Follow-up·May 28, 2025

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with Administrator (ADM), Nicholas Inneh. The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on 10/23/2024. LPA discussed the non-compliance plan with the ADM to include ensuring that all staff are trained to provide resident care meeting physical, emotional, and social needs; plan for regular observation from the resident and documentation of resident functioning changes; ensuring the facility is kept clean, safe, sanitary and in good repair, addressing bed bugs proactively and promptly; ensuring all incident and death reports are documented and reported to CCL per Title 22; ensuring all staff obtain a criminal record clearance and association to the facility; ensure all residents medical assessments include a TB result prior to admission; ensure all resident’s reappraisals are updated annually; ensure all meals meet dietary and physician ordered nutritional requirements, and ensuring the Administrator provides proper oversight and administration of the facility operations in alignment with Title 22 regulations. During visit, LPA toured the facility to include the resident bedrooms, hallways, bathrooms, dining room, kitchen, and exterior. 3 staff members present were observed to be fingerprint cleared and associated to the facility. See LIC809-C. LPA entered into all the resident bedrooms. There were no observation of bed bugs. Staff and ADM states the facility does not have any active cases of bed bugs. LPA observed staff actively cleaning the facility to include the resident bedrooms, bathrooms, and shower rooms during tour of the facility. LPA observed the facility has completed the cleaning and maintenance log. ADM showed that the pest control company last visited the facility on 05/19/2025. LPA observed bedroom #9 is currently occupied. 2 staff files (S1 - S2) was reviewed. 2 out of 2 staff were provided training by a certified trainer to include topics of assisting resident with ADLs (activity of daily living), dementia care, personal rights, basic medication training, reporting requirements, first aid, emergency procedures, food services, nutrition & hydration, infection control, