Zealcare Home

Type of visit: Case Management - Other

On 07/012026, at approximately 3:30 PM, Licensing Program Analyst (LPA) Julie Florio met with Martha Martinez, Designated Responsible Party for a Case Management visit to follow up on substantiated complaint allegations; complaint number 21-AS-20250411091753. On August 11, 2025, the Department concluded an investigation which alleged that staff caused injuries to a resident while in care. The licensee was cited for violating Health and Safety Code (H&S) §1569.269(a)(6) Enumerated rights; severability. At the time of the complaint visit on August 11, 2025, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation." This is evidenced by the facility not providing proper care and supervision resulting in a resident (R1) falling. R1 sustained a right nasal bone fracture, a frontal scalp hematoma, and bruising of the central forehead, which resulted in hospitalization. Today, 07/01/2026, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. Continued on LIC809C... Continued from LIC809... However, since an immediate civil penalty of $500 was previously issued on August 11, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted, with Martha Martinez, Designated Responsible Party, whose signature on form confirms receipt of documents. Appeal rights provided, found on page two of LIC421D.the state’s words, verbatim · CDSS document, Jul 1, 2026

Type of visit: Required - 1 Year

At approximately 10:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and quarterly non-compliance visit. LPA met with Lousita Makalintal, Designated Responsible Party (DRP). Administrator, Madonna Grace Martinez was contacted via telephone and was unable to attend today's inspection. Facility is a Residential Care Facility for the Elderly (RCFE) with five (5) residents in care. All residents were present during today's inspection. Facility has a hospice waiver for three (3) and is approved for all non-ambulatory residents. At approximately 11:00 AM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured above the allowable range of 105 to 120 degrees F per Title 22 regulations. Staff turned the water heater down immediately bringing the temperature into the allowable range. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all of the appropriate furnishings as required per regulations. Cabinets containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPA observed a structure in backyard which a background cleared and associated staff member resides in. LPA observed residents watching TV in their rooms or in the common area. Continued on LIC809C... Continued from LIC809... Facility has an internet access device designated for resident use. Facility has internet service available to residents in care and the telephone was tested an operational during inspection. Smoke and carbon monoxide detectors were tested and operational during inspection. Facility's two fire extinguishers were observed fully charged and were last inspected 03/2026. Additionally, LPA observed the required postings in a conspicuous area of the facility. At approximately 12:00 PM, LPA reviewed 5 of 5 resident files. LPA observed 1 of 5 residents missing a current physician's report. DRP agreed to schedule this resident for their exam immediately to bring the facility back into compliance with regulation. LPA observed 2 of 5 residents missing a current appraisal needs and services plan and consent for emergency medical treatment on file, (see LIC9102TVs). LPA observed, 3 of 5 resident files missing a completed centrally stored medication destruction record (CSMDR), (see LIC9102TV). At approximately 1:00 PM, Martha Martinez, Designated Responsible Party (DRP), arrived to complete the remained of today's inspection with LPA. At approximately 1:30 PM, LPA reviewed 4 staff files. 4 of 4 staff files reviewed contained proof of current First Aid/CPR certification and the required annual training hours. 3 of 4 staff files did not contain evidence of completed initial training and initial medication training hours as required by Title 22 regulation. DRP agrees to complete these documents and submit them to the Department upon completion in order to bring the facility into compliance. LPA was presented with proof of current administrator Certificate for Madonna Grace Martinez #7020245740 expires on 6/20/2027. DRP provided LPA with proof of current liability insurance in the required amounts. Continued on LIC809C... Continued from LIC809C... During today's visit, LPA reviewed and discussed all previously uncleared Plans of Correction (POCs) for nine (9) citations issued since the initial legal non-compliance office meeting held on 06/26/2024 with DRP who agreed to clear by EOB 05/29/2026 along with the Technical Violations issued during today's visit in order to bring the facility into compliance with regulations. The citations previously issued were for the following areas of concern: Medication Administration Prompt Response to Resident's Representative Admissions Agreements Reporting Requirements Staff Training Appraisal Needs and Services Plans Staffing Postural Support Orders Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC500 Personnel Report (updated) LIC610D Emergency Disaster Plan Clear all outstanding Plans of Correction (POCs) previously cited No citations issued during today's visit. Exit interview conducted with Martha Martinez, DRP, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 11, 2026

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

At approximately 2:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Deficiencies and Plan of Correction (POC) visit to issue civil penalties. LPA met with Designated Responsible Party (DRP), Luisita Makalintal. Administrator, Madonna Grace Martinez was contacted via telephone and DRP left a message regarding today's visit. LPA toured the building and found it to be clean and orderly. Food was plentiful and stored in a safe manner. Facility is a Residential Care Facility for the Elderly (RCFE) with five (5) residents in care. During the 10/22/2025 Quarterly Case Management - Legal/Non-Compliance Visit, LPA reviewed and discussed all previously uncleared Plans of Correction (POCs) for nine (9) citations issued since the initial legal non-compliance office meeting held on 06/26/2024 with Administrator who agreed to clear by EOB 10/31/2025 in order to bring the facility into compliance with regulations. The citations issued were for the following areas of concern: Medication Administration Prompt Response to Resident's Representative Admissions Agreements Reporting Requirements Staff Training Appraisal Needs and Services Plans Staffing Postural Support Orders Continued on LIC809-C... Continued from LIC809... Due to a failure to clear the POCs, LPA returned to facility on 11/13/2025 to reissue all nine (9) citations and informed Administrator that a failure to correct the citations by the POC due date of 11/14/2025 would result in LPA returning to issue civil penalties. As of today, 11/25/2025, Administrator has not made contact with the Department and has not submitted the requested paperwork to correct the citations issued. A civil penalty of $100 per day, for each of the nine (9) citations issued for eleven (11) days is being issued, totaling $9,900. A civil penalty of $100 per day, per citation will continue to be assessed until the requested information has been received by the Department. LPA attempted to contact Administrator via telephone and left a voicemail regarding today's visit. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat citations within a twelve month period, may result in a civil penalty assessment. **An Immediate Civil Penalty in the total amount of $9,900.00 is being assessed for failure to correct Plans of Correction by due date, which poses/posed an immediate health, safety, and/or personal rights violation to persons in care, (see LIC421FC).** Exit interview conducted with DRP whose signature on form confirms receipt. Appeal rights were given.the state’s words, verbatim · CDSS document, Nov 25, 2025

