Health check·July 24, 2025

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Case Management – Health Checks Inspection. LPA met with Staff #1 (S1) Richard Robles and discussed the purpose of the inspection. Administrator (AD) Cherie Wood arrived at the facility at around 9:45AM, about two hours after AD was called to the facility. AD stated they live about one to two hours away, depending on traffic, and Licensee (LE) Jing Struve lives about an hour away. Per AD, S1 is in charge when AD is not present at the facility, AD comes to the facility three or four times a week, and LE comes to the facility once or twice a month. AD stated they are the administrator for only one other facility in Los Angeles County Per S1, AD comes to the facility twice or three times a week, LE comes to the facility once or twice a month, and S1 is in charge when AD and LE are not here. LPA found S1 to be knowledgeable and competent to oversee the facility and assist LPA during the inspection before AD arrived and S1 was also highly knowledgeable about the conditions and needs of the residents. LPA reviewed the facility’s infection control policies, emergency disaster plan, and fire drills, and noted the facility does not have an infection control plan. LPA reviewed and obtained a copy of the resident roster, staff roster, staff schedule, and liability insurance. LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 8-bedroom, 10-bathroom, one-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA observed 2 staff and 6 residents present at the facility in addition to AD. Resident Bedrooms: the 6 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the 2 staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 110 and 116 degrees F in the 7 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are not yet due. LPA reviewed 6 resident files and 5 staff files, interviewed 6 residents and 3 staff, and inspected medications for 6 residents. Facility does not handle resident money. During the inspection, LPA hand-delivered the Noncompliance Conference letter dated July 15, 2025, to AD scheduling a Noncompliance Conference to be held in-person at the Orange County Regional Office on Tuesday, July 29, 2025, at 10:00 AM. During the inspection, LPA and AD observed the following: based on observation, the licensee is not following its fire clearance by placing a latch on the very top of the front door which LPA observed Staff #2 (S2) was unable to unlatch for almost 2 minutes while trying to open the door to allow LPA entry and which AD stated was installed to address Resident #1’s (R1) wandering; based on documents and admission, the facility does not have an infection control plan; based on documents and admission, the licensee has not been conducting quarterly emergency disaster drills as there is only one partially completed disaster drill log for 2025; based on documents and observations, the licensee did not ensure Resident #3 (R3) received assistance with medications when they did not receive their evening Donepezil 10MG once this month; and based on documents and admission, the licensee does not have Staff #4’s (S4) personnel file present at the facility or otherwise accessible during the inspection Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.