Victor Jem Happy Homes

Type of visit: Required - 1 Year

At 9:30 AM Licensing Program Analyst (LPA) Nadia Shahbazian and Licensing Program Manager (LPM) Mary Flores, conducted an unannounced annual inspection at the facility mentioned above. LPA/LPM met with the Administrator Nathaniel Hemedes and explained the reason for the visit. The facility's total capacity is approved for six (6) non-ambulatory residents. Facility has hospice waiver for two (2) residents. The current census is five (5) residents. At 9:45 AM, Physical tour was conducted with the Staff Janenet Maca and LPA/LPM observed the following: Kitchen: The kitchen appliances consisted of a stove/oven, refrigerator, dishwasher and microwave oven. All appliances were observed to be functional. LPA/LPM observed enough food supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a kitchen drawer. LPA/LPM observed medications belonging to the administrator in the refrigerator. LPA/LPM observed a table in the kitchen with additional food supplies stored on top and underneath the kitchen table. Common Areas: The living room and dining area is a large space, with the office space in the corner of the living room. The office area included the telephone and internet for resident use. The living room was furnished with sofas, chairs and a table and the dining room has a round table and chairs, appropriate for number of residents. The living room has a television set and a fireplace, secured with a screen. There is a freezer in the dining room, with additional food supplies. Common areas seemed cluttered and LPA/LPM observed several insects and small roaches on dining room table. Continued on 809-C Laundry Room: The laundry is located between the kitchen and bathroom in room# 1. There is a joining door between the bathroom and the laundry room. LPA/LPM observed unlocked laundry detergents and chemicals in the laundry cabinets and on top on the washer and were accessible to residents. There is an exit door, with several small stairs, leading to the backyard.. Bedrooms/Bathrooms: There are three shared bedrooms for resident use. Bedroom #1 has it's own bathroom, with a shared door to the laundry room. There is a another bathroom in between bedrooms #2 and #3. Both Bathrooms have grab bars and a non-skid floors. Hot water temperature was taken from both bathroom and was measured between 117.1 and 117.2 degrees Fahrenheit. Surrounding Area/Back Yard: LPA/LPM toured the side paths and back yard. The emergency exit gates were unlocked, and paths were free from debris. The outdoor furniture consisted on table, chairs and an umbrella. There is a locked shed for storage. The garage is currently used as a Accessory Dwelling Unit (ADU) or bedroom for the administrator and staff. A citation will be provided for licensee to obtain a permit for the ADU or convert the room, back to garage or storage. There are several exit doors in the facility but auditory devices on two doors were not working and facility currently has three dementia residents. Medications: The medications are stored in a locked kitchen cabinet. First aid kit and manual was also kep in the medication cabinet. LPA/LPM reviewed the medication record for all five (5) residents to ensure the accuracy of the medication administration. Medications belonging to the staff were also observed in the kitchen refrigerator. Resident Records: LPA reviewed records for all five (5) residents were reviewed to ensure all required documents were contained. Three (3) out of five (5) residents physician reports noted residents were bedridden. During the visit LPA observed R1, R2 and R3 ambulating or seating in a chair. Due to time constraints, LPA/LPM were unable to complete today's visit. LPA will return on a later date to address staff records, training records, facility files. Deficiencies were observed during today’s visit. An exit interview was held. A copy of this report, and appeal rights were provided to the administrator.the state’s words, verbatim · CDSS document, Jan 29, 2026

Allegation investigated: Staff do not dispense medication as prescribed by physician Staff do not ensure centrally stored medication is locked Staff do not refill resident’s medication prescriptions in a timely manner Staff do not ensure that facility is free of pests Staff do not ensure that residents are provided with activities

During today’s Noncompliance Conference Meeting (NCC), held at the Woodland Hills Regional Office, LPA Panushkina delivered final findings for all allegations mentioned above. LPA met with the Administrator and explained the reason. On 01/29/2025, LPAs Panushkina and Shahbazian initiated the complaint. LPAs conducted tour of the facility and requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Centrally Stored Medication and Destruction Record (SCMDR), relevant to the investigation. Between 10:20am – 1:00pm, LPAs conducted an interview with the Administrator, two (2) staff and five (5) out of five (5) residents who were able to communicate. Continue on LIC9099-C Substantiated Allegation: Staff do not dispense medication as prescribed by physician It was alleged that R1's eyedrops were not dispensed/given as prescribed. To investigate this allegation, LPAs conducted an interview with the Administrator and requested R1's CSMDR. Review of R1's CSMDR records revealed that the last medication registered on the form (LIC622) was Levothyroxine (date filled on 10/18/24). LPAs also observed that the medication bottle had quantity of 30 pills and the bottle starting date was registered as of 10/25/25. Based on the physician's prescription, the bottle was going to be refilled in November 2024. Moreover, LPAs did not observe any eye drops registered on CSMDR. In addition, LPAs observed two boxes of the same eye drops present in R1's room. During the Interview with the Administrator and S1, LPAs asked to explain how the staff follows the physician's order, when two (2) bottles of the same eyedrops are present, one (1) of which was filled on 09/10/24 and the second eyedrop was filled on 01/10/25. Administrator and S1 were unable to provide any explanation and confirmed that the facility made an error by not always following the physician’s order. Therefore, based on interviews, LPAs record reviews and observation, this allegation is Substantiated. Allegation: Staff do not ensure centrally stored medication is locked Upon arrival, LPAs observed a plastic 32qt clear view storage bin placed on a kitchen table. LPAs also observed the bin had R3's sixteen (16) prescribed medications accessible to residents in care. LPAs conducted an interview with the Administrator and were informed that one (1) of the medication cabinet locks is broken and must be replaced, therefore, the staff kept the storage bin on a kitchen table. At 10:15am, LPAs checked the medication cabinet in the kitchen and confirmed that the lock was broken, and all medications were accessible to residents in care. Moreover, LPAs observed five (5) bottles of vitamins on a kitchen table. Interview with the Administrator revealed that the vitamins belong to the staff/Administrator and LPAs were informed that all vitamins will be locked immediately. Lastly, at 10:29am, LPAs observed Ibuprofen bottle with nine (9) tablets, also prescribed to the Administrator, on the top of a drawer, in the living/dining room area accessible to residents in care. Therefore, based on interviews, LPAs observation and inspection, this allegation is Substantiated. Continue on LIC9099-C Allegation: Staff do not refill resident’s medication prescriptions in a timely manner It was alleged that R1’s eyedrops are not being refilled in a timely manner. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that the staff contacts R1’s responsible party to refill the eyedrops. Administrator also confirmed that the facility notifies the responsible party regarding the refill, but the medications are not always delivered timely. Moreover, LPAs conducted review of R1's CSMDR records and observed that the last medication registered on the form (LIC622) was Levothyroxine (date filled on 10/18/24). LPAs did not observe any eyedrops registered on CSMDR. In addition, LPAs observed R1’s two boxes of the same eye drops present in R1's room. First eyedrop was filled on 09/10/24 and the second eyedrop was filled on 01/10/25. Each bottle had a quantity of 2.5ML with the instruction to have 1 drop in each eye twice a day. 2.5ML contains approximately fifty (50) drops, and following the physician’s order, each bottle can last only 12.5 days. The last bottle was refilled on 01/10/25 and LPAs observed it to be full. During the interview with the Administrator and S1, LPAs asked to explain the reason why the bottle was still full, when on 01/23/24 the refill was due. Both parties were unable to provide any explanation. Therefore, based on interviews, LPAs record reviews and observation, this allegation is Substantiated. Allegation: Staff do not ensure that facility is free of pests To investigate this allegation, LPAs conducted interviews with five (5) residents and four (4) out of five (5) residents confirmed seeing cockroaches at the facility bathrooms and common areas. Moreover, during the physical walk tour, at approximately 10:20am, LPAs observed a cockroach on the wall, in the living room. LPAs asked the staff to exterminate. In addition, at 10:48am, LPAs observed another cockroach in the kitchen wall and in the dining area. Interview with the Administrator confirmed that the facility has pests and LPAs were informed that pest control will be hired. Therefore, based on interviews and LPAs observation, this allegation is Substantiated. Continue on LIC9099-C Allegation: Staff do not ensure that residents are provided with activities To investigate this allegation, LPAs conducted interviews with five (5) residents and all residents interviewed informed LPAs that the facility has no activities during the day. LPAs were also informed that residents watch TV all day long. During the visit conducted on 01/29/25 from 10:00am to 4:30pm, LPAs observed four (4) residents sitting in the living room and watching TV, and one resident was in their bedroom, sitting on the bed. LPAs conducted an interview with the Administrator who confirmed that the facility has no daily activity scheduled for the residents. Therefore, based on interviews and LPAs observation, this allegation is Substantiated. Deficiencies issued per Title 22. Exit interview conducted appeal rights explained and copy of this report provided to the Executive Director.the state’s words, verbatim · CDSS document, Feb 25, 2025 · control 31-AS-20250122142449