Type of visit: Case Management - Deficiencies

On 11/13/2025, at approximately 1:15 PM, Licensing Program Analyst (LPA) Julie Florio arrived at facility unannounced, to conduct a Case Management - Deficiencies visit and met with Corina Anguiano, Caregiver/Designated Responsible Party (DRP). Administrator, Madonna Grace Martinez was contacted via telephone and DRP left a message regarding today's visit. LPA toured the building and found it to be clean and orderly. Food was plentiful and stored in a safe manner. Today's Case Management - Deficiencies visit is to follow up on areas on non-compliance identified and discussed with Licensee during LPA's quarterly Legal/Non-Compliance visit on 10/22/2025 and previously uncleared deficiencies issued since facility was placed on the current non-compliance plan on 06/26/2024, which Licensee agreed to clear by EOB 10/31/2025. To date, the Department has not received any of the requested information or communication from Licensee. As a result, LPA is issuing citations for the following areas of concern which are reflected in each of the uncleared plans of correction issued since 06/26/2024: Medication Administration Prompt Response to Resident's Representative Admissions Agreements Reporting Requirements Staff Training Appraisal Needs and Services Plans Staffing Postural Support Orders Continued on LIC809-C... Continued from LIC809... Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809Ds with Plans of Correction, and Appeal Rights discussed and provided to DRP. Signature on forms confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 14, 2025

87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure medications were administered as ordered. Resident did not receive eye drops as ordered and resident antibiotics were not given as ordered. This poses an immediate Health risk to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Licensee to ensure residents are assisted with medication as ordered by physician. Licensee to conduct training for all staff on medication procedures. Training to be scheduled and completed by11/14/2025. Sign in sheet of completed training to be submitted to CCL by 11/14/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(9) · Plan of correction due date: Nov 14, 2025

87468.1 Personal Rights of Residents in All Facilities: (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 conducted, Licensee did not promptly respond to resident representatives This poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Licensee to ensure residents representatives communications are answered promptly. Licensee to review regulation 87468.1 and submit self certification of their understanding. Self certification to be submitted to CCL by POC date of 11/14/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Nov 14, 2025

87507 Admission Agreements:(e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. This requirement is not met as evidenced by: Based on interviews conducted, resident nor their representative received a copy of the admission agreement immediately after signing. This poses a potential Health, Safety or Personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Licensee shall review regulation 87507 and submit self certification that they understand and will comply going forward. Self certification shall be submitted to CCL by POC date of 11/14/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Nov 14, 2025

87211 Reporting Requirements:(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on records reviewed Licensee did not follow regulation by not notifying the Department of a residents visit to the emergency room. This poses a potential Health, Safety or Personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Licensee shall review regulation 87211 and submit self certification that they understand and will comply going forward. Self certification shall be submitted to CCL by POC date of 11/14/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c) · Plan of correction due date: Nov 14, 2025

87412 Personnel Records:(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not have documentation of completed staff training. This poses a potential Health, Safetly or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Licensee shall submit evidence of completed staff training for All staff to CCLD by POC date of 11/14/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR85068.2(b) · Plan of correction due date: Nov 14, 2025

85068.2(b) Needs and Service Plan. If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan…..***Based upon records reviewed, this requirement has not been met as evidenced by: Appraisal & Needs Service Plan for 5 out of 5 residend as of 04/01/2025 is not complete or signed by all partiesThis poses a potential Health and Safety risk to clients in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Licensee agrees to ensure that all staff obtain and complete staff required annual training-ensure all staff have required training. Submit proof if training to CCL by POC due date of 11/14/2025.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Nov 14, 2025

§1569.269 Enumerated rights; severability (a)(6) 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 is not met as evidenced by: Based on file review, interviews conducted and record review, the licensee did not ensure that facility was staffed sufficiently or that staff were competently trained to ensure injuries were not caused to R1 during their care, which poses a health, safety, and/or personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Licensee agrees to submit a self-certifaction that they understand regulation 1569.269 as it pertains to the care and safety of residents to CCL by POC due date of 11/14/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(5)(B) · Plan of correction due date: Nov 14, 2025

87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on file review, interviews conducted and record review, the licensee was unable to produce orders for full bedrails observed on R1's hospital bed as required per regulation, which poses a potential health, safety, and/or personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Licensee to submit a self-certification that they unerstand the requirements for the half anf full bedrails in the operation of the facility per title 22 regulations to CCL by POC due date 11/14/2025.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625 · Plan of correction due date: Nov 14, 2025

H&S Code 1569.625 Staff training; legislative findings; contents: training requirements . This requirement is not met as evidenced by: ***Based on file review & interview with Licensee, the licensee failed to ensure that all staff had completed the required annual training as required by title 22 regulations and H&S Code which poses a potential health and safety risk to residents in care. LPA observe during file reviews 3 out of 3 staff have not completed all of the required 20 hours of ongoing annual training.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Licensee agrees to ensure that all staff obtain and complete staff required annual training-ensure all staff have required training. Submit proof if training to CCL by POC due date of 11/14/2025.

