Villa Natomas Elderly Care

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a quarterly on-site visit regarding the Stipulation and Waiver and Order, effective three years from February 6, 2025 to February 6, 2028. LPA met with Licensee and staff and explained the purpose of the visit. During today's visit, LPA conducted a file review to confirm all staff listed on LIC 500 has an active first aid and CPR certificate. LPA observed monthly training present for May 2026, June 2026 and July 2026. Training for month of August is pending. Licensee confirmed there are no residents in care under the age of 60. Based on the Stipulation and Waiver and Order, Administrator is to be on site 40 hours weekly. LPA was informed there is no current administrator on file as previous administrator has resigned effective on July 31, 2026. Licensee stated his administrator renewal is pending but he will look for another administrator for time being. Please see deficiency cited on LIC809-D. Exit interview conducted and a copy of report and appeal rights will be provided.the state’s words, verbatim · CDSS document, Aug 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Aug 28, 2026

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator... The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by: Based on interview and file review, Licensee failed to comply to the section cited above as there is no active administrator working at the facility, which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Licensee is to appoint a new active administrator. Administrator must work at the facility at least 40 hours a week per Stipulation and Order and Waiver. Licensee must submit proof of interviewing and/or hiring. This plan of correction is due on Friday August 28, 2026. Failure to provide proof of correction may result to a civil penalty of $100 per day until corrected.

Allegation investigated: The facility allowed excluded individuals to work in the facility. The Administrator is not present at the facility for a sufficient amount of time.

On 5/27/26, Licensing Program Analysts (LPA)s Kevin Mknelly and Kerry Hiratsuka conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with caregiver. Administrator was call and unavailable. LPA conducted records review . LPA is unable to find and or meet the preponderance, per policy. LPAs did not find evidence of excluded individuals working at this home. LIC 602- Physician reports, and other documents present did not show signs of forgery. No significant evidence was found that Administrator duties and respobsibilities are not fulfilled. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview withcaregiver. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 27, 2026 · control 59-AS-20260212164311

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analysts (LPA) Hiratsuka and Mknelly arrived unannounced at the facility to conduct a quarterly on-site visit regarding the Stipulation and Waiver and Order, effective three years from February 6, 2025 to February 6, 2028. LPAs met with staff and explained the purpose of the visit. During today's visit, LPA conducted a file review to confirm all staff listed on LIC 500 has an active first aid and CPR certificate. LPAs observed training for February through March 2026. Staff member stated there are some files online. LPAs conducted a physical plant tour. The following was observed during today's visit: -the smoke detector was missing from room one. The bracket that holds it was on the ceiling but with no smoke detector. An immediate $500.00 civil penalty was observed during today's visit. *** smoke detector was installed during today's visit*** -One staff training log is not present at the facility. The staff member started end of April 2026. Staff member stated they did not have the required training prior to working by themselves. The staff member does not proof of medication training. Staff stated there is an online training this week. A record review confirmed no residents in care under the age of 60. Based on the Stipulation and Waiver and Order, Administrator is to be on site 40 hours weekly. LPA is requesting for facility to keep a live time sheet for Administrator in Probation binder. Reminder, failure to comply with the Stipulation and Waiver and Order may affect facility's licensure. Based on the above noted deficiencies, the facility will be issued citations pursuant to California Code of Regulations, Title 22 and documented on the attached LIC809-D. Immediate civil penalties of $500.00 was issued today for the smoke detector missing in room 1. An exit interview was conducted and a copy of this report was left with facility staff.the state’s words, verbatim · CDSS document, May 27, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: May 28, 2026

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement not met as evidence by the facility based on observation that the smoke detector for room one was not on the ceiling. The bracket that holds the detector was there, but the smoke detector was not, which poses an immedate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: By 05/28/2026, licensee shall submit a statement stating how they shall ensure all smoke detectors are working at all times. $500.00 immediate civil penalty was issued today due to the smoke detector not on the ceiling of room 1. ***it was installed during today's visit***

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a)(2) · Plan of correction due date: Jun 5, 2026

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. Based on record review, the licensee did not comply with the section cited above in one out of one staff person does not have the required training per the regulations. The training shall be specific to this facility, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: By 06/05/2026. the licensee shall ensure all staff shall have medication training per the health and safety code and shall submit a written plan of correction how they shall ensure staff have the required training.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(1) · Plan of correction due date: Jun 5, 2026

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. Based on record review and interview, the licensee did not comply with the section cited above inone out of one staff member does not have the required training for this facility. which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: Licensee shall submit a written plan of correction how they shall have staff training for this facility prior to a staff member working at this facility.

