Westborough Manor 6

Type of visit: Required - 1 Year

On 8/20/2026, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Licensees Sheila & Anthony Diaz. LPA explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms, garage, and kitchen area and backyard. While touring the facility it was observed that the room temperature was at 72 deg F. Hot water was also tested in the bathrooms and the temperature was 112 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked. Food supply in kitchen and garage refrigerator was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill is done every quarter. Six resident records and three staff records were reviewed. All records have been updated. Resident files have updated appraisals and staff have updated training. Centrally stored medication was locked and inaccessible by residents. All medication was labeled and sorted by resident name. All medication logs are complete and updated. Administrator will send the Liability Insurance to LPA. No deficiencies cited today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Aug 20, 2026

Type of visit: Required - 1 Year

On August 22, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrators, Anthony Diaz and Bella Terciano and explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a single story facility. There are six resident rooms; all of which are private resident rooms. Resident rooms were observed to be clean with all required furniture. There is one staff room. Two full bathrooms were observed to be clean, odor-free and in good repair. Water temperature throughout the facility measured between 108-114 degrees F. Extra linen was observed to be present. First aid kit was observed to be complete. Dining room was observed free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed two day perishables, however did not observe seven day non-perishables. Medications and chemicals were observed locked an inaccessible to residents in care. Sharps were observed unlocked and accessible to residents. Sharps were immediately locked by caregiver. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of July 2024. LPA reviewed 5 resident records and 5 staff records. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Aug 22, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 1/28/2025, Licensing Program Analyst (LPA), Murial Han conducted an unannounced case management visit. LPA met with caregiver, Lirio Hernandez and explained the purpose of today's visit. During today visit, LPA provided an invoice of a civil penalty that the facility was assessed on 11/19/2024 in the amount of $800 as the mail was "Return To Sender". LPA also spoke to the Licensee, Sheila Diaz over the phone who requested CCL to change the facility's mailing address to the facility's address. No deficiency is cited today. This report is reviewed and discussed with the caregiver. A copy is provided.the state’s words, verbatim · CDSS document, Jan 28, 2025

Type of visit: POC

On 11/19/2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced plan of correction visit. LPA met with caregiver, Ferdinand and explained the purpose of today's visit. Caregiver called the co-licensee, Sheila Diaz to inform LPA's visit and LPA explained the purpose of today's visit to the co-licensee over the phone. On 11/6/2024, facility received a civil penalty for not having a copy of the current General Liability Insurance and the civil penalty was assessed from 10/25/2024- 11/6/2024 in the amount $1200 ($100 per day). On 11/15/2024, LPA received a copy of the current General Liability Insurance. During today visit, an additional civil penalty is being assessed from 11/7/2024 - 11/14//2024 in the amount of $800 ($100 per day) and civil penalty has been stopped on 11/15/2024 as the citation has been corrected. This report is reviewed and discussed in person with the caregiver and on the phone with the co-licensee. A copy is provided.the state’s words, verbatim · CDSS document, Nov 19, 2024

Type of visit: POC

On November 6, 2024, Licensing Program Analyst (LPA), Murial Han conducted an unannounced plan of correction visit. Upon entrance, LPA met with caregiver, Linda Mondejar, and explained the purpose of today's visit. Caregiver called the administrator/licensee, Anthony Diaz and informed him of LPA's visit. During the case management visit on 10/23/2024, LPA issued a deficiency under Health and Safety Code 1569.605 as the facility did not have a copy of the current Liability Insurance and the plan of correction was due on 10/25/2024. On 10/28/2024, the facility Licensees submitted a copy of the Worker’s Compensation and Employer’s Liability Policy from Berkshire Hathaway Guard Insurance Companies and on the 1st page of the liability policy, it stated that the insured period was from May 15, 2024 to May 15, 2025, 12:01AM, the 2nd page, it indicated that name insured was Westborough Manor and the 3rd page, it indicated the facility’s address. After viewing the insurance policy, LPA proceeded with calling the insurance company and the insurance retailer (Board Spectrum Insurance) for verification and both confirmed that this policy was not active, it was terminated in 2018-2019 due to non-payment and when it was active, it did not cover this facility and it only covered worker's compensation. They also stated that they did not know how the facility’s address appeared on the 3rd page of the policy. Due to the above observation and deficiency not corrected as the administrator/licensees was not able to provide a copy of the current general liability insurance, a civil penalty is being assess today in the amount of $100 a day from 10/25/2024- 11/6/2024. A total of civil penalty of $1200 is being assessed today and will continue to accrue until corrected. This report is reviewed and discussed with the caregiver, Linda Mondejar and licensee, Sheila Diaz over the phone. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 6, 2024