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

At approximately 12:30 PM, Licensing Program Analyst (LPA) Julie Florio arrived at facility unannounced, to conduct a quarterly Legal/Non-Compliance visit and met with Administrator, Madonna Grace Martinez. LPA toured the building and found it to be clean and orderly. Food was plentiful and stored in a safe manner. At approximately 1:30 PM, LPA reviewed five (5) of five (5) resident files. LPA observed five (5) of (5) residents' files missing two (2) or more of the required documents. Administrator agrees to complete these documents and submit them to the Department by EOB 10/31/2025 in order to bring the facility into compliance. At approximately 4:00 PM, LPA reviewed previously uncleared POCs issued since the initial legal non-compliance office meeting held on 06/26/2024 with Administrator who agrees to clear by EOB 10/31/2025 in order to bring the facility into compliance with regulations. Technical Support Provider (TSP) assistance was offered to Administrator during the office meeting on 08/11/2025 where Administrator agreed to engage services. However, Administrator never responded to communications from TSP and the referral was closed. LPA discussed this option with Administrator again during today's facility visit and Administrator agreed to engage services. No citations issued during today's visit. Exit interview conducted with Administrator whose signature on form confirms receipt of documents. Continued from LIC809...the state’s words, verbatim · CDSS document, Oct 22, 2025

Allegation investigated: Staff are operating without liability insurance

On 08/11/2025, Licensing Program Analyst (LPA) Julie Florio met with Madonna Grace Martinez, Administrator/Licensee in the Santa Rosa Regional Office to deliver complaint 21-AS-20250411091753 investigation findings regarding the above allegations. Reporting Party (RP) alleges that facility staff are operating without liability insurance. LPA Florio conducted a 10-day complaint investigation visit on 04/16/2025 and obtained documents, made observations, and conducted interviews. During this visit it was revealed through records review and liability insurance documents obtained that the facility does have the required liability insurance. Based on record review, the department received conflicting information. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Based on interviews conducted and records obtained, the allegation that the facility staff are operating without liability insurance is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted. Copy of report discussed and provided to Licensee, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 11, 2025 · control 21-AS-20250411091753

Allegation investigated: Staff caused injuries to a resident while in care

On 08/11/2025, Licensing Program Analyst (LPA) Julie Florio met with Madonna Grace Martinez, Administrator/Licensee in the Santa Rosa Regional Office to deliver complaint 21-AS-20250411091753 investigation findings regarding the above allegations. Reporting Party (RP) alleges that facility staff caused injuries to a resident while in care. LPA Florio conducted a 10-day complaint investigation visit on 04/16/2025 and obtained documents, made observations, and conducted interviews. During this visit it was revealed through records review of Hospice pre-admission “suggested orders” for Resident 1 (R1) that a hospital bed with half rails was listed as an approved item for R1. During this visit, LPA observed R1’s hospital bed equipped with full bedrails (see photos). Facility was unable to produce orders for full bed rails. A citation is being issued on a LIC809 - case management/office visit report dated 08/11/2025. Continued on LIC9099C... Substantiated Continued from LIC9099... Based on an interview with Administrator/Licensee it was revealed that staff 1 (S1) changed R1 and put the rails up to step away to throw the garbage away from the changing R1 when S1 heard a thump. Additionally, based on an incident report dated 10/11/2024 and received by the Department on 10/16/2024, It was revealed that S1 also stepped away to answer the front door to the facility during the time when the thump was heard by S1. LPA attempted to contact S1 on 04/16/2025, 07/30/2025, and 08/08/2025 but was unsuccessful. Per interview conducted with R1’s responsible party, R1’s husband ordered the hospital bed, which came with full bed rails, prior to the 10/11/2024 incident. LPA spoke with the Hospice Nurse on 08/08/2025 and received emailed transcribed notes from R1’s Hospice file which state that R1 was admitted to Hospice services on 10/13/2024 and a Hospice nurse reported observing the bed rails broken. Additionally, the Hospice notes indicate that R1’s family refused the Hospice ordered bed with half rails. Based on an interview with Staff 2 (S2) on 08/08/2025, facility staff are trained to prepare briefs and items for incontinent care prior performing incontinent care, stay with the resident until done, reposition the resident on their back and put the bedrails up before walking away. Based on further record review, it was revealed on R1’s hospital discharge summary dated 10/13/2024 that as the result of this above-mentioned fall on 10/11/2024, R1 sustained a right nasal bone fracture, a frontal scalp hematoma, bruising of the central forehead, and a small superficial abrasion to the inner left nare. Subsequently, on 04/11/2025, the Department received said complaint #21-AS-20250411091753 which indicated that R1 sustained a second injury on 04/06/2025. During the course of an interview with Administrator/Licensee, it was revealed that while performing incontinent care, S1 rolled R1 resulting in R1’s head coming in contact with the bedside table causing injury and bruising to R1’s upper right eye area as captured in photos taken by LPA on 04/16/2025, (see LIC9099D). An immediate civil penalty in the amount of $500 if being issued during today's visit, (see LIC421IM). Based on a death report received by the Department on 05/15/2025, R1 passed away on 05/07/2025 on Hospice care. Based on interviews conducted and records obtained, the allegation that the facility Staff caused injuries to a resident while in care is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Continued on LIC9099C... Continued from LIC9099C... Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). The licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f). Exit interview conducted. Copy of report discussed and provided to Licensee, whose signature on form confirms receipt of documents. Appeal rights provided.the state’s words, verbatim · CDSS document, Aug 11, 2025 · control 21-AS-20250411091753

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Aug 12, 2025

§1569.269 Enumerated rights; severability (a)(6) 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 is not met as evidenced by: Based on file review, interviews conducted and record review, the licensee did not ensure that facility was staffed sufficiently or that staff were competently trained to ensure injuries were not caused to R1 during their care, which poses a health, safety, and/or personal rights violation tothe state’s words, verbatim · CDSS document, Aug 11, 2025

Plan of correction: residents in care. Licensee agrees to submit a self-certifaction that they understand regulation 1569.269 as it pertains to the care and safety of residents to CCL by POC due date of 08/12/2025.