Type of visit: Case Management - Other

On February 12, 2026, Licensing Program Analyst (LPA) Cassie Yang arrived at facility to conduct an unannounced case management visit due to the Licensee's failure to pay licensing fees. LPA met with Administrator and explained the purpose of the visit. This facility has an outstanding balance for annual fees due. Annual fee of $495 and probation fee of $495 was billed on September 3, 2025. Payment was not received which resulted to late fee assessed on December 25, 2025. The current amount owed is $1,237.00. As of today's date, the fees are overdue. LPA explained to Administrator that proof of payment and/or proof of payment plan needs to be provided to CCL by March 13, 2026. Annual fee can be made online at https://www.ccld.dss.ca.gov/facilitybill/default.aspx Information needed for payment will be facility number and pin number. The following information was provided to Administrator in person. Per California Code of Regulations, Title 22, Type B deficiency is being cited today in violation of California Code of Regulations and follows on LIC 809-D. Exit interview conducted and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 12, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87156(b)(1)(F) · Plan of correction due date: Mar 13, 2026

87156(b)(1)(F)Licensing Fees. (b) (1) In addition to fees set forth in subdivision (a), the department shall charge the following fees: A late fee that represents an additional 50 percent of the established annual fee when any licensee fails to pay the annual licensing fee on or before the due date as indicated by postmark on the payment. This requirement is not met as evidenced by: Based on file review, Licensee failed to comply as facility has an outstanding fee of $1,237.00 which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: Licensee is to submit proof of payment to LPA by POC due date of March 13, 2026. POC can be submitted to LPA: email:cassie.yang@dss.ca.gov or cclascpsacramentonorthro@dss.ca.gov and/or fax to 916-263-4808 Failure to correct by due date may result to an additional civil penalty of $100 per day until received.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a quarterly on-site visit regarding the Stipulation and Waiver and Order, effective three years from February 6, 2025 to February 6, 2028. LPA met with staff and explained the purpose of the visit. During today's visit, LPA conducted a file review to confirm all staff listed on LIC 500 has an active first aid and CPR certificate. LPA observed monthly training present for October 2025 and November 2025. Administrator stated training were completed but just not on file. Administrator confirmed no residents in care under the age of 60. Based on the Stipulation and Waiver and Order, Administrator is to be on site 40 hours weekly. LPA is requesting for facility to keep a live time sheet for Administrator in Probation binder. Reminder, failure to comply with the Stipulation and Waiver and Order may affect facility's licensure. Exit interview conducted and a copy of report will be provided.the state’s words, verbatim · CDSS document, Dec 18, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection. LPA met with staff and explained the purpose of the visit. Today's visit, LPA and staff conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: residents bedrooms, bathroom, laundry room, garage, staff room, storage room, kitchen, and the common areas. LPA informed staff that although laundry room is locked, the keys are to be inaccessible to residents as LPA observed keys to be hanging on the door knob. Inspection of the exterior of the facility, LPA observed fence gate to be locked. LPA informed staff that emergency exit layout will need to be updated as it is showing the locked gate as an exit. File review conducted of facility's emergency disaster plan, LPA observed plan to be reviewed on February 1, 2025. Fire drill records was reviewed and observed quarterly drills conducted. LPA spoke with Administrator via telephone and discussed the status of Licensee's limited liability company, this matter will remain under review until resolved. LPA is requesting facility's liability insurance to be emailed to LPA at cassie.yang@dss.ca.gov by Monday December 22, 2025. At this time, no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Dec 18, 2025