Type of visit: Case Management - Deficiencies

On November 6, 2024, Licensing Program Analyst (LPA), Murial Han conducted an case management visit to follow up on a case management visit on 10/23/2024. LPA met with caregiver, Linda Mondejar who called the administrator/licensee Anthony Diaz and explained the purpose of today's visit. During the case management visit on 10/23/2024, LPA issued a deficiency under Health and Safety Code 1569.605 as the facility did not have a copy of the current Liability Insurance and the plan of correction was due on 10/25/2024. On 10/28/2024 at 10:54am, the facility Licensees submitted a copy of a one page Worker’s Compensation and Employer’s Liability Insurance from the Berkshire Hathaway Guard Insurance Companies and initially LPA observed the facility was not listed under named insured. LPA informed the Licensees of the observation, and a few hours later at 1:16PM, the Licensee submitted an addendum of 2 more pages including the name insured- Westborough Manor on the 2nd page and facility's address on the 3rd page. After viewing the insurance policy, LPA proceed with calling the insurance company and the insurance retailer (Board Spectrum Insurance) for verification and they confirmed that this policy was for Worker's Compensation and it did not cover for General Liability Insurance and that the policy was terminated in 2018-2019 due to non-payment. In addition, they stated that when the policy was active, it did not include this facility and they did not know how the facility’s address appeared on policy. Based on observation and record review, the administrator/licensees provided a copy of the expired worker’s compensation insurance policy and not the general liability insurance and the policy was altered as the insurance company confirmed that this facility was not included on the policy yet it appeared on the policy that was provided by the licensees. In addition, the administrator did not conform to the laws, rules, and regulations as the administrator did not ensure the facility has an active Liability Insurance Policy. Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the caregiver and administrator/licensee over the phone. A copy of this report and the Appeal Rights are provided.the state’s words, verbatim · CDSS document, Nov 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Nov 7, 2024

87207 False Claims ..No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evicenced by based on interviews, observation and record review, the administrator/licensee provided an insurance policy that was terminated in 2018-2019 and when it was active, it did not insure this facility which poses an immediate health risks to residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The administrator/licensee will develop a plan in writing and the plan shall indicate that the administrator/licensees has reviewed this regulation and what the administrator/licensees will do to prevent this from happening again. The administrator/licensees will provide a copy of the plan to CCL by 11/7/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(2) · Plan of correction due date: Nov 7, 2024

87405 Administrator - Qualifications and Duties..(d) The administrator shall have the qualifications..(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirment is not met as evidenced by based on observation, record review and interview, the administrator did not ensure the facility has an active General Liability Insurance Policy which poses an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The administrator/Licensees will develop a plan in writing and the plan shall indicate that the administrator/licensees have reviewed the Regulation and the plan to ensure the facility is in compliance with the Regulations, and laws including but not limiting on obtaining a current General Liability Insurance for the facility. The administrator/Licensees will provide a copy of the plan to CCL by 11/7/2024.

Type of visit: Case Management - Other

On October 23, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management- Other visit to obtain a copy of the current Liability Insurance. LPA met with caregiver, Linda Mondejar and explained the purpose of today's visit. During the facility annual inspection on 8/22/2024, LPA requested for a copy of the current liability insurance, and on 8/23/2024, LPA reminded the licensee in writing for a copy of the liability insurance. During a case management visit on 10/17/2024, the Licensees/administrator stated that they did not have a copy of the liability insurance at the facility and they would provide a copy by 10/18/2024. As of today, the Licensees did not provide a copy of the liability insurance. During today's visit, caregiver called the licensees/administrator who stated that they did not have a copy of the current liability insurance and that they would work on it and provide a copy by 10/25/2024, Deficiency is cited under Health and Safety Code, Title 22 Division 6 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with caregiver, Linda Mondejar in person and administrator/licensee, Anthony Diaz on the phone. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 23, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.605 · Plan of correction due date: Oct 25, 2024

1569.605 Liability insurance; coverage requirements... Based on interview, observation and record reveiw, This requirement is not met as evidenced by the facility did not provide a copy of the current liability insurance after several verbal and written reminders which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Oct 23, 2024

Plan of correction: The administrator/licensee will provide a copy of the current liability insurance to CCL by 10/25/2024.

Type of visit: Case Management - Other

On October 17, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management- Other visit to obtain a signature for a civil penalty that was assessed on 3/23/2021. LPA met with caregiver, Linda Mondejar and explained the purpose of today's visit. After entrance, LPA called and spoke to the Licensee who was able to recall the time when the civil penalty was issued and authorized the caregiver to sign the Civil Penalty Assessment. The original Civil Penalty Assessment report was provided to the caregiver. This report is reviewed and discussed with the caregiver. A copy is provided.the state’s words, verbatim · CDSS document, Oct 17, 2024

Type of visit: Required - 1 Year

On August 21, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Linda Mondejar and explained the purpose of today's visit. The Licensees, Anthony and Sheila Diaz arrived and assisted with the inspection. Upon entrance, LPA observed PPE supplies and disinfectants on the floor by some of the resident's rooms and the facility staff stated that a few residents tested positive for COVID-19. According to the Licensees, this was not reported to CCL and Local Public Health. LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The outdoor passageways were cleared. The facility has 6 residents and all of them are in private rooms. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Comfortable temperature is maintained and lighting is sufficient for comfort. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care. Hot water temperature in the kitchen and bathroom were measured at 111-114 degrees Fahrenheit. Fire extinguishers were checked. During tour of the garage, LPA observed a mattress, a medication bottle, a toaster, etc and staff stated that it is an area for staff to take breaks. A review of (6) resident files was conducted and noted on the LIC 858. A review of (3) staff files was conducted and noted on the LIC 859. The following documents were requested submitted to CCL by 8/22/24: - Liability Insurance, Administrator Certification and LIC 500 Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. . This report is reviewed and discussed with the Licensees. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 21, 2024