Type of visit: Office

At approximately 11:30 AM, on 08/11/2025, an informal office meeting was conducted in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager, Bethany Moellers, Licensing Program Analysts, Julie Florio, and Madonna Grace Martinez, Administrator/Licensee. The purpose of the informal office meeting was to discuss areas of non-compliance and observed concerns in the of the operation of Zealcare Home #286804025. The Licensee was informed that this informal meeting is a part of the Administrative Action process and that further and/or repeat citations may result in further action by the Department. The legal administrative action process was explained to attendees which is based on areas of non-compliance found during the quarterly non-compliance visit conducted on July 30, 2025 and correspondence received by CCL on 07/31/2025 that the City of Napa Fire Department has not received the required emergency disaster fire drill log from the facility which is due by Close of Business (COB) 08/11/2025. Administrator/Licensee is aware that failure to comply with Napa Fire Department's request may result in a citation and civil penalties being issued by CCL. Items addressed in today's meeting include but are not limited to observed areas of noncompliance in the areas below: Fire Clearance Administrator Qualifications and Duties Full Bedrails Reporting Requirements Continued on LIC809C... Continued from LIC809... Licensee agrees to maintain communication with the Napa City Fire Department to resolve the areas of non-compliance. Technical Support Provider (TSP) assistance was offered to Licensees during this meeting and agreed to engage services. Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). Exit interview conducted with Administrator/Licensee, whose signature on form confirms receipt of documents. Appeal rights provided.the state’s words, verbatim · CDSS document, Aug 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Sep 22, 2025

87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on file review, interviews conducted and record review, the licensee was unable to produce orders for full bedrails observed on R1's hospital bed as required per regulation, which poses a potential health, safety, and/or personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Aug 11, 2025

Plan of correction: Licensee to submit a self-certification that they unerstand the requirements for the half anf full bedrails in the operation of the facility per title 22 regulations to CCL by POC due date 09/22/2025.

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

At approximately 2:30 PM, Licensing Program Analyst (LPA) Julie Florio arrived at facility unannounced, to conduct a quarterly Legal/Non-Compliance visit. LPA was greeted at the door by caregiver, Benjamin Filomeno. Administrator, Madonna Grace Martinez was contacted via telephone and arrived at approximately 2:45 PM. LPA toured the building and found it to be clean and orderly. Food was plentiful and stored in a safe manner. At approximately 3:00 PM, LPA reviewed 3 of 3 resident files. LPA observed 3 of 3 residents did not have completed re-appraisals/care plans or consents for emergency medical treatment on file. Additionally, 1 of 3 residents, (R1) did not have proof of negative TB results on file. Administrator agrees to complete these documents and submit them to the Department upon completion in order to bring the facility into compliance. At approximately 3:30 PM, LPA reviewed 3 staff files. 3 of 3 files contained proof of current First Aid/CPR certification. 3 of 3 staff files did not contain evidence of completed annual training of health screening as required by Title 22 regulation. Administrator agrees to complete these documents and submit them to the Department upon completion in order to bring the facility into compliance. LPA was presented with proof of current administrator Certificate for Madonna Grace Martinez #7020245740 expires on 6/20/2027. Continued on LIC809C... Continued from LIC809... LPA will return to regional office to discuss with licensing program manager and may return to issue citations and possible civil penalties at a later date. Updated copies of the following documents shall be submitted to CCL within 30 days of this visit: LIC 308 Designated Responsible Party LIC 500 Personnel Summary No citations issued during today's visit. Exit interview conducted with Administrator whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 30, 2025

Type of visit: Required - 1 Year

At approximately 9:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Corina Anguiano, Designated Responsible Party (DRP). Administrator, Madonna Grace Martinez was contacted via telephone and was unable to leave the other facility they were working at today. LPA was given permission to proceed with today's inspection with DRP. Facility is currently on a quarterly non-compliance plan with the most recent non-compliance visit conducted on 04/01/2025. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. All residents were present during today's inspection. Facility has a hospice waiver for three (3) and is approved for all non-ambulatory residents. At approximately 10:30 AM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPA inspected structure in backyard which a background cleared and associated tenant resides in. LPA also inspected two attached exterior closets which were observed to contain personal and household items. Continued on LIC809C... Continued from LIC809... LPA observed residents watching TV or reading in the common area and in their bedrooms. Facility has an internet access device designated for resident use. Facility has internet service available to residents in care and the telephone was tested an operational during inspection. Smoke and carbon monoxide detectors were tested and operational during inspection. Facility's two fire extinguishers were observed fully charged and were last inspected 02/2024. DRP spoke with Administrator who states they plan to take both to be serviced on of before 4/15/2024. Administrator agrees to submit proof of service to the Department. Additionally, LPA observed personal rights, a current administrator certificate, and the facility's emergency disaster plan not posted in a conspicuous area of the facility. LPA informed DRP these items shall be posted in order to bring the facility back into compliance with regulation. No deficiencies were cited during inspection. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC500 Personnel Report (updated) Any other item previously requested during the noncompliance quarterly visit on 04/01/2025. Exit interview conducted with DRP whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 10, 2025

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

At approximately 9:05AM, Licensing Program Analyst (LPA) Ali Deniz arrived at this facility unannounced to conduct a quarterly Legal/Non-Compliance visit. LPA met with facility Licensee/Administrator Madonna Grace Martinez. The facility currently provides care for 6 clients, 6 of 6 which were present at the time of visit. Facility is a 1 story building with 5 Resident bedrooms, 1 staff bedroom, 3 bathrooms, and common spaces. At approximately 09:45AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed the amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff were in the process of cleaning up after breakfast at the time of this inspection. Toxins are stored in a locked housekeeping closet in the hallway. Water temperature in sink accessible to residents in care measured at 107.6 degrees F which is within the allowable range of 105 to 120 degrees F. Fire extinguishers inspected were charged and last inspected February 2024. However, the fire extinguishers pressure gauge was on green zone mark line. Licensee agrees to service fire extinguishers. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. At approximately 10:25M, LPA reviewed 5 resident records and found all in order. 5 of 5 records contained current and signed admission agreements and physician's orders on file. LPA observed 5 out of 5 residents, did not have completed Appraisals & Needs Service Plans on file. Also, resident R3, R4, and R5 did not have pre-appraisals/care plans in file (See LIC809-D page). Medication records are thorough and contained physician's orders for each resident. Continued on LIC809-C… Continued from LIC809… At approximately 11:45AM, LPA reviewed 3 staff files. 3 out of 3 files contained evidence of completed First Aid/CPR certification. 3 of 3 staff files did not contain evidence of completed annual training as required by Title 22 regulation (See LIC809-D page). Administrator agrees to submit proof of training for all staff once trainings complete. Facility has supplies enough to operate for more than 72 hours in an emergency. LPA was presented with proof of current administrator Certificate for Madonna Grace Martinez # expires on 6/20/2025. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 04/15/2025: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Copy/Proof of Updated Certificate of Liability Insurance Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 1, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 85068.2(b) · Plan of correction due date: Apr 8, 2025

85068.2(b) Needs and Service Plan. If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan…..***Based upon records reviewed, this requirement has not been met as evidenced by: Appraisal & Needs Service Plan for 5 out of 5 residend as of 04/01/2025 is not complete or signed by all partiesThis poses a potential Health and Safety risk to clients in care.the state’s words, verbatim · CDSS document, Apr 1, 2025

Plan of correction: Licensee agrees to submit updated and complete Needs and Service Plan for the all residents in care by the plan of correction date 04/08/2025 in order to clear deficiency.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.625 · Plan of correction due date: Apr 8, 2025

H&S Code 1569.625 Staff training; legislative findings; contents: training requirements . This requirement is not met as evidenced by: ***Based on file review & interview with Licensee, the licensee failed to ensure that all staff had completed the required annual training as required by title 22 regulations and H&S Code which poses a potential health and safety risk to residents in care. LPA observe during file reviews 3 out of 3 staff have not completed all of the required 20 hours of ongoing annual training.the state’s words, verbatim · CDSS document, Apr 1, 2025

Plan of correction: Licensee agrees to ensure that all staff obtain and complete staff required annual training-ensure all staff have required training. Submit proof if training to CCL by POC due date of 04/08/2025.

Allegation investigated: Facility did not re-order medications timely Staff are not properly trained

At approximately 11:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA was met by Caregiver Corina Anguiano. LPA interviewed staff and reviewed records. Based on records reviewed, resident ran out of several medications on several occasions and no refill request was sent until after the medication was gone. This resulted in a family member having to secure an emergency supply until the replacement order was received. LPA issued a citation regarding medication administration on 11/15/2024. During the course of the this investigation, LPA requested staff training records. Licensee was not able to provide documentation of completed staff training to meet the number of hours required by regulation. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Corina Anguiano and Appeal rights were given. Substantiatedthe state’s words, verbatim · CDSS document, Jan 9, 2025 · control 21-AS-20241011111939

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c) · Plan of correction due date: Jan 31, 2025

87412 Personnel Records:(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not have documentation of completed staff training. This poses a potential Health, Safetly or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Licensee shall submit evidence of completed staff training for All staff to CCLD by POC date of 01/31/2025.

Allegation investigated: Facility not administering medication as ordered Licensee did not communicate with family in a timely manner Licensee did not provide an Admission Agreement within 7 days Licensee did not follow reporting requirements

At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA was met by Caregiver Corina Anguiano. LPA toured the building, interviewed staff and reviewed records. Based on interviews conducted, facility staff did not assist with administering medications as ordered. Resident was prescribed antibitics and they were not given as ordered. Resident required eye drops that were not administered as ordered. Based on interviews conducted, there were long delays in communication with Licensee. Residents responsible party requested information and it took several days for a return call. This occurred on multiple occasions. Based on records reviewed, resident moved into the facility on 12/12/2023 and did not receive a copy of the agreement until February. Based on records reviewed, resident went to the emergency room on 09/10/2024. Licensee did not send notification to the department of this unusual incident. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Corina Anguiano and Appeal rights were given. Substantiatedthe state’s words, verbatim · CDSS document, Nov 15, 2024 · control 21-AS-20241011111939

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 16, 2024

87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure medications were administered as ordered. Resident did not receive eye drops as ordered and resident antibiotics were not given as ordered. This poses an immediate Health risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: Licensee to ensure residents are assisted with medication as ordered by physician. Licensee to conduct training for all staff on medication procedures. Training to be scheduled by POC date of 11/16/2024 and to be completed by 12/20/2024. Sign in sheet of completed training to be submitted to CCL by 12/20/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Dec 20, 2024

87468.1 Personal Rights of Residents in All Facilities: (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 conducted, Licensee did not promptly respond to resident representatives This poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: Licensee to ensure residents representatives communications are answered promptly. Licensee to review regulation 87468.1 and submit self certification of their understanding. Self certification to be submitted to CCL by POC date of 12/20/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Dec 20, 2024

87507 Admission Agreements:(e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. This requirement is not met as evidenced by: Based on interviews conducted, resident nor their representative received a copy of the admission agreement immediately after signing. This poses a potential Health, Safety or Personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: Licensee shall review regulation 87507 and submit self certification that they understand and will comply going forward. Self certification shall be submitted to CCL by POC date of 12/20/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Dec 20, 2024

87211 Reporting Requirements:(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on records reviewed Licensee did not follow regulation by not notifying the Department of a residents visit to the emergency room. This poses a potential Health, Safety or Personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: Licensee shall review regulation 87211 and submit self certification that they understand and will comply going forward. Self certification shall be submitted to CCL by POC date of 12/20/2024.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