Type of visit: Case Management - Legal/Non-compliance

On September 23, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a quarterly on-site visit regarding the Stipulation and Waiver and Order, effective three years from February 6, 2025 to February 6, 2028. LPA met with Administrator and explained the purpose of the visit. During today's visit, LPA observed the Stipulation and Waiver and Order to be posted in a conspicuous space. LPA observed probationary license to be posted. File review confirmed all staff listed on LIC 500 has an active first aid and CPR certificate. LPA was able to observe a current resident roster on file. LPA observed monthly training present for March 2025, July 2025, and August 2025. LPA informed Administrator training for month of September 2025 is still needed. No training was conducted for April 2025, May 2025 and June 2025. Administrator stated training were completed but just not on file. Administrator confirmed no residents in care under the age of 60. Based on the Stipulation and Waiver and Order, Administrator is to be on site 40 hours weekly. LPA is requesting for facility to keep a live time sheet for Administrator in Probation binder. Reminder, failure to comply with the Stipulation and Waiver and Order may affect facility's licensure. Exit interview conducted and a copy of report will be provided.the state’s words, verbatim · CDSS document, Sep 23, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a quarterly on-site visit regarding the Stipulation and Waiver and Order, effective three years from February 6, 2025 to February 6, 2028. LPA met with Caregiver and explained the purpose of the visit. Additionally, LPA spoke with Administrator via telephone. Administrator was unable to attend the visit; however, Administrator provided LPA instructions of locating Probation Binder. During today's visit, LPA observed two caregivers working on shift. LPA was able to confirm via Guardian that staff has fingerprint clearance. LPA observed the Stipulation and Waiver and Order to be posted in a conspicuous space. LPA observed probationary license to be posted. File review confirmed all staff listed on LIC 500 has an active first aid and CPR certificate. LPA is advising facility to provide copies of certificate into Probation binder as they were located in a different file. LPA was able to observe a current resident roster on file. Based on the Stipulation and Waiver and Order, Administrator is to be on site 40 hours weekly. LPA is requesting for facility to keep a live time sheet for Administrator in Probation binder. Additionally, as agreed on the Stipulation and Waiver and Order, Licensee is to provide monthly training to all staff from outside vendor regarding Title 22 regulations including mental health assessment, behaviors, and medication. Licensee failed to comply as LPA observed one training conducted on March 28, 2025. No documentation of trainings conducted in April, May or June 2025. Failure to comply with the Stipulation and Waiver and Order may affect facility's licensure. Exit interview conducted and a copy of report and appeal rights will be provided.the state’s words, verbatim · CDSS document, Jul 9, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analysts (LPAs) Cassie Yang and Kerry Hiratsuka arrived unannounced at the facility to conduct a quarterly on-site visit regarding the Stipulation and Waiver and Order, effective three years from February 6, 2025 to February 6, 2028. LPAs met with Administrator and explained the purpose of the visit. Probationary License was signed and provided for Administrator to post. Administrator was unaware of the facility probationary status. LPA read the Stipulation and Waiver and Order to Administrator to explained the "Revocation: Stayed With Probation". LPAs and Administrator discussed facility creating a Stipulation Compliance Binder to store the required documents stated in the Stipulation and Waiver and Order. During today's visit, LPAs observed four (4) pages of the Stipulation and Waiver and Order to be pinned behind the dining chairs. LPAs informed Administrator the Stipulation and Waiver and Order posted was incomplete as the Stipulation and Waiver and Order is 15 pages. LPA Yang provided Administrator a new copy of the full Stipulation and Waiver and Order to post. Additionally, LPAs informed Administrator that it shall be posted in a conspicuous space, LPAs advised Administrator to post the Stipulation and Waiver and Order by the sign-in desk. File review revealed Licensee has not conduct monthly training for staff from outside vendor regarding Title 22 regulations including mental health assessment, behaviors, and medication. File review revealed one (1) caregiver has an expired CPR and First Aid certificate. Deficiencies cited. Exit interview conducted and a copy of report and appeal rights will be provided.the state’s words, verbatim · CDSS document, Mar 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Apr 10, 2025

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive...(1) Staff providing care shall receive appropriate training in first aid from... agencies as the American Red Cross. This requirement is not met as evidenced by: Based on file review, Licensee did not comply to the section cited above as LPAs observed S1's CPR/First Aid training to be expired on March 13, 2025 which poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Licensee is to conduct an audit of personnel files to ensure all staff has an active first aid and CPR certificate on file. Licensee is to notify LPA with proof of audit completion by POC due date. Failure to correct by due date may result to $100 per day until corrected and/or received.

