at 37 F and Freezer at 0 F LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care in Blossom Home and Wisteria Place. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by Licensee Jesus Arcilla. Fire extinguishers were last serviced on 9/16/2025. The facility fire system was inspected by a third party vendor on 6/17/2025 and passed inspection. The facility emergency drill log was reviewed. The facility's last drill was conducted on 6/11/2026. Page 1 of 2 LPA toured 10 random resident bedrooms. All 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 7 resident bathrooms. All 7 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature with a range of 95.2 F to 115.4 F. Licensee adjusted the water heater during the visit, however water temperatures were still not within range. A Technical Violation was issued, see LIC9102 for more information. LPA observed the facility to be clean, safe, sanitary and in good repair. LPA reviewed 3 resident records. LPA reviewed 3 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA reviewed 3 staff records. No deficiencies were cited during today's visit per California Code of Regulations Title 22. A Technical Violation was issued, see LIC9102. An exit interview was conducted with Licensee Josephine and Jesus Arcilla, and Administrator (ADM) Minerva Velasco and a signed copy of this report was provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Aug 26, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Licensee Josephine and Jesus Arcilla, and ADM Minerva Velasco. LPA stated the purpose of the visit. The facility has two buildings (Blossom Home and Wisteria Place) and a licensed capacity of 48. LPA toured the interior and exterior of both Blossom Home and Wisteria Place with ADM and Licensee to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. LPA observed a facility pantry near the facility storage garage. LPA observed all exit and passageways were free and clear of obstruction. During exterior inspection of Wisteria Place, LPA observed wood rot on the roof corner located outside of the living room exit door. Licensee states the facility will repair the wood rot by 10/31/2025 and submit a letter to include the repair timeline to the Department by 8/29/2025. LPA toured the 2 kitchen areas in Blossom Home and Wisteria Place and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed refrigerator and freezer temperatures in 5 refrigerators maintained at Title 22 87555 General Food Service Requirements. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. Page 1 of 2 The facility was equipped with smoke and carbon monoxide detectors, which were last inspected by a third party vendor on 6/17/2025. Fire extinguishers were last serviced on 9/17/2024. The facility emergency drill log was reviewed. The facility's last drill was on 6/26/2025. Posters observed in Blossom Home and Wisteria Home to include the licensing complaint poster, ombudsman poster, and facility license. LPA toured 25 resident bedrooms. All 25 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 7 resident bathrooms. All 7 bathrooms had hand soap, paper towels, functioning lights, and trash bins. 1 out of 7 resident bathroom water temperatures were measured with a range of 105 F to 120 F. 1 out of 7 resident bathrooms water temperatures was below 105 F. A Technical Assistance was issued, see LIC 9102 for more information. LPA reviewed 5 resident records. LPA reviewed 5 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPAs reviewed 5 staff records. No deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Licensee Josephine Arcilla and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a case management incident visit. LPA met with Licensees Jesus and Josephine Arcilla. LPA stated the purpose of the visit. On 8/12/2025 the Department received an Death Report for Resident R1, which stated R1 had passed away on 8/10/2025 at the facility. LPA interviewed 3 staff (S1 to S3) and requested pertinent documentation to include but not limited to physicians report, Medication Administration Record (MAR), and service plan. LPA requested a copy of resident R1's death certificate once it becomes available. LPA determined this case management needs further investigation. No deficiencies cited during today's visit. An exit interview was conducted with Licensee Josephine Arcilla and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 13, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management visit. LPA met with Administrator (ADM) Josephine Arcilla. LPA stated the purpose of the visit. ADM stated the facility has 28 residents and 10 staff. On 2/7/2025 the Department received a Death Report for Resident R1. The Death Report states Resident R1 died on 2/1/25. The Death Report states R1 had a fall on 1/27/2025 and and was treated by a Hospice nurse at the facility. LPA interviewed ADM, and reviewed R1's file to include physician's report, progress notes, and service plan. LPA obtained the following documentation during the visit: R1's service plan, progress notes and functional capabilities assessment. ADM stated the facility would request R1's death certificate and submit to the Department. LPA determined that this incident requires further investigation. No citations were issued during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Administrator Josephine Arcilla and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 23, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management visit. LPA met with Administrator (ADM) Josephine Arcilla. LPA stated the purpose of the visit. ADM stated the facility has 28 residents and 10 staff. On 4/16/2025 the Department received an SOC341 stating R1 had gone for a walk with Witness W1 on 4/14/2025 at approximately 4:45PM. The SOC341 states that R1 was found approximately 2 miles from the facility by an off-duty staff S1 on 4/14/2025 at approximately 6:20PM. The facility states W1 was recently diagnosed with neurocognitive disorder. LPA interviewed ADM. LPA reviewed R1's file to include physician's report, needs and service plan. LPA obtained the following documentation during the visit: R1's service plan, physician's report. ADM stated a Plan of Action will be submitted to the Department by 4/25/2025 to ensure the health and safety of R1. LPA determined that this incident requires further investigation. No citations were issued during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Administrator Josephine Arcilla and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 23, 2025

Allegation investigated: Staff are sedating resident. Staff do not ensure resident is being fed resulting in weight lost. Staff are not providing resident nutritious foods.