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

At approximately 9:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a quarterly Legal/Non-Compliance visit. LPA was greeted at the door by caregivers Luisita Makalintal and Rachel Espaldon. LPA toured the building and found it to be clean and orderly. Food was plentiful and stored in a safe manner. At approximately 10:15AM, LPA reviewed 5 of 5 resident files. LPA observed 4 of 5 residents, (R1, R2, R4, R5) did not have completed re-appraisals/care plans on file. 2 of 5 residents, (R2, R5) did not have completed Pre-Placement Appraisals on file. 1 of 5 residents, (R1), did not have a completed LIC 602, Physician report on file. At approximately 11:30AM, LPA reviewed 3 staff files. 3 of 3 files contained evidence of completed First Aid/CPR certification. 3 of 3 staff files did not contain evidence of completed annual training as required by Title 22 regulation. At approximately 12:40PM, Administrator Madonna Martinez arrived at the facility. Administrator informed LPA that she is working on having resident files digitally. Administrator provided LPA with the completed LIC 602, Physician Report for R1. Administrator stated all residents have care plans, with only 1 still in process. Administrator will send completed care plans to LPA upon completion. Administrator will send LPA an updated LIC500, that details hours for Administrative work and hours for providing assistance with residents. Administrator stated staff training has been completed and will send self certification when records are updated. No citations issued during today's visit.the state’s words, verbatim · CDSS document, Oct 2, 2024

Type of visit: Office

A non-compliance conference was conducted today in the Santa Rosa Regional Office. Present in the meeting: Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst, Julie Florio, and Facility Licensee/Administrator, Madonna Martinez. An informal office meeting was conducted on 6/12/2024, to discuss identified compliance concerns, not limited to clearing POCs. During this meeting, Licensee agreed to submit documents to clear POCs by close of usiness 6/14/2024 and failed to do so. The purpose of today's meeting is to review ongoing compliance concerns. This non-compliance conference is being conducted to discuss concerns identified by community care licensing in regards to the operation of Zealcare Home, 286804025 and Magnolia Gold Home Care, 486803895. Areas of noncompliance not limited to below were discussed: Administrator Duties and Qualifications Active Administrator in place for facility oversight per regulation Clearing POCs Reporting Requirements Timely response to CCL when communication is engaged LIcensee was informed of Technical support program and agrees to engage in services. No deficiencies sited during this noncompliance conference.the state’s words, verbatim · CDSS document, Jun 26, 2024

Type of visit: Office

An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Regional Manager, Carla Nuti-Martinez, Licensing Program Managers, Bethany Moellers and Kimberley Mota, Licensing Program Analysts, Julie Florio, David Leibert, and Jill Nakagawa, Administrators, Madonna Martinez and Gwen Martinez. The purpose of the informal meeting was to discuss citations for deficiencies observed on March 28, 2024, and recited on April 30, 2024, for failure to correct Plan of Corrections (POC) by the due date, as well an additional citation issued on this date. The following areas of concern were discussed: - Reporting Requirements - Administrator to ensure clearing POCs and responding to Community Care Licensing (CCL) communication requests. Administrator to submit the following outstanding POCs to CCL by COB 6/14/2024. Licensee was informed failure to submit by agreed upon date may result in additional civil penalties. - Administrator to sign self-certification stating they have reviewed regulation 87456 Incidental Medical and Dental Care. - Administrator to ensure that at least one staff on duty has CPR training at all times & all staff have First Aid. Administrator to submit proof of staff S1-S5 have current CPR training per regulation and S1-S4 have proof of current First Aid given by American Red Cross. - Administrator to submit copies of health screening by a physician, including a TB test and results for staff member S1. ** Licensee informed S1 is no longer working in facility and will submit written notice that all staff will have required documents on file for CCL review. Continued on 809-C... Continued from LIC809... - Administrator to send in proof of current medical assessment for resident R1 and statement from Administrator acknowledging their understanding of regulation 87705(c)(5) - Administrator to review all residents’ care plans, update them accordingly, and send self-certification to CCL that this process is complete. Licensee was informed that a citation is being issued today for administrator qualifications and duties, a written plan is requested to clear the citation due by 6/14/2024. The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and appeal of rights provided. Signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jun 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(a)(1) · Plan of correction due date: Jun 12, 2024

87405(d)(a) - (d)The administrator shall have the qualifications specified... (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by: inspection, the licensee diLPAs interviews, observations and records reviewed which show that Adminstrator has not been present a sufficent number of hours to properly meet the responsibilities of operating the facility. This is a potential risk to the health and safety of all residents in care.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: Licensee to ensure that the facility has a qualified, certified RCFE Administrator on-site as required by regulation. Licensee will also have a designated person listed on LIC308 to ensure continuity of care and operating regulations are met in the absence of Administrator. Submit the following documents to CCL by COB 6/14/2024: LIC500, LIC308, copy of Administrator's Certificate. Attn: LPA Florio

Type of visit: POC

Licensing Program Analyst (LPA) Hansen arrived unannounced on this day 5/7/2024 to conduct a Case Management -Plan of Corrections (POC) visit. Staff/LPA attempted to call Licensee/Admin Madonna Martinez but could only leave message regarding today's visit. On 3/28/2024 LPA conducted a continuation of annual inspection and cited facility 5 citations on deficiencies observed during inspection: 87705(c)(5) Care Persons with Dementia, resident did not have a physician’s report, 87463(c) Reappraisals, resident did not have reassessed care plan, 1569.618(c)(3) Employee Scheduling, staff did not have required current CPR or First Aid certification, 87411(f)Personnel Requirements, staff did not have health screening or TB report, & 87465(i) Incidental Medical and Dental Care, 4 months of medications to be destroyed were still at facility. Plan of Correction (POC) date for all was 4/10/2024. LPA gave extension to Licensee on 4/19/2024 to submit all POC’s by 4/22/2024. Facility did not clear citations and on 4/30/2024 LPA re-cited for all 5 citations & included citation 87405(a) Administrator – Qualifications and Duties as the RCFE Administrator's Certificate expired on June 20, 2023; A renewal application was submitted on February 26, 2024; The status of the renewal application is pending; The Administrator has stated that a renewal application was submitted timely in 2023 but has not produced documentation to prove the claim. LPA has conducted multiple visits and has yet to meet with the Administrator. All 6 POC’s were due 5/2/2024. Licensee has not corrected the POC’s by the due date. Civil Penalties issued for all 6 citations. Civil penalties are being assessed today in the amount of $500 X 6 = ($3,000.) for failure to correct POC’s and will continue to run at $100.00 per day per citation until corrected. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..the state’s words, verbatim · CDSS document, May 7, 2024