Type of visit: Office

An office meeting was held today via Microsoft Teams to discuss the Stipulation and Waiver and Order for Licensee Ratu Vunimatana. Present in today’s meeting from Sacramento South Regional Office: Regional Manager (RM) Stephanie Doub, Licensing Program Manager (LPM) Czarrina Camilon -Lee, LPM Stephen Richardson, Licensing Program Analyst (LPA) Christina Valerio, LPA Kevin Gould Present in Today’s meeting from Sacramento North Regional Office: LPM Anthony Perez Present in today’s meeting from representatives of Love and Comfort LLC and Villa Natomas Elderly Care LLC: Licensee Ratu Vunimatana The preceding Stipulation herby is adopted by the Department as its Decision in this matter. It is so ordered this 6th day of February 2025. Topics Discussed: · Findings · Revocation of License – Love and Comfort LLC, Facility #342700758 and #342700731 · Revocation of Administrator Certificate · Revocation- Stayed with Probation – 3 Years - Villa Natomas Elderly Cre LLC, Facility #342700925 · Exclusion- Stayed with Probation · Terms of Probation · Application for Administrator’s Certificate · Future Application for a License, Registration, Certification of Approval · Tolling of Probationary Period · Completion of Probation Continues on LIC 809 - C... continued from LIC 809 Topics Discussed: · Violation of Stipulation Term · Department’s Authority · Monitoring Fee · Waiver of Hearing Rights · Waiver of Appeal/Modification Rights · Waiver of Claims · Severable Terms · Public Record · Signatures · Counterparts · Effective Date · No Oral Modification · Representations RE: Corporate Licensee Licensee will do the following: · Provide CCL with a copy of the Registry of Facility Resident (LIC 9020) by COB 02/26/2025 · Shall operate the facility in strict compliance with regulations and statutes governing the operation of a residential care facility for the elderly · Shall ensure all individual working, residing or volunteering in the facility shall obtain criminal record clearance or exemption prior to their initial present in the facility and shall maintain proof o such criminal record clearance or exemption at the facility · Shall maintain current personnel records of each employee at the facility and ensure that all employee have a current certificate of CPR and first aid training on file at the facility · Shall post this Stipulation in a conspicuous place at the facility during the duration of the probationary period · Maintain an accurate, complete and current client roster Continues on LIC 809 - C, Page 3... continued from LIC 809 - C, Page 2 Licensee will do the following: · Shall report to the licensing office the following: any unusual incident… these incidents must be reported by the next working day, and a written report of the incident must be submitted within seven day following the occurrence of the incident. · Shall provide monthly training from an outside vendor to facility staff on application Title 22 regulations including mental health assessment, client behaviors, and medication · Shall not accept residents or clients under the age of sixty (60) years · Shall ensure and document that a qualified administrator is on-site at least forty (40) hours per week. CCL will do the following: · Continue to collaborate and communicate with licensee · Conduct quarterly monitoring Per California Code of Regulations (CCR) – Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was held, and a copy of this report will be delivered via email. Licensee Ratu Vunimatana will review, sign, and send the signed report to assigned LPA.the state’s words, verbatim · CDSS document, Feb 25, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 12/6/24 and met with the caregiver and Administrator to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are five (5) bedrooms and four (4) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 119.4 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguisher and first aid kits are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files and also reviewed two (2) staff files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Dec 6, 2024

Type of visit: Case Management - Incident

On June 26, 2024,Licensing Program Manager, Laura Munoz and Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to complete a case management visit. LPM and LPA met with Ratu, Licensee, and informed the reason for the visit. During todays visit, LPA and LPM toured each room. LPA and LPM met with SacFire David Vu, to see, what need to get the fire clearance. The fire clearance was not issued due to a few issues that would need to be repaired and finished before being issued a fire clearance. Mr. David Vu had given the facility 30 days to complete the problems. The licensee is aware of all issues. LPA will return to the facility within the next 15 days to get a status on the fire clearance. Per California Code of Regulations, Title 22, no citations were issued. An exit interview was conducted and a copy of the report was left with Ratuthe state’s words, verbatim · CDSS document, Jun 26, 2024

