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Inspection visit

Follow-up

ROWENA CARE HOMELicense 3427014928 citations on this visit
8 citations recorded

Inspector’s narrative

What the inspector wrote

On 12/15/2025, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced visit to the facility to complete a continued Post-Licensing inspection initiated on 12/12/2025. LPA Lee met with care staff Linjey Peart, who notified the licensee/administrator, Violet Mubeezi, of LPA’s presence. Approximately 30 minutes later, Administrator Mubeezi arrived at the facility, and LPA Lee explained the purpose of the visit. The facility census is 6 residents, with two staff members on duty. Administrator Mubeezi informed LPA Lee that resident R3 had been transferred to a skilled nursing facility and that R3’s responsible party had collected approximately half of R3’s belongings and will collect the rest at a later date. LPA Lee did observe that some of R3’s belongings remained in the resident’s room. The administrator holds a current certificate expiring on 09/09/2027. The facility is licensed for 6 non-ambulatory residents, has hospice waivers for 4 residents, and currently has one resident receiving hospice services. LPA Lee inspected the physical plant, including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, and outdoor courtyards, to assess compliance with Title 22 regulations. LPA Lee reviewed seven resident files on 12/12/2025 and today and they were not properly maintained or complete. All 7 resident files were missing Needs and Services Plans. R1’s file did not contain an LIC 602 Physician’s Report and tuberculosis (TB) clearance. LPA Lee was informed that R1 was transported to the emergency room, and the documents were provided to emergency medical personnel. CONTINUED LIC 809-C LPA Lee advised the administrator to maintain duplicate copies of required documents so one copy may be provided to emergency responders while another remains in the resident’s file. Additionally, LPA Lee reviewed the Centrally Stored Medication and Destruction Record (CSMDR) and Medication Administration Records (MARs) and found them to be inaccurate and not properly maintained. It was also learned that two of the seven residents had emergency room visits for which incident reports were neither completed nor submitted to the Department. Administrator Mubeezi acknowledged this omission. R3’s file did not have admission agreement for Rowena Care Home; however, the admission agreement was for Administrator’s other facility Crown Point Villa. Two staff files were reviewed and found to be complete. During 12/12/2025 visit, LPA Lee reviewed 2 out of 7 residents’ medication and it was learned that R7 had two medications that did not have a doctor's order to be administer to R7. R1 had 3 medications that were on hand; however, it was not documented in R1's CSMDR. LPA Lee advised that all residents’ medications need doctor’s order even medications that resident’s responsible party brings to the residents/facility. During the visit, LPA Lee observed that the lock previously attached to the refrigerator had been removed. However, a lock was observed on the pantry. Staff 1 (S1) stated that the pantry is locked at times. LPA Lee advised that neither the pantry nor the refrigerator may be locked in a manner that restricts resident access. The lock on the pantry was removed by S1 during the visit. The facility was observed to have an adequate supply of food. LPA Lee further observed that toxins and knives were accessible to residents in care. Administrator Mubeezi stated that cabinet locks had been ordered but would not be delivered until Wednesday. LPA Lee advised that these items be immediately secured in a locked area until the locks arrive. Administrator Mubeezi complied by relocating the items to a secured locked cabinet. During LPA Lee’s visit on 12/12/2025 , S1 was observed seated in staff room #4 supervising resident R7 . S2 was observed sleeping in resident room #8 , as S2 was assigned to the NOC shift . LPA Lee questioned the facility’s ability to provide adequate care and supervision to the remaining residents, as only one awake care staff member was on duty and was observed spending the majority of the visit in staff room #4 with the door closed while supervising R7 which raised concerns regarding who was providing care and supervision to the remaining residents during that time. CONTINUED LIC 809-C LPA Lee observed that the baby gate in resident room #3 had been removed; however, the bathroom in room #3 still did not a non-slip mat and during today's visit care staff purchased non-slip mat and was placed on residents bathroom. A non-slip mat was observed in the shower of resident room #1. The baby monitor camera in resident room #2 had been removed. During the facility tour, LPA Lee observed R7 sleeping in staff room #4, which is not a licensed resident bedroom and is not approved for non-ambulatory residents. LPA Lee advised the administrator that resident R7 will need to be relocated to an approved resident bedroom in accordance with the facility’s fire clearance , as resident room #8 is vacant. LPA Lee was informed that R7 would be relocated to resident room #1 , as resident R1 is not returning to the facility . LPA Lee advised the administrator that R1’s personal belongings remained in room #1 and instructed that the party responsible for R1 be contacted to inform them that the facility would gather and secure R1’s belongings in preparation for family retrieval, as the room would be occupied by another resident. LPA Lee observed that resident room #6 did not have a non-slip mat in the shower as well. Additionally, a Hoyer lift was observed blocking the emergency exit door leading to the backyard in resident room #6. The administrator removed the Hoyer lift during the visit. LPA Lee also observed that the emergency exit gate located on the right side of the facility has been removed; however, the exit door was not easily operable. Administrator stated that they will fix the gate. As a result of this continued post-licensing inspection, the facility was found to be out of compliance with California Code of Regulations, Title 22, and Health and Safety Code requirements. Deficiencies are documented on LIC 809-D and deficiencies cited during the initial post-licensing visit conducted on 12/12/2025. An exit interview was conducted with Administrator Mubeezi, and copies of LIC 809, LIC 809-D, and Appeal Rights were provided.