Type of visit: Case Management - Deficiencies

License Program Analyst (LPA) Shannan Hansen arrived at 9:30 AM to conduct an unannounced case management and met with Luisita Makalintal, staff who called Madonna Martinez, Administrator to inform of visit but was unable to speak with Admin. LPA also called Administrator but also was only able to leave a message. On 3/28/2024 LPA conducted a continuation of annual inspection and cited facility 5 citations on deficiencies observed during inspection: 87705(c)(5) Care Persons with Dementia, resident did not have a physician’s report, 87463(c) Reappraisals, resident did not have reassessed care plan, 1569.618(c)(3) Employee Scheduling, staff did not have required current CPR or First Aid certification, 87411(f)Personnel Requirements, staff did not have health screening or TB report, & 87465(i) Incidental Medical and Dental Care, 4 months of medications to be destroyed were still at facility. Plan of Correction (POC) date for all was 4/10/2024. LPA gave extension to Licensee on 4/19/2024 to submit all POC’s by 4/22/2024. As of today (4/30/2024) the department has not received corrections and is re-citing all 5 citations. LPA is also citing facility for 87405(a) Administrator – Qualifications and Duties as the RCFE Administrator's Certificate expired on June 20, 2023; A renewal application was submitted on February 26, 2024; The status of the renewal application is pending; The Administrator has stated that a renewal application was submitted timely in 2023 but has not produced documentation to prove the claim. LPA has conducted multiple visits and has yet to meet with the Administrator. Staff signed for administrator at today's visit. Exit interview conducted with Luisita Makalintal, Staff. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..the state’s words, verbatim · CDSS document, Apr 30, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: May 2, 2024

87405(a) Administrator – Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. *** Based on statements and documents reviewed, this requirement has not been met as evidenced by: The facility’s Administrator Certificate expired on June 20, 2023 and the renewal application, submitted 2/26/2024, is in pending status. This poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Apr 30, 2024

Plan of correction: Facility management shall hire an Administrator to comply with 87405(a) until the pending Administrator’s Certificate renewal application is approved. Administration to submit documentation that identifies the interim Administrator and will follow-up with documentation of the granted renewal certificate when issued.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(i) · Plan of correction due date: May 2, 2024

87465(i) Incidental Medical and Dental Care (i) Prescription medications which are not taken.. upon termination of services..are otherwise to be disposed of shall be destroyed. This requirement is not met as evidenced by: Based on LPAs observation and discussion with Administrator that the facility did not destroy aprox 8 bags of medications that have been kept for aprox 4 months, poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2024

Plan of correction: Administrator to ensure that facility is following required destruction procedures at all times. Items must be immediately destroyed according to Title 22 procedures. Administrator to sign self-certification that they have reviewed regulation 87456 Incidental Medical and Dental Care. Administrator agrees to send LPA Hansen self certification by 5/2/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: May 2, 2024

87705(c)(5) Care Persons with Dementia - Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: during inspection of R1's records it was observed R1 did not have a Physician Repoprt & Admin informed it was taken out to be replaced with updated after visit that has been scheduled . This is a potential risk to the health and safety of residents in carethe state’s words, verbatim · CDSS document, Apr 30, 2024

Plan of correction: Administrator agrees to send in proof of current medical assessment for resident R1 and statement they understand regulation 87705(c)(5) by POC due date of 5/2/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(c) · Plan of correction due date: May 2, 2024

87463(c) Reappraisals- (c)The licensee shall arrange a meeting with the resident, the resident’s representative... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement has not been met as evidenced by: Based on LPA file review showing that resident's care plans for 1 out of 4 resident (R1) were not been performed within last 12 months. This is a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Apr 30, 2024

Plan of correction: Administrator agreed to review all resident's care plans, update them accordingly and send self-certification that this process had been done to CCL by POC due date 5/2/2024.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.618(c)(3) · Plan of correction due date: May 2, 2024

1569.618(c)(3) Employee Scheduling - Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement was not met as evidenced by: Based on interview the licensee failed to have at least one staff member who has CPR and 1st Aid training on duty at all times. Facility has 5 out of 5 caregivers that work at the facility without a valid CPR certificate which poses a potential health, safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 30, 2024

Plan of correction: Administrator to ensure that at least one staff on duty has CPR training at all times & all staff have First Aid. Administrator to submit proof of staff S1-S5 have current -- CPR trained per regulation and S1-S4 have proof of current First Aid given by American Red Cross by POC due date 5/2/2024 or contact LPA to request extension.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: May 2, 2024

87411(f)Personnel Requirements – General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. This requirement is not met as evidenced by: Based on review of records, Staff S1 lack a health screening report, including TB test and results. the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2024

Plan of correction: Administrator to submit a health screening, including a TB test, and results and to submit copies of the documents to CCL by POC due 5/2/24.

