Via Esmeralda

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:20 A.M. LPA met with licensee/administrator Esmeralda Ocampo-Nunez and explained the reason for the visit. Administrator On-call Janette Villapando arrived shortly after. At 10:40 A.M. LPA and licensee 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. Fire extinguishers are fully charged and last serviced 03/21/2026. Between 11:13 A.M. and 11:17 A.M. smoke detectors and carbon monoxide detectors units in each room, living room and kitchen were tested and functioned properly. The facility converted the garage into an ADU (accessory dwelling unit). ADU has a separate address (3521 1/2 East Elma St.). The adults living in the facility and the ADU are all fingerprint cleared and associated to this facility. BEDROOMS: There are three double-occupied resident bedrooms which were furnished appropriately with clean linen, appropriate furnishings and sufficient lighting. The facility has two other rooms used as bedrooms by staff. BATHROOMS: There are three (3) bathrooms at the facility. One in the main suite which would be used by residents sharing that room. One in the hallway used by the other residents and staff. One in a staff suite which is used only by staff/ADU occupants. Bathrooms are clean and sanitary and in operating condition with grab bars and slip-resistant mats and surfaces. Between 10:54 A.M. and 11:25 A.M. hot water temperature measured between 105-120 degrees Fahrenheit which was within the required range. Continued on LIC 809 Continued from LIC 809-C KITCHEN: The kitchen appeared clean. There was a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. Appliances appear to function properly. Knives are stored locked in an outdoor storage shed. At 11:35 A.M. hot water measured at 114.6 degrees Fahrenheit. COMMON AREAS: LPA observed common areas, including living room, dining area, and patio to be clean and properly furnished at the time of the visit. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a temperature of 71 degrees. LPA observed cameras throughout the common areas only. LPA observed a working phone available for residents use whenever needed. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture. Facility has two total gates; both were observed to be self-closing gates with clear passageway for emergency exit use. During the inspection the LPA observed 7 locked sheds located in the backyard, in them there were PPE supplies, pans, pots and kitchen supplies, sharps, yard tools, emergency food, party and decoration supplies, mechanical aids and devices such as crutches, walkers, and wheelchairs, folding chairs and tables, exercise equipment and extra storage room. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed outside cameras around the perimeter of the house and a small water fountain. Laundry room: Inside a locked room adjacent to the living area, LPA observed the washer and dryer. The laundry room leads to the ADU where cleaning supplies and disinfectants are kept stored in a locked cabinet inside. Continued on LIC 809-C Continued from LIC 809-C RECORD REVIEW: Between 11:50 A.M. and 1:00 P.M., staff and resident records were reviewed. Facility staff and residents’ files are stored in a locked file cabinet. Four (4) resident and three (3) personnel 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, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were observed to be complete. MEDICATION REVIEW: Between 1:12 P.M. and 2:40 P.M. Medications for four (4) residents were observed. During the record reviewed the LPA observed that four (4) out of four (4) residents did not have a current medication list on file. Additionally, physician orders were not maintained in the resident’s file as required. While the LPA was auditing the medication, the Administrator contacted Resident #1’s (R1’s) physician’s office and requested a current medication list. Upon receipt, it was noted that two (2) medications (Ferrous Sulfate and Furosemide) listed by the physician were not documented on the Centrally Stored Medication and Destruction Record, nor were corresponding prescriptions available. According to the Administrator, these medications had been discontinued; however, documentation of the discontinuation order from the physician was not available for review. 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 03/06/2026. 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.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 9, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:45 A.M. LPA met with licensee/administrator Esmeralda Ocampo-Nunez and explained the reason for the visit. At 11:00 A.M. LPA and licensee 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. Fire extinguishers are fully charged and last serviced 03/10/2025. Between 12:20 P.M. and 12:25 P.M. smoke detectors and carbon monoxide detectors units in each room, living room and kitchen were tested and functioned properly. The facility converted the garage into an ADU (accessory dwelling unit). ADU has a separate address (3521 1/2 East Elma St.). The adults living in the facility and the ADU are all fingerprint cleared and associated to this facility. BEDROOMS: There are three double occupancy resident bedrooms which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The facility has two other rooms used as bedrooms by staff. BATHROOMS: There are three bathrooms at the facility. One in the main suite which would be used by residents sharing that room. One in the hallway used by the other residents and staff. One in a staff suite which is used only by staff/ADU occupants. Bathrooms are clean and sanitary and in operating condition with grab bars and slip-resistant mats and surfaces. Between 11:07 A.M. and 11:23 A.M. hot water temperature measured between 105* - 120 *F which was within the required range. Continued on LIC 809 Continued from LIC 809- KITCHEN: The kitchen was clean. There was a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. Appliances appear to function properly. Knives are stored locked in an outdoor storage shed. At 10:35 A.M. hot water measured at 114.6 * F. COMMON AREAS: LPA observed common areas, including living room, dining area, and patio to be clean and properly furnished at the time of the visit. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 71 degrees. LPA observed cameras throughout the common areas only. LPA observed a working phone available for residents use whenever needed. Facility has a small office area next to the laundry room. Facility staff and resident’s file are stored in a locked file cabinet. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture. Facility has two total gates; both were observed to be self-closing gates with one exit to have a clear passageway for emergency exit use and one to have a planter blocking a side gate used as an emergency exit. Administrator stated that facility staff uses the planter to prevent Resident #1 (R1), a wheelchair user, from leaving the facility. The LPA reminded the licensee that per RCFE regulations and fire clearance concerns the emergency exits shall not be blocked and staff shall supervise residents as need it. There were no bodies of water on the premises During the inspection the LPA observed 7 locked sheds located in the backyard, in them there was PPE supplies, pans, pots and kitchen supplies, sharps, yard tools, emergency food, party and decoration supplies, mechanical aids and devices such as crutches, walkers, and wheelchairs, folding chairs and tables, exercise equipment and extra storage room. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed outside cameras around the perimeter of the house. Laundry room: Inside a locked room adjacent to the living area, LPA observed the washer and dryer. The laundry room leads to the ADU where cleaning supplies and disinfectants are kept stored in a locked cabinet inside. Continued on LIC 809-C Continued from LIC 809-C RECORD REVIEW: Between 1:34 P.M. and 2:30 P.M., staff and resident records were reviewed. The following was observed; Resident’s #1 (R1’s) needs and service plan and personal rights form (LIC 613) did not contain responsible party’s signatures. Resident’s 2 (R2’s) admission agreement was incomplete and did not have either the licensee or the responsible party’s signatures, Resident’s #3 (R3’s) was missing personal rights form (LIC 613). At 2:30 P.M. LPA reviewed staff records the following was observed: Staff #1 (S1) had an expired CPR certificate and Staff #2 (S2) was missing the health screening form. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility's infection control practices and emergency disaster plan. Facility had an updated emergency disaster plan; however, licensee was not able to provide an infection control plan. Technical violation issued. Facility has an ample supply of emergency food, however, during today’s visit, facility did not have an emergency water supply. Emergency disaster drills are conducted quarterly; however, licensee was unable to provide documentation. LPA explained licensee that based on Health and Safety regulations, documentation of the drills shall by keep in facility’s records. MEDICATION REVIEW: Between 3:12 P.M. and 3:40 P.M. Medications for three (3) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. 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.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 9:37 a.m. LPA met with licensee/administrator Esmeralda Ocampo-Nunez and explained the reason for the visit. At 9:39 a.m. LPA and licensee 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: BEDROOMS: There are three double occupancy resident bedrooms which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The facility has two other rooms used as bedrooms by staff. The facility has a permitted accessory dwelling unit (ADU) with a separate address (3521 1/2 East Elma St.). The adults living in the facility and the ADU are all fingerprint cleared and associated to this facility. BATHROOMS: There are three bathrooms at the facility. One in the main suite which would be used by residents sharing that room. One in the hallway used by the other residents and staff. One in a staff suite which is used only by staff/ADU occupants. Bathrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. KITCHEN: The kitchen was clean. There was a sufficient supply of perishable and non-perishable food and water. Appliances appear to function properly. Knives are stored locked in a storage cabinet outside next to the outdoor kitchen. Continued on LIC 809-C Continued from LIC 809 COMMON AREAS: LPA observed common areas, including living room, dining area, and patio to be clean and properly furnished at the time of the visit. Fire extinguishers appeared fully charged and were last serviced on 3/4/2024. Hot water temperature measured 109*F. Smoke detectors and carbon monoxide detectors were tested and functioned properly. Cleaning supplies are stored in the locked garage. INTERVIEWS: Beginning at 10:00 a.m. LPA interviewed two staff and there were no concerns. LPA was not able to interview the one resident as the resident was sleeping. RECORDS: LPA reviewed medications and documents for the only resident. LPA reviewed employee records and training records for four staff. There were no concerns. The emergency evacuation form was completed and updated annually. Evacuation drills are conducted monthly. No deficiencies cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 29, 2024