Correction check·June 30, 2025

Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a case management (CM) Plan of Correction POC follow up visit. LPA Tamayo met with facility staff Isikeli Tuikenatabua (S2) and explained the purpose of the visit. Ombusdman Byron Toiliver was also present during this visit. Upon arrival, LPA Tamayo observed three staff members (S2-S4) present and working. Administrator, Cleopatra Gardiner (S1) was not present during this CM POC follow up visit nor was she at the facility during the last case management visit that was conducted on 6/13/25. on 6/13/25,S2 stated S1 was not working that day due to being out sick. On 6/17/25, LPA Tamayo emailed a copy of the 809-D from CM visit that took place 6/13/25. S1 responded back via email on 6/17/25 stating they will submit the POC by the due date of 6/27/25. No POC verification has not been received by the Regional Office as of today, 6/ 30/ 2025 and POC is overdue. A civil penalty for failure to correct applied due to outstanding plan of correction regarding reporting requirements. Additionally, a posted LIC 500 Personnel Report dated 6/202/25 indicates S1 is scheduled to work Monday thru Wednesday 7:00 AM-7:00 PM. There is no LIC 308 on file or submitted to Community Care Licensing informing the administrator will be out of the facility and who is designated facility responsibility. The return date for the administrator is unknown by staff (S2, S3, S4 ) and residents (R1, R2, R3. During today’s visit S3 stated has been out of the facility on vacation in New York for about one month. Three residents stated they have not seen S1 for a long time for about “2 months” and do not know where S1 is. Initially, S2 stated S1 has been out on vacation for two weeks, but when LPA Tamayo asked why staff (S3) and 3 residents (R8, R4,and R3) say they have not seen S1 for 1- 2 months. [continued on 809-C] S2 then stated that S1 has not been at the facility since 1 month and does not know S1’s return date. S2 stated they are “kind of” in charge while S1 is out. S2 called S1 via phone call and they sent over an LIC 308 which designates S2 as responsible. S2 stated they do not have an administrator certificate. LPA Tamayo is concerned for the operation of the facility due to having no/minimal administrator oversight. LPA measured the water temperature in the two resident bathrooms, temperature measured at 144 degrees F which does not meets the 105-120 degree Fahrenheit regulation. LPA measured the water temperature in kitchen faucet, temperature measured at 98 degrees F which does not meets the 105-120 degree Fahrenheit regulation. LPA observed toxins including cleaning products such as Clorox and Lysol sprays were located in bathroom cabinet and under the kitchen and kept unlocked and accessible to residents. LPA observed toxins including cleaning products such as Clorox and Lysol sprays were located in bathroom cabinet and under the kitchen and kept locked and inaccessible to residents. LPA observed S2 lock both cabinets immediately during this visit when asked to do so. As this is a repeat violation, an additional civil penalty of $250 is hereby assessed. LPA reviewed Resident Records for R1-R8 and observed there were incomplete forms including missing signatures/name, dates, and information for resident forms including consent forms to receive medical treatment and admission agreements. LPA reviewed Physicians report for residents (R1-R8). R3 is prescribed Morphene (To be administered three times per day). LPA saw there is no Morphene medication left, as the 90 pills were filled on 5/22/25 and were finished on 6/21/2025. However, MARS records show that S2 signed off on Morphene medication being administered to R3 three times a day 6/22/25-6/29/25 and at 8:00AM on 6/30/25. S2 stated they signed/initialed the MARS for R3 Morphene medication was taken but they shouldn’t have from 6/22-6/20/2025. Additionally, S2 stated they gave R3 their personal over the counter Tylenol on 6/29/25 around noon due to R3 having pain. Tylenol is not listed for R3. LPA Tamayo was concerned about R3’s medical state and asked R3 if they would like EMS to be contacted. R3 requested immediate medical attention at 3:40 and EMS was immediately contacted by S2. EMS arrived at 3:55PM and transported R3 to the hospital. LPA Tamayo reminded staff an Unusual Incident Report (UIR/SIR) is required for Emergency Transport of residents. S2 gave LPA Tamayo SIR at 4:30PM. Continued on 809-C No Plan of Correction for CM visit dated 6/13/25 has been received, a civil penalty is assessed due to failure to correct. The follong deficiencies are cited on the corresponding 809-D per California Code of Regulations, TITLE 22. At 6:54 PM and exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.