Citations

8 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87464(d)Type A

    Acceptance obligations tied to pre-admission appraisal needs

    87464(d) Basic Services(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.This was not met as evidenced by: During LPA Lee’s visit on 12/12/2025, S1 was observed seated in staff room #4 supervising resident R7. S2 was observed sleeping in resident room #8, as S2 was assigned to the NOC shift. LPA Lee questioned the facility’s ability to provide adequate care and supervision to the remaining residents, as only one awake care staff member was on duty and was observed spending the majority of the visit in staff room #4 with the door closed while supervising R7 which raised concerns regarding who was providing care and supervision to the remaining residents during that time. This is immediate health, safety or personal rights to person in care.

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  • 87465(a)(4)Type A

    Assist residents with self-administered medication

    87465(a)(4) Incidental Medical and Dental Care:(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.This was not met as evidenced by: Based on record review and interviews, the Licensee did not comply with the section cited above. During 12/12/2025 visit, LPA Lee reviewed 2 out of 7 residents’ medication and it was learned that R7 had two medications that did not have a doctor's order to be administer to R7. R1 had 3 medications that were on hand; however, it was not documented in R1's CSMDR. This posed an immediate health and safety risk to R1.

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  • 87468.1(a)(3)Type A

    Protection from punishment and intimidation

    87468.1(a)(3) Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.This was not met as evidenced by: The LPA Lee observed a chain and lock on the refrigerator and the pantry, which is an immediate health, safety or personal rights to persons in care.

  • 87468.1(a)(6)Type A

    Freedom to leave and not be locked in

    87468.1(a)(6) Personal Rights of Residents in All Facilities Type A(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above. LPA Lee observed resident in bedroom #3 had a gate on their door to prevent the resident from going out of their room to cause disturbances to other residents and from injuring themselves. Moreover, another resident was placed in staff room #4 with a gate installed by the door which poses an immediate health, safety or personal rights risk to persons in care.

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  • 87468.2(a)(1)Type A

    Right to personal privacy in daily care

    87468.2 (a)(1) Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.This was not met as evidenced by: Based on observation and interview residents were not permitted a reasonable level of privacy in their private bedrooms since there was a camera in the resident’s room, which poses an immediate health, safety or personal rights risk to persons in care.

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  • 87207Type A

    Prohibit false or misleading facility statements

    87207 False ClaimsNo licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.This was not met as evidenced by: During 12/12/2025 visit, both administrator and caregiver gave false statement in regard to R7 not being a resident but a grandmother or S1 who is babysitting S1’s son since the facility was over capacity by 1. This is immediate health, safety or personal rights to person in care.

  • 87211(a)(1)(D)Type B

    87211(a)(1)(D) Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…(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 interviews and record reviews, 2 residents went to the ER due to a fall and there was no incident report pertaining to the residents ER discharge records. Administrator admitted not completing any incident reports and submitting it to CCLD which poses a potential health, safety or personal rights risk to persons in care.

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  • 87405(d)(2)Type B

    Conformance with applicable laws and regulations

    87405(d)(2) Administrator - Qualifications and Duties(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.This requirement is not met as evidenced by: Based on observation, record review and interviews, the licensee/administrator did not ensure to comply with regulations to ensure that the facility is within compliance and fire clearance are being followed which poses a potential health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the December 15, 2025 inspection of ROWENA CARE HOME?

This was an other inspection of ROWENA CARE HOME on December 15, 2025. 8 citations were issued: 6 Type A (serious) and 2 Type B.

Were any citations issued to ROWENA CARE HOME on December 15, 2025?

Yes, 8 citations were issued (6 Type A, 2 Type B). The first citation was for: "87464(d) Basic Services(d) A facility need not accept a particular resident for care. However, if a facility chooses to..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.