On 4/10/2025 the Department received a complaint alleging that staff are sedating resident 1 (referred to as R1). On 4/14/2025 LPAs interviewed Witness 1 and Witness 2 (referred to as W1 and W2). W1 and W2 states R1 is being sedated because R1 attempts to get out of his/her wheelchair. Both W1 and W2 do not know what medications are used to sedate R1, and do not know what medications are prescribed to R1. W1 and W2 stated they do not know R1’s medical diagnosis. On 4/15/2025 LPAs Marcella Tarin and Manuel Monter conducted the initial complaint investigation. LPAs interviewed 5 staff (referred to as S1-S5), and 5 residents (referred to as R1-R5) regarding the above allegation. Page 1 of 4 Unfounded 5 out of 5 staff state he/she has not observed R1 being sedated by staff. All staff interviewed stated R1 does attempt to stand up from his/her wheelchair. All staff interviewed stated staff will redirect R1 with other choices such as walks, snacks, using the restroom or sitting in a different chair. All staff interviewed stated if R1 continues to be restless and agitated, a PRN medication can be administered. LPAs interviewed ADM. ADM stated the facility is not sedating R1. ADM stated R1 is given PRN medication for agitation/restlessness when needed. ADM stated facility staff will attempt to redirect R1 before a PRN medication is possibly administered. On 4/15/2025 LPAs interviewed W3. W3 stated they have not observed facility staff intentionally sedating R1. W3 stated he/she has no issues with medications and his/her family members health and safety at the facility. On 4/15/2025 LPAs interviewed hospice staff H1 and H2. H1 and H2 stated they have not observed facility staff intentionally sedating R1. H1 and H2 stated there has not been any discrepancies regarding R1’s medications being over-administered. H1 and H2 stated R1 does attempt to get up from his/her wheelchair but have observed staff redirect R1. H1 and H2 stated if R1 continued to be agitated, then staff would administer PRN medication. LPAs reviewed R1’s medications. LPAs cross-referenced the Centrally Stored Medication and Destruction Record (CSMDR) with the Medication Administration Record (MAR), and the medication containers/bottles. No discrepancies were noted. The Department has completed the investigation of the above allegation. Based on interviews conducted and records review, the department has found that the above allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or are without a reasonable basis. Page 2 of 4 Staff do not ensure resident is being fed resulting in weight lost/Staff are not providing resident nutritious foods. On 4/10/2025 the Department received a complaint alleging staff are not ensuring R1 is being fed resulting in weight loss, and staff are not providing R1 nutritious meals. On 4/14/2025 LPAs interviewed W1 and W2. W1 and W2 state staff are not ensuring that R1 is being fed, resulting in weight loss. W1 and W2 were unable to provide additional details regarding R1s weight loss. W1 and W2 stated the staff are feeding R1 cakes, cookies and sugary drinks (lemonade). W1 and W2 stated they do not know if R1 has any dietary restrictions and do not have knowledge of R1’s medical diagnosis. W2 stated he/she is not a dietician and cannot say for sure if the meals meet R1’s needs. On 4/15/2025 LPAs interviewed R1-R5. 4 out of 5 residents interviewed stated staff help with eating. R2 stated he/she does not need assistance with eating. All residents interviewed stated the facility provides meals that are balanced and meet their needs. R1 stated he/she does receive assistance when eating. R1 states the meals are meeting his/her needs. LPAs interviewed 5 staff S1-S5 and ADM. All staff and ADM stated they assist residents with eating, if needed. All staff and ADM stated if a resident is sitting with a full plate of food or is struggling to eat, staff will assist resident with eating their food. All staff and ADM stated that the facility is providing well-balanced and nutritious meals to residents that include proteins, carbohydrates and fresh vegetables or salads. LPAs interviewed W3. W3 stated he/she has no issues/concerns with R1s weight, or the food provided by the facility. Page 3 of 4. LPAs interviewed hospice staff H1 and H2. Both H1 and H2 stated R1 has not had a significant change in weight and R1’s weight has been consistent in the past 6 months. H1 and H2 stated they have observed facility staff assisting R1 with eating. H1 and H2 stated the facility is providing meals that are meeting R1’s needs. H1 and H2 stated based on R1’s physicians report, R1 does not have any dietary restrictions. LPAs toured facility kitchen and observed staff preparing lunch. Staff were cooking mixed vegetables, chicken with marinara sauce, scalloped potatoes and bread pudding with raisins. LPAs observed R1 eating during lunch. LPAs observed R1 was eating his/her lunch independently at a slow pace. LPAs reviewed R1 weight record from 11/2024 to 4/2025, R1s weight ranged between 186lbs to 192lbs. Based on review of R1’s physicians report 07/12/2024, R1 does not have any dietary restrictions. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited during today's visit. An exit interview was conducted with Administrator Josephine Arcilla and signed copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 15, 2025 · control 26-AS-20250410092026