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 26, 2025

Incidental Medical and Dental Care: c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not comply with the section above failing to administer R1 eyedrops as prescribed. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: Administrator agreed to schedule vendorized training for all staff and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Feb 26, 2025

Incidental medical and dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place... This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above by not assuring medications for R5 and the Administrator are kept locked and inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: Administrator agreed to schedule vendorized training for all staff and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 1, 2025

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: Based on inspection, and observation the Licensee did not ensure that the facility is safe and sanitary for wellbeing of residents and others. LPA observed cockroaches in the living room, dining room and kitchen areas. This poses a potential health, safety risk and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: The Administrator will take all measures to maintain the facility free from cockroaches. Administrator will submit updated documentation of Pest Control service agreement to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a)(1)(A-D) · Plan of correction due date: Apr 1, 2025

Residents shall be encouraged to maintain and develop their quality of life... The activities made available shall include: (1) Socialization to promote or enhance personal relationships. Activities may include, but are not limited, to: This requirement is not met as evidenced by: Based on LPAs observation, the licensee did not comply with the section cited above by not providing planned activities. During the visit conducted on 01/29/25, LPAs observed five out of five residents watching TV from 10:00am-4:30pm. This poses a potential health, safety risk and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: The Administrator will conduct an in-service meeting with all staff regarding this regulation and provide a daily activity to all residents. Copy of the training will be submitted to LPA by POC date

Type of visit: Required - 1 Year

At 9:30 AM, Licensing Program Analysts (LPAs) Nadia Shahbazian and Mariana Agban conducted an unannounced mandated annual inspection of the facility. LPAs met with the administrator, Nathaniel Hemedes, and explained the reason for the visit. At 9:45, a tour of the facility was conducted with the Administrator, and LPAs observed the following: The facility's total capacity is approved for six (6) non-ambulatory residents. The current census is five (5) residents. Kitchen: At 9:45 AM, LPAs toured the kitchen area and observed enough supplies of staple non-perishable for a minimum of 1 week and perishable for 2 days at the facility. All knives and sharps were observed to be locked in a kitchen drawer. The medications cabinet was locked. LPAs observed a roach on the kitchen wall by the food table. LPAs also observed medications in the fridge without being locked. LPAs also found bags of medications on the floor. The administrator stated that those medications will be destroyed. Under the sink cabinet LPAs found chemicals were unlocked. Laundry: The laundry is located between the kitchen and garage. LPAs observed unlocked laundry detergents accessible to residents in the laundry room. LPAs observed a fire extinguisher hanging on the wall purchased on 08/12/2019. Administrator was advised to buy a new fire extinguisher. (continue on 809 C) Bedrooms: The facility has six (3) bedrooms in total. All bedrooms were clean and odorless. Furniture was in good repair. All bedrooms are designated for shared use. LPAs observed in Bedroom #1 stow away bed. Interviews with R2 and R3 indicated that there was a caregiver who used to sleep in the room. LPAs also observed that R2 and R3 had half (½) bed rails. Review of R2’s and R3's facility records revealed that no Physician's order was available. LPAs advised Administrator to update residents' records and provide doctors' orders for residents' bedrails. Bathrooms: The facility had two bathrooms. Bathroom #1 is located in the main hallway. Bathroom#2, located in Room #2, LPAs observed both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 112.7 and 113.9 degrees Fahrenheit. LPAs observed in both bathrooms cleaning supplies under the cabinet sink. Administrator was advised to remove or lock chemicals. Common Areas: The facility maintains a comfortable temperature of 75°F. The living room and dining area appeared clean and were properly furnished. The living room has a television and comfortable furniture. No obstructions and or tripping hazards throughout the facility. Outside and Back Yard: LPAs toured the one side path and back yard. The emergency exit gate was unlocked, and the path was free from debris. LPAs observed appropriate outdoor furniture, with a covered shaded area for residents. Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 11:00 AM, the smoke alarms were tested and were NOT observed to be operational. Carbon monoxide was in the living room and was also tested and observed to be operational. LPAs heard functioning auditory alarms on all exit doors. Resident Files: LPAs conducted a file review of resident records and observed five (5) out of five (5) residents' facility files were incomplete, missing forms and signatures. LPAs were informed that Resident#6 had deceased a month ago. Records review indicated that there was no Death report sent to CCL. Administrator was advised to submit death report to CCL promptly. (Continue on 809 C) LPAs interviewed R1 and R2, who stated the facility doesn't provide any activity and that they spend most of their time watching TV. LPAs asked the Administrator for an activity calendar. Administrator doesn't have one in place. Staff Files: LPAs also conducted a file review of staff records and observed that there’s there’s no physical file for the Administrator and Staff#2. Staff#3 employee file is incomplete and has missing forms. LPAs discovered that Staff#3 is cleared but not associated with the facility. Administrator was advised to associate Staff #3 promptly. Medications: Medication and Medication Records were incomplete. LPAs could not complete an accurate medication count due to the inaccuracy of the medication records. Exit interview conducted, citations and civil penalty issued. Appeal rights are given, and a copy of this report is signed and delivered.the state’s words, verbatim · CDSS document, Feb 13, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs), Nadia Shahbazian and Angela Panushkina, conducted a CASE MANAGEMENT visit at this facility to issue deficiency in conjunction with complaint control no: 31-AS-20250122142449. LPAs met with the Administrator and explained the reason for the visit. LPA conducted a physical plant walk through, at approximately 10:15 AM, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. At 10:20 AM, LPAs conducted an interview with the Administrator, two (2) staff members and five (5) residents. LPAs also requested and reviewed five (5) resident files. Upon review of documents LPA observed the following: Resident #2 (R2) is currently on hospice and R3 (non-hospice) had full bed rails. Review of records revealed that both residents had no Physician's order on file. R1 and R5 had half (½) bed rails. Review of R1's and R5's facility records revealed that no Physician's order was available. Moreover, LPAs observed five (5) out of five (5) residents facility files were incomplete, missing forms and and signatures. During the interview with S1 and S2, LPAs were informed that they stay at the facility at night and S1 is sleeping in a stow away bed and had his/her personal items in the room #1 Continue on LIC809-C In addition, during the interview with R2, LPAs were informed that S2 sleeps on the bed in room #3. Interview with S2 confirmed that during the night time, S2 is sleeping in R2's room. LPAs reviewed the facility license and observed that the facility is licensed for awake staff. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted. Appeal rights explained. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jan 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Jan 31, 2025

Bed rails that extend the entire length of the bed are prohibited except for... hospice care and have a hospice care... This requirement is not met as evidenced by: Based on LPAs observation and record review, the licensee did not comply with the section cited above by not requesting an exception for a non hospice resident R3 to have a full bed rail. Moreover, no written Doctors' order was observed on file for R2's full bed rail and R1's and R5's 1/2 bed rails, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Licensee/Administrator will request a current and updated hospice care plan for R2 and which indicates the need for the full rails. Administrator will remove R3's full bed rail and request 1/2 bed rail for R1's, R3's and R5's physicians. Copy of the Hospice care plan fro R2 and physician orders will be submitted as POC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Feb 5, 2025

Resident Records. The licensee shall ensure that... current record is maintained... readily available.... This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above by not maintaining complete facility files for 5 out of 5 residents which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Licensee/Administrator will complete files for all residents. Once completed licensee/administrator will submit a signed, dated self certification that all resident files have been, reviewed, updated and complete as required by the cited regulation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Feb 5, 2025

Personal Accommodations and Services: Living accommodations and grounds shall be related to the facility's function... This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above by allowing staff to sleep in residents’ rooms, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Licensee/Administrator will notify the LPA/Department in writing how this deficiency is cleared. In-service training will be also provided to all current and future staff members. Copy of the in-service training will be submitted to LPA by POC date

Allegation investigated: Staff did not refund authorized representative Staff will not respond to authorized representative