Type of visit: Case Management - Other

On June 20, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to inform the administrator that the documents he filled out was incorrect. LPA met with staff Adi, caregiver and informed her the reason for the visit. Ratu, the administrator, filled out an application and a facility sketch which was incorrect. LPA wanted to instruct him on how it is supposed to be filled out. Ratu was not available at the facility today. LPA instructed the facility staff on the process so she will be able to show Ratu on how it is to be done. LPA was able to instruct staff on how it should look. An exit interview was conducted and a copy of this report was given to Adi.the state’s words, verbatim · CDSS document, Jun 20, 2024

Type of visit: Case Management - Deficiencies

On May 9, 2024 Licensing Program Manager, Laura Munoz and Licensing Program Analyst, DeAnna Williams-Lyons conducted a case management visit to this facility. Upon further review of documentation, interviews and observations, the Department has returned to the facility today, 5/13/2024 to issue deficiencies for identified issues from the May 9, 2024 visit. · Based on R2's physician’s report (LIC602), page 2, 8.c. indicates “suprapubic cath to be flushed daily”. The flushing of a catheter is within the scope of a licensed medical professional. This facility is not staffed with a licensed medical professional to perform the daily required flushing. Note: a citation will not be issued for this violation today as 87468.2(a)(4) was issued on May 9, 2024. Based on R2's physician’s report (LIC602), page 2, 7.a. indicates R2 has stage 4 pressure injury on their left elbow. Interviews indicated home health comes to the facility to address R2's wounds. The facility was unable to provide documentation from home health during the May 9, 2024 visit. Additionally, the facility was unable to provide a care plan for R2 in regard to wound care. Lastly, with R2's documented a stage 4 wound, the facility did not request an exception request from the Department to retain a resident with a stage 4 wound are required. · When R1 was being discharged from the facility on May 9, 2024, it was observed that R1's wheelchair has been inoperable since February 20, 2024, when R1 was admitted to the facility. R1 is bedridden and unable to independently transfer. To continue see 809-C... · A medication audit was conducted on 05/09/2024. Upon review, three (3) medications prescribed to R1 ran out as of May 5, 2024 and were not refilled. This resulted in R1 not having three (3) prescribed medications for (4) four days. Additionally, the facility is utilizing Medical Administration Records (MARs). It was observed that numerous signatures were missing for R1 therefore it is unclear if R1 was administered medications are prescribed. Based on the above noted deficiencies, the facility will be issued citations pursuant to California Code of Regulations, Title 22 and documented on the attached LIC809-D. An exit interview was conducted and a copy of this report was left with facility staff.the state’s words, verbatim · CDSS document, May 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615 · Plan of correction due date: May 13, 2024

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on documentation and interviews conducted, the facility accepted R2 with a Stage 4 pressure injury and did not request a required exception from the Department which is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 13, 2024

Plan of correction: Licensee shall not admit any resides with Prohibited Health Conditions. The Licensee shall write why it is important not to admit residents with Prohibited Health conditions and submit it to the Department no later than June 1, 2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465 · Plan of correction due date: May 13, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by : compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on documentation and interviews conducted, R1’s wheelchair was inoperable for (3) three months while residing at the facility which posses a possible health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 13, 2024

Plan of correction: Licensee shall write A plan for incidental medical and dental care shall be developed by each facility. This shall be completed and submitted to the Department no later than June 13, 2024. Licensee shall make sure all equipment is in good working good working condition prior to accepting resident in facility. Licensee shall write why it is important to do so by June 1, 2024 and submit it to the Department.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: May 13, 2024

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. . This requirement was not met as evidenced by:Based on documentation and observation, three (3) medications prescribed to R1 ran out as of May 5, 2024 and were not refilled. This resulted in R1 not having three (3) prescribed medications for (4) four days which is an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, May 13, 2024

Plan of correction: Plan of corrections corrected during the visit.