Type of visit: Case Management - Annual Continuation

License Program Analyst (LPA) Shannan Hansen arrived at 10:30 AM to complete an unannounced annual inspection and met with Alice Jusi, staff called Madonna Martinez, Administrator to inform of visit. LPA spoke with Admin who authorized staff to sign today. There is a total of 4 residents. At approximately 10:40 am LPA recheck hot water temperatures in bathroom faucets used by residents, finding readings of 110.4 degrees F within regulations of 105 to 120 degrees F. At approximately 11:15 AM, LPA reviewed 4 of 4 resident records and found 4 of 4 residents have current Pre-Admissions Appraisals on file and 1 resident is needing Re-Appraisals, Licensee did not have on file. (see LIC 809-D) Physician’s reports (602’s) were current for all residents except 1 who has a dementia diagnosis and did not have in file (see LIC809D). At approximately 12:15 PM, LPA reviewed 5 of 5 staff records and learned, 5 of 5 staff (all work alone for some hours of shift) do not have proof of CPR training & 4 of 5 staff do not have proof of First Aid (see LIC809-D). Staff S1 does not have proof of Health Screening or TB clearance (see LIC 809-D). At approximately 1:30PM, LPA conducted review of Medication records which were found to be thorough and contained physician’s orders for each resident. LPA observed approximately 8 bags of medications in locked medication cabinet needing to be destroyed for over 4 months. (see pic & LIC 809-D). Administrator Certificate for Madonna Grace Martinez 6053462740 expired 6/20/2023. Administrator provided LPA proof they have sent in documents to renew certificate. Continue on LIC809-C LPA Hansen is requesting Licensee to update and submit the following documents by 4/24/2024 to SRRO: LIC 308 Designation of Facility Responsibility (if changed) LIC 500 Personnel Record LIC 610 Emergency Disaster Plan (if changes) Copy of Administrator Certificate Proof of Liability Insurance Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..the state’s words, verbatim · CDSS document, Mar 28, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Apr 10, 2024

87705(c)(5) Care Persons with Dementia - Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: during inspection of R1's records it was observed R1 did not have a Physician Repoprt & Admin informed it was taken out to be replaced with updated after visit that has been scheduled . This is a potential risk to the health and safety of residents in carethe state’s words, verbatim · CDSS document, Mar 28, 2024

Plan of correction: Administrator agrees to send in proof of current medical assessment for resident R1 and statement they understand regulation 87705(c)(5) by POC due date of 4/10/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(c) · Plan of correction due date: Apr 10, 2024

87463(c) Reappraisals- (c)The licensee shall arrange a meeting with the resident, the resident’s representative... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement has not been met as evidenced by: Based on LPA file review showing that resident's care plans for 1 out of 4 resident (R1) were not been performed within last 12 months. This is a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Mar 28, 2024

Plan of correction: Administrator agreed to review all resident's care plans, update them accordingly and send self-certification that this process had been done to CCL by POC due date 4/10/2024.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.618(c)(3) · Plan of correction due date: Apr 10, 2024

1569.618(c)(3) Employee Scheduling - Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement was not met as evidenced by: Based on interview the licensee failed to have at least one staff member who has CPR and 1st Aid training on duty at all times. Facility has 5 out of 5 caregivers that work at the facility without a valid CPR certificate which poses a potential health, safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 28, 2024

Plan of correction: Administrator to ensure that at least one staff on duty has CPR training at all times & all staff have First Aid. Administrator to submit proof of staff S1-S5 have current -- CPR trained per regulation and S1-S4 have proof of current First Aid given by American Red Cross by POC due date 4/10/2024 or contact LPA to request extension.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Apr 10, 2024

87411(f)Personnel Requirements – General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. This requirement is not met as evidenced by: Based on review of records, Staff S1 lack a health screening report, including TB test and results. the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 28, 2024

Plan of correction: Administrator to submit a health screening, including a TB test, and results and to submit copies of the documents to CCL by POC due 4/10/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Apr 10, 2024

87465(i) Incidental Medical and Dental Care (i) Prescription medications which are not taken.. upon termination of services..are otherwise to be disposed of shall be destroyed. This requirement is not met as evidenced by: Based on LPAs observation and discussion with Administrator that the facility did not destroy aprox 8 bags of medications that have been kept for aprox 4 months, poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 28, 2024

Plan of correction: Administrator to ensure that facility is following required destruction procedures at all times. Items must be immediately destroyed according to Title 22 procedures. Administrator to sign self-certification that they have reviewed regulation 87456 Incidental Medical and Dental Care. Administrator agrees to send LPA Hansen self certification by 4/10/2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Administrator, Madonna Grace Martinez was unavailable for today’s visit. There is 4 residents at facility, 4 with a dementia diagnosis, & 1 on hospice. LPA initiated a tour of the facility at approximately 10:30am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Hot water temperature measured between 162.8. degrees F to 145. degrees F in 3 out of 3 resident’s bathroom faucets falling out of Title 22 acceptable regulation of 105 to 120 degrees F. Staff adjusted water heater during visit and informed maintenance will be out today to adjust further. Facility has had previous water heater problems last year and water heater replacement. LPA will return at a later date to check water temperatures. Extra hygiene products and linens were available. Cabinet in kitchen containing cleaning supplies and cabinet containing knives was locked with a baby lock. LPA discussed the limitations of a baby lock in order to keep dangerous items inaccessible and discussed other options with Administrator. LPA observed a can of disinfectant in the bathroom cabinet that was not locked allowing access to residents in care. Staff immediately locked cleaner. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. During visit it was revealed in conversation with Home Health Nurse that resident (R1) has a stage 4 ulcer and facility will need to submit exception request by close of business tomorrow (3/20/2024). Failure to do so will result in a citation for retaining a resident wit a prohibited condition. Fire extinguisher was last inspected 2/14/2024. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent fire/disaster drill was conducted January, 2023. LPA initiated a file review of four resident files and 3 personnel files but were unable to complete. LPA was also unable to review medication and will return at a later date to complete annual inspection. No deficiencies cited during today's inspection.the state’s words, verbatim · CDSS document, Mar 19, 2024