Western Assemblies Home

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Administrator Lynn Hughes and explained the purpose for today’s visit. The facility is licensed to serve 36 Non-Ambulatory Adults ages 60 and above, with a hospice waiver of up to 3 residents. The facility currently has 3 residents utilizing hospice services. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility has sufficient PPE supplies and maintain the required Infection Control Plan. Operational Requirements: Facility maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested and was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinets and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguishers were observed and are fully charged. Facility has video surveillance inside common areas and outside perimeter of the facility. Call buttons were tested and operable. Staffing: There appears to be sufficient staffing at all times in the facility. Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED and sufficient on-going training. Lynn Hughes maintains a valid Administrator Certificate that expires 11/2025 (and confirmed has submitted renewal). (Continued on LIC9099-C) Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters displayed: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides activities and there is sufficient space both indoor/outdoor for activities. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled, are centrally stored in their original containers. Resident Records-Incident Reports: Resident files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 5 resident files with no issues. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 9/10/25. Residents with Special Health Needs: There are currently 3 residents using hospice services, LPA reviewed 2 of the residents files and hospice records with no issues observed. LPA observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report provided to Administrator Lynn Hughes.the state’s words, verbatim · CDSS document, Oct 13, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Ramirez and Luis De Leon conducted an unannounced required annual inspection visit on 10/15/2024 and was greeted by Administrator Lynn Hughes. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPAs observed carbon monoxide detectors and smoke alarms in hallways. LPAs inspected eight (8) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Shared shower/bathroom was observed to be wheelchair accessible. Facility has video surveillance inside common areas and outside perimeter of the facility. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. The facility employs an activities director part-time. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 09/26/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. See 809-C Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Staffing: Administrator Certificate for Lynn Hughes expires 11/16/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for thirty-six (36) non-ambulatory. This facility may retain no more than two (2) hospice residents. There were two (2) residents under hospice care during inspection. Resident Records/Incident Reports: LPA reviewed Resident files for five (5) residents in care. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were observed during visit. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 15, 2024

Allegation investigated: Staff unlawfully removed a resident's medication Staff are borrowing materials from other residents while in care

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Lynn Hughes and explained the reason for the visit. The Investigation consisted of the following: LPA conducted interviews with Administrator Lynn Hughes, Staff 1-2 (S1-2) and Residents 1-3 (R1-3). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1-3's medications and Medication Administration Records (MARs) and collected copies of R1-3 MARs for December 2023 and January 2024. LPA additionally conducted a tour of the facility including supply storage room, medication room and observation of medication cart. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Staff unlawfully removed a resident's medication, it is alleged that a facility staff (administrator) has on more than one occasion put medications in their pocket to take home after a resident has passed away. Interview conducted with Administrator Lynn Hughes revealed that she has never taken any resident's medication out of the facility at any time. She stated that when a facility resident has passed away their medications are properly destroyed and are not taken out of the facility by anyone. Interviews conducted with facility staff revealed that facility staff have never unlawfully removed any resident's medication out of the facility. Staff stated that when a resident is no longer taking a certain medication or if a resident has passed away the facility will properly destroy the medication(s). Interviews conducted with 3 out of 3 residents revealed that they are satisfied with their medication management, they get their medications on time on a daily basis and they have never seen any staff take their medications out of the facility. LPA reviewed R1-3's MARs and observed that MARs were properly completed by facility staff after medication administration at the time of visit. LPA observed staff as they were administering medications to facility residents and did not observe anything of concern. LPA reviewed R1-3's Centrally Stored Medication and Destruction Records and observed the forms to be properly completed. LPA toured medication room and did not observe anything of concern. Based on interviews conducted with facility staff, facility residents, LPA review of records and observations, there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff are borrowing materials from other residents while in care, it is alleged that the facility does not have all the materials that are needed for each resident because supplies are not ordered timely and staff have to borrow materials from other residents. It is also alleged that there are residents that need extra care with lifting, dressing, hygiene care, assistance with feeding, assistance with wiping, diapering, and there are some residents that seem to have early onset dementia and don't have the capability of doing things independently who are not getting the assistance that they need at the facility due to the facility being short staffed. Interviews conducted with Administrator Lynn Hughes and S1-2 revealed that there are enough staff on schedule per shift to properly care for the residents in placement. They stated that there are 2-3 caregivers scheduled per shift along with other staff like housekeeping, cooks/ kitchen staff, activities, and maintenance. They stated that staff on schedule are able to meet the needs of all residents and provide the proper care that facility residents need which do include assistance with Activities of Daily Living (ADLs). Staff stated that there are always enough supplies available at the facility to meet the needs of the residents. They stated that supplies are ordered weekly and for the resident's that the families provide supplies, the administrator will contact the family when their supplies are running low and inform the family in a timely manner to ensure that the residents have their needed supplies in storage at the facility so that staff can meet their needs. Staff deny ever having to borrow materials from other residents and staff stated that they do not have any labor related concerns at the moment and indicated that they know who to contact if they ever do have any concerns. Interviews with 3 out of 3 residents revealed that the are satisfied with all the services that they receive at the facility, and staff assist them in a timely manner. They stated that the staff are always helpful and they do not have any concerns regarding there not being enough staff on schedule. They stated that they do not have any concerns regarding their materials, they always have the materials that they need and staff do not borrow any of their materials to use with other residents. During the visit, LPA inspected the storage closet and observed enough materials such as diapers, wipes and mattress pads to meet the needs of the resident's in placement. LPA observed some residents to have their incontinence materials in their rooms. LPA reviewed facility schedule and observed that there are enough staff on schedule to properly oversee and tend to residents daily needs, and facility daily operation. LPA observed enough staff on schedule during the visit. Based on interviews conducted with facility staff, facility residents, and LPA record review and observations, there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Administrator Lynn Hughes.the state’s words, verbatim · CDSS document, Jan 30, 2024 · control 28-AS-20240122142232