Type of visit: Case Management - Deficiencies

On April 9, 2024, Licensing Program Manager Laura Munoz and Licensing Program Analyst DeAnna Williams-Lyons arrived unannounced to conduct a case management visit. Met with Ratu Vunimatana, Licensee and informed him the reason for the visit. Upon entering the facility, LPA and LPM conducted a facility walk through and records reviewed. During the facility walk through and records reviewed, the following deficiencies we found. R1 is documented bedridden and R2, although documented non-ambulatory, is unable to independently transfer or rotate independently. This facility does not have approved bedridden fire clearance. In addition to citations being issued for bedridden fire clearance, immediate civil penalties will be assessed in the amount of $500. During the inspection of R3’s bedroom (#6), it was observed that a double cylinder deadbolt was present on the exit door in R3’s room restricting R3 from exiting in the event of an emergency. Based on records reviewed and interviews conducted, R1 and R2 have needs that require 24 hour care. At this time, the facility does not have awake staff therefore R1 and R2's needs are not being met during non-waking hours. Based on records reviewed, there is no needs and service plan available for review for R1, facility file records are incomplete for R2 and the identification and emergency form is incomplete for R3. To continue see 809-C...the state’s words, verbatim · CDSS document, May 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: May 9, 2024

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2)Bedridden person. This requirement was not met as evidenced by: Based on records review and observations, R1 and R2 are bedridden and not recieving Hospice service. This facility does not have approved bedridden fire clearnace which posses an immediate health and safety risk.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Fire District arrived to this facility during the Department visit and determined this facility does not meet bedridden and non-ambulatory fire clearance at this time. Based on today's fire inspection, R1, R2 and R3 will need to be relocated. Licensee shall obtain an appropriate fire clearance approved by the fire department and effective today's date SHALL NOT accept any resident's that are deemed bedridden and/or non-ambulatory until approval is granted.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(6) · Plan of correction due date: May 9, 2024

87468.1 Personal Rights (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. Based on observation, R3 's room has a double dead lock on the door that restricted resident from exiting room. This poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Licensee repaired the lock during the visit. POC cleared

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 10, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement has not been met as evidenced by: Based on records reviewed and interviews conducted, R1 and R2 have needs that require 24 hour care. At this time, the facility does not have awake staff therefore R1 and R2's needs are not being met during non-waking hours.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Licensee shall ensure awake staff are available to any resident's who are in need of night supervision. Staff plan shall be submitted to CCL by 05/10/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: May 16, 2024

87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement has not been met as evidenced by: Based on records reviewed, there is no needs and service plan available for review for R1, facility file records are incomplete for R2 and the identification and emergency form is incomplete for R3.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Licensee shall complete and update all residents records no later than May 20, 2024.

Type of visit: Case Management - Other

On April 10, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a case management visit. LPA met with Adi, caregiver and explained the reason for the visit. The Licensee charged resident $5,000. for October 2023 rent. LPA saw the agreement contract. Residents insurance overpaid the licensee and sent $7,000. from October 2023, November 2023, December 2023, January, 2024, and February 2024 for a total of $10,000. overpayment. No change of condition occurred with the resident. Licensee left the facility and was not able to speak to the LPA regarding this incident. No citations was issued. An exit interview was conducted and a copy of this report was given to caregiver.the state’s words, verbatim · CDSS document, Apr 10, 2024

Type of visit: Case Management - Other

On March 28, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced at the facility to conduct a case management visit. LPA spoke with staff and informed them the reason for the visit. LPA had a discussion with resident. His needs aren't being met and he is trying to call other facilities to inquire on the status of their facility. LPA resident of a placement and will follow up with this situation. Resident is doing well as to be expected but is hoping to be transferred soon. No citations were issued today. An exit interview was conducted and a copy of this report was given to staff.the state’s words, verbatim · CDSS document, Mar 28, 2024