Allegation investigated: Staff sexually abused resident while in care

Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin conducted an unannounced visit to deliver the finding of the complaint investigation. LPAs met with Adminstrator, Josephine Arcilla. On 05/08/2024, the Department received the complaint alleging staff (S1) sexually abused resident (R1) while in care. On 05/09/2024, the initial complaint investigation was conducted. Based on interview with R1, R1 stated S1 came into his/her room and when asked about details of what happened, R1 replied “we had intercourse, I think”. R1 explained that R1 thinks R1 and S1 had intercourse, denied the observation, denied any feeling, and think it’s because of R1’s medical condition. R1 believed the only reason he/she thought that he/she had some type of interaction with S1 is that R1 “thinks” S1 “felt something”. However, R1 does not remember how he/she knew that S1 “felt something”. PAGE 1 OF 2. Unsubstantiated The week of 04/29/2024 to 05/05/2024, S1 worked on Monday, 04/29/2024 on the morning shift and Friday, 05/03/2024, on the afternoon shift. Administrative staff ruled out the incident occurring between S1 and R1 on Monday, 04/29/2024 because R1 was not in his/her room during the morning shift. For the afternoon shift on Friday, 05/03/2024, S1 was working with 2 caregivers (S2) and (S3). S2 and S3 did not mention anything unusual while working with S1. Residents interviewed also did not mention any issues with S1. Based on interview with S1, S1 denied the allegations. It was stated that on 05/03/2024, the only incident he/she remembered with R1 was attempting to clean R1 after R1 defecated. S1 stated that he/she had to lift R1 in other to clean R1, and then S2 came to finishing wiping and changing R1. S2 corroborated S1’s statement and confirmed to help S1 clean up R1. According to S2, there was nothing inappropriate that occurred. S2 indicated that R1 did not have any other interactions with R1 the remainder of the shift. The Sheriff’s spoke with R1’s relative who stated R1 indicated that no sexual intercourse had occurred. R1’s relative explained that the staff might have climbed on top of R1 and performed outercourse, but there was no penetration. The Department has investigation the above allegation. Based on interviews and record review the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Josephine Arcilla and a copy of the report was provided. PAGE 2 OF 2.the state’s words, verbatim · CDSS document, Sep 10, 2024 · control 26-AS-20240508140805

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Administrator/Licensee, Josephine Arcilla. During visit, LPA toured the facility with the Licensee to include Blossom Home, Wisteria Place, garage, storage tent, and exterior. All fire exits routes are free and clear of obstruction. Facility staff present are fingerprint cleared and associated to the facility. Chemicals, sharp objects, and medications observed secured. Cameras observed in the common areas. Fire extinguishers last serviced on 09/20/2023. LPA entered into 10 resident bedrooms in Blossom Home. Bedrooms equipped with adequate lighting and proper furniture. Bedroom #9's sliding door was difficult to open. During visit, Licensee fixed the sliding door. Bedroom #4's screen door needed repair. During visit, Licensee fixed the screen door. Bathroom hot water temperature maintained between 106 and 122 degrees F. Bathroom showers equipped with non-slid mats and grab bars. Carbon monoxide detector present. Activities calendar and menu posted in a visible area. Residents observed participating in activities during visit. LPA entered into 7 bedrooms in Wisteria Place. Bedrooms equipped with adequate lighting and proper furniture. Bedroom #7 observed with 2 half rails making a full bed rail which was not in use. Licensee states the resident only has an order for half rails. During visit, staff removed 1 of the half rails from the bed. Licensee was advised. Bathroom hot water temperature in bedroom #9 maintained at 112 degrees F. Bathroom shower equipped with non-slid mats and grab bars. Carbon monoxide detector present. Activities calendar and menu posted in a visible area. Residents observed participating in activities during visit. SEE LIC809-C. Facility is equipped with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperatures maintained between 30 - 40 degrees F. Freezer temperatures maintained below 0 degrees F. 5 staff files were reviewed and observed maintained. 5 out of 5 staff are fingerprint cleared and CPR/1st Aid certified. 5 staff are provided annual training. 5 resident files were reviewed and observed maintained. LPA reviewed residents orders for oxygen, half bed rails, and a CPAP machine. 5 resident's centrally stored medications and records were reviewed with staff. No issues noted during review. Posters observed in Blossom Home and Wisteria Home to include the licensing complaint poster, ombudsman poster, and facility license. Facility has an infection control plan. Hand sanitizer and gloves observed throughout the facility. Facility has an updated emergency disaster plan. Emergency drills are being conducted quarterly. LPA observed 2 small generators which may be used for resident's who require oxygen upon a power outage. Licensee states they have 3 large generators in case of a power outage. Documents obtained to update the facility file: Emergency Disaster plan. Licensee will email the facility's updated LIC500. Licensee/Administrator names observed on the pending Administrator Certificate list. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator/Licensee Josephine Arcilla and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 29, 2024