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegations. LPA arrived at the facility and was granted access by staff. Administrator Nathaniel Hemedes was present at the facility and explained the reason for the visit. LPA requested copies of LIC 500 and Resident Roster. LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Allegation: Staff did not refund authorized representative It was alleged that R1's responsible party wrote a check for $2,500 on 10/23/23 . Facility staff had noticed that the numerical and the written number doesn't match. Facility staff had asked R1's responsible party to write a second check and they would destroy the first check. R1's responsible party wrote a second check on 10/24/23 for the amount $2,500.00. However, the facility had cashed both checks and had not refunded R1's responsible party. (Continue on 9099C) Substantiated Interview with the Administrator confirmed the allegation. The administrator admitted that they cashed both checks and they were unable to refund R1's responsible party due to financial hardships. The administrator confirmed that they will communicate with R1's responsible party and will refund them with amount of $2,000.00. Based on information obtained the allegation deemed Substantiated at this time. Allegation: Staff will not respond to authorized representative It was alleged that staff hasn't returned calls from R1's responsible party. Interview with the Administrator confirmed the allegation. Administrator admitted that R1's responsible party had called the facility multiple times regarding the refund and they didn't respond. Administrator stated that he wasn't able to return the calls due to busy schedule. Based on information obtained the allegation deemed Substantiated at this time. Exit interview conducted, citations issued, appeal rights are given and a copy of this report is delivered.the state’s words, verbatim · CDSS document, Jul 15, 2024 · control 31-AS-20240711120733

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652 · Plan of correction due date: Jul 29, 2024

Termination of admission agreement upon death of resident; ...and refunds (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual …responsible for the fees within 15 days after the personal property is removed. This requirement is not met as evidenced by; Based on the interviews and record review. The Licensee has not issue a refund of the prorated portion of the rent paid in advance. This poses potential risk to the personal rights of the residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: Administrator will refund R1's responsible party with the amount of $2,000 via check. Administartor will sent a copy of the front and back of the check by the POC date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(5) · Plan of correction due date: Jul 29, 2024

87507 Admission Agreements; (g) Admission agreements shall specify the following: (5) Refund conditions. (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death…This requirement is not met as evidenced by Based on interviews and record review the Licensee failed to assure that the admission agreement includes condition of refund upon death of the resident. R1’s admission agreement does not indicates the procedure of the refund of payments upon death of the resident. This poses potential risk to the personal rights of the residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: Administrator will provide a copy of revised admission agreement and submit to the Licensing Office for review and approval by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(A)(9) · Plan of correction due date: Jul 29, 2024

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately This requirement is not met as evidenced by;. Based on interviews, the Administrator did not respond to authorized representative.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: Administrator will provide a statement of understanding this section of the CCR by the POC date.

Type of visit: Case Management - Deficiencies

In conjunction to the complaint number 31-AS-20240711120733 Licensing Program Analyst (LPA) Mariana Agban conducted a case management- Deficiencies visit. During the complaint investigation, it was confirmed that Licensee failed to submit a death report for Resident 1(R1) to CCL. LPA conducted a file review and didn't observe death report on file. In addition, during records review, LPA observed that Staff#1 (S1) and Staff #2 (S2) are not cleared nor associated to work in the facility. Administrator was advised to remove S1 and S2 immediately from the facility until they are clear and associated to the facility. Exit Interview Conducted. Citations and Civil Penalties issued and a copy of this reportthe state’s words, verbatim · CDSS document, Jul 15, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jul 16, 2024

This requirement is not met as evidenced by: Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. This requirement was not met by evidence of: Based on records review Staff 1 and Staff 2 are not cleared. Civil penalties are being assessed in the amount of $500.00 for each staff.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: Administrator shall ensure that all staff obtain a Criminal Record Background Clearance and are associated to the facility prior to employment. Uncleared persons cannot return to work until they are cleared and associated to the facility. Submit copies of Livescan and transfer requests by POC due date (tomorrow).

From the deficiency page — Deficiency type: Type A · Section cited: CCR87533(e)(2) · Plan of correction due date: Jul 16, 2024

Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met by evidence of: Based on records review S1 and S2 are NOT associated to this facility. Licensee shall ensure all staff are cleared and associated to the facility prior to beginning employment.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: Administrator will provide proof of association for S1 and S2 by the POC date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80061(b) · Plan of correction due date: Jul 29, 2024

80061(b) Reporting Requirements. Upon the occurrence…a report shall be made to the licensing agency..., a written report ...within seven days following the occurrence of such event. This requirement was not met as evidence by Based on file document review, the Licensee did not comply with the section cited above. Lincesee didn't submit a death report for R1 since they passed away on or around October or November 2023. This poses a potential health and safety risk to clients in carethe state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: Administrator will submit death report for R1 by the POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with the administrator, Nathaniel Hemedes, for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 12:40 PM and the following was noted: There is one entrance being utilized at the facility. The facility has a total of three (03) resident bedrooms and two (02) bathrooms. The facility is fire cleared for six (06) non-ambulatory. The facility is currently occupying three (03) non-ambulatory residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for storage. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 70°F. The smoke and carbon monoxide were NOT observed to be operational. The detector in the hallway and rear entrance are missing. Facility is equipped with pull alarm. Fire extinguisher is located near the kitchen, observed to be full and last purchased 08/12/2019. (continued on LIC 809-C) The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 113.2°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication and first aid kit to be locked and inaccessible to residents. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Feb 3, 2024

Allegation investigated: Staff are not properly storing residents medication

Licensing Program Analysts (LPA) Antonia Alvizar-Ettima conducted unannounced complaint visit to the facility. LPA met with staff (S#1 and S#2) and granted entry. At 12:20p.m. Administrator arrived, and LPA explained the purpose of this visit. At 11:50p.m., LPA Alvizar-Ettima and S#2 conducted a physical plant inspection. At approximately 11:55 a.m., LPA Alvizar interviewed two (2) staff, two (2) out of two (2) residents. At 12:20p.m. LPA requested copies of staff, residents’ roster and other pertinent documents relevant to the investigation. Staff are not properly storing residents’ medication. It is alleged that medication is being found sitting out in the kitchen area. During inspection LPA did not observe any medication in the kitchen area or elsewhere in the facility. However, during inspection, LPA discovered that medication cabinet lock is broken, and medications are accessible to the residents. Substantiated Continuation from LIC 9099 During interview, Administrator admitted that medication cabinet lock has been broken for a couple days. Based on inspection and interviews there is sufficient information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Citation was issued and recorded on LIC9099D. Exit interview was conducted, appeal rights were discussed, and a copy of report was provided to Nathaniel Hemedes. Continuation from LIC 9099 -A At about 11:53 AM LPA Alvizar- Ettima observed a resident calling staff’s name and staff went to the resident’s room for assistance. Based on interviews, and observation, there is an insufficient information to support the allegation. Therefore, the allegation are UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report was provided to Administrator Nathaniel Hemedesthe state’s words, verbatim · CDSS document, Jan 9, 2024 · control 31-AS-20240102152100

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(C)(2) · Plan of correction due date: Jan 10, 2024

Incidental Medical and Dental Care(h)The following requirements shall apply to medications which are centrally stored(C) Because...dangers related to the medication itself(2)...medicines shall be kept in a safe and locked place that is not accessible to persons other than employees… Based on inspection LPA discovered that medication cabinet lock is broken, and medications are accessible to the residents. This poses a potential risk to resident in care.the state’s words, verbatim · CDSS document, Jan 9, 2024

Plan of correction: Administrator has agreed to replace the lock on the medication cabinet and email pictures of new lock and proof of purchase receipt by POC due date.

Type of visit: Case Management - Deficiencies

This Case Management visit is conducted in conjunction with complaint investigation to address the deficiencies unrelated to the complaint has nothing to do with complaint visit. During Complaint Investigation, LPA Alvizar-Ettima discovered the following Full-Time Staff (S1) and (S2) have been present without a Criminal Background Clearance or Transfer and Association to this facility. S1 job title is Caregiver, first day of work was 12/28/2023. S2 job title is Caregiver, first day of work was 12/20/2023. LPA request/received S1 Washington Driver License. LPA request/received S2 Passport. LPA verified using Guardian Background System Check, staff S1 and S2 names did not appeared on facility roster. Based on review of Licensing visit History, LPA noted that on 08/23/2023 Licensee was cited for allowing 2 uncleared individuals to be present and work at the facility. This is a second deficiency within last 12 month period. Therefore additional civil penalties $100.00 per/day per individual, up to 30 days, will be assessed at the time of this visit. A citation and civil penalty were issued and recorded on LIC809D Copy of this report was provide to Nathaniel Hemedes.the state’s words, verbatim · CDSS document, Jan 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(f)(e)(1) · Plan of correction due date: Jan 9, 2024

Criminal Record Clearance(f)Violation of Section 87355(e)... an immediate asse- ssment of civil penalties of one hundred dollars($100) per violation per day... (1) Subsequent violations within a 12 month period will result in a civil penalty of $100 per violation per day for a maximum of 30 days. Based on interview and review of Guardian Background System Check facility staff S1 and S2 are not criminal background clearenced and association to this facility. No documentation has been submitted to Community Care Lisensing. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jan 9, 2024

Plan of correction: Administrator has agreed to email the completed criminal background clearance and associate staff S1 and S2 to facility by POC due date