Type of visit: Case Management - Other

On February 15, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a Case Management Visit. LPA met with Ratu, Administrator and informed him the reason for the visit. LPA received a call from resident #1 (R1), asking LPA to please come to the facility so he can inform LPA of the mistreatment he is receiving from the staff at the facility. During today's visit, LPA spoke with the administrator regarding the resident's version of how he is being treated. Administrator admits he shouldn't have accepted the Resident because the facility is having a hard time meeting his needs. Administrator stated he will continue to try to meet the resident's needs until the resident is transferred to another facility. LPA spoke with R1 about his treatment at the facility. See 812. No citations were issued at today's visit. LPA will return to discuss treatment of residents at a later date. An exit interview was conducted and a copy of this report was given to Staffthe state’s words, verbatim · CDSS document, Feb 15, 2024

Allegation investigated: Admission agreement: Resident has not signed an agreement.

On 12/13/23, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to deliver complaint findings for above allegation and met with Staff (caregiver)- Adi Sautu.LPA explained the purpose of the visit. LPA reviewed records and conducted interviews to investigate this allegation. LPA observed that the facility did not have all the required documents in resident’s (R1) file who was admitted to the facility on 10/20/23. Upon R1s file review, LPA observed that R1s file was missing a signed Admission Agreement as well as the ID form, Consent Form, Pre-Admission Appraisal, Personal Belongings Form, Personal Rights Form, Release of Medical Information form, Medical Assessment forms as required per Title 22 regulations. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met.Therefore,the above allegation is found to be SUBSTANTIATED. No citations were issued today as citations were issued for this on 12/05/23 during case management visit on LIC809 per Title 22 regulations. Exit interview conducted and copy of report was provided. Substantiated Allegation- Neglect: Staff does not provide care for residents - Unsubstantiated The department conducted staff and residents' interviews, reviewed records to investigate the allegation. During residents’ interviews, residents stated that staff respond to residents needs in a timely manner, however sometimes there is a delay in response due to staff assisting other residents’ needs. Interviews and record reviews indicated that resident’s ADL’s which includes residents showering, incontinence and care needs are met as required and documented accordingly. Residents’ interviews indicated that staff were providing care in a professional manner and did not express any concerns. Furthermore, LPA observed facility found to be clean and odor free during visit on 12/05/23 and residents interviews indicated no issues with care, therefore this allegation is found to be UNSUBSTANTIATED. Allegation- Facility is not accessible for wheelchair and Hoyer lift.- Unsubstantiated The department conducted staff and residents' interviews, reviewed records to investigate the allegation. Resident interviews indicated that their care needs were met as required including use of wheelchair and Hoyer lifts. During the department visit on 12/05/23, it was observed that the facility offers more than one shower and toilet use access to all residents per their needs and service plan. Staff training documents indicated that staff were aware about residents’ care needs and were using Hoyer lift for transferring residents with 2-person assist as required without any issues. Based on this, this allegation is Unsubstantiated. Due to the information above, LPA finds all the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and copy of report was provided.the state’s words, verbatim · CDSS document, Dec 13, 2023 · control 59-AS-20231129144920

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to do a case management visit . LPA met with staff, caregiver- Adi Sautu and explained the purpose of the visit. LPA get permission from Administrator, Ratu Vunimatana via phone that staff, caregiver -Adi Sautu can sign the report for today . LPA found out these issues at the facility while doing the complaint investigation on 12/06/23 . While doing record review, LPA observed that facility did not have all required documents in resident (R1) file who got admitted on 10/20/23 to the facility. Upon,R1s file review, LPA observed that R1s file is missing Admission Agreement, ID form, Consent Form, Pre Admission Appraisal ,Personal Belongings Form, Personal Rights Form, Release of Medical Information form , Medical Assessment forms as required per Title 22 regulations. While doing residents and staff interviews, LPA found out that facility staff (S1) called law enforcement on facility resident (R1) on 11/23/23. No charges were filed on R1 and S1 been moved to another facility location after that incident. This incident should have been reported to department per Title 22 regulation but record review indicated that facility did not report this incident to department till date. Additionally, it has been concluded that administrator was aware about this incident which happened at the facility between staff, S1 and resident, R1 but administrator did not comply with reporting requirement. While doing residents and staff interviews, LPA learned that sometime between 10/20/23 and 11/23/23 , staff, S1 was in verbal altercation with resident, R1. During this verbal altercation, S1 was recording the conversation on S1s cell phone without R1s consent. S1 did not treat R1 with dignity and respect and violated R1s personal rights. Based on record review and interviews, Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 809-D page. Failure to clear POC by due dates can lead to civil penalties. Exit interview conducted. Appeal Rights and copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Dec 5, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Dec 6, 2023

87211(a)(1)(D) -Reporting Requirement- Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse …. This requirement is not met as evidenced by; Based on the records reviewed, it has been determined that the facility did not report an incident which happened between staff, S1 and resident, R1 on 11/23/23 which poses an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2023

Plan of correction: Licensee shall send a written statement to CCL of understanding of regulation for 87211 for reporting requirements and shall do training with staff. POC documents should be sent to CCL by POC date-12/06/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(2) · Plan of correction due date: Dec 6, 2023

87405- Administrator - Qualifications and Duties(d)(2)- Knowledge of and ability to conform to the applicable laws, rules and regulations….. This requirement is not met as evidenced by; Based on the records reviewed and interviews, it has been determined that the administrator did not report an incident related to staff ,S1 and resident ,R1 for 11/23/23 which poses an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2023

Plan of correction: Administrator agreed to submit a self-certification of understanding the regulation ,87405 (d)(2) and will make sure to report any reportable incidents to CCL as required and submit proof to CCL by POC date-12/06/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b) · Plan of correction due date: Dec 31, 2023

87506(b)- Each resident’s record shall contain at least the following information....this requirement is not met as evidence by; Based on record review for resident, R1, LPA observed that R1s file is missing Admission Agreement, ID form, Consent Form, Pre Admission Appraisal ,Personal Belongings Form, Personal Rights Form, Release of Medical Information form , Medical Assessment forms as required which poses a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2023

Plan of correction: Licensee/administrator shall complete all required docuemts for residents including R1 in thier files per this regulation 87506 and will send proof to department by POC date-12/31/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Dec 6, 2023

87468.1(a)(1)- Personal Rights of Residents in All Facilities- 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 evidence by; Based on interviews and record review, staff,S1 had verbal altercation with resident R1 and S1 did record that incident on thier cell phone without R1s consent ( between 10/20/23 to 11/23/23) which poses a immediate helath and safety risks to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2023

Plan of correction: Licensee/administrator shall send a letter of understanding of regulation 87468.1 and will staff training as well. Proof of all documents shall be send to department by POC date-12/06/23.

Type of visit: Required - 1 Year

On October 26, 2023 at 11:00am Licensing Program Analyst (LPA) De Anna Williams-Lyons met with Barbara Williams, Caregiver, to conduct a required annual inspection. Licensee was unavailable. Administrator's certificate expires 11/24/2023. LPA toured the facility inside and out. The inside of the facility was observed to be in good condition and repair. LPA observed a table in the dining area. Plates and utensils were observed to be in place. Knives are observed to be locked in the kitchen. Dishwasher, stove, refrigerator, and microwave all present and working. This facility has a fire clearance. The facility also has a fully charged fire extinguisher and functioning, smoke alarms/carbon monoxide detector and all exit doors have sound alarms. Storage and lighting were adequate in the home. All bedrooms were observed to have furniture as required by Title 22 Regulations. The facility has Six bedrooms were observed, with single occupancy. Bathrooms were observed to be in good repair. Adequate linens such as sheets, blankets, etc. were observed. Cleaning supplies and toxins were found to be locked. Medications was locked in a cabinet in the kitchen. Water temperature was measured at 105 degrees. First aid kit was present and included the required scissors, tweezers, thermometer and guide. The living room was furnished. Washer and dryer is in place and ready for use. There are no pools or bodies of water on the premises. LPA observed shaded areas in the backyard. LPA reviewed 2 files and 2 staff files. All files had the required update documents. Barbara and LPA completed the infectious Control questionnaire with no problems or issues. Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed. The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensing no later than November 26, 2023.the state’s words, verbatim · CDSS document, Oct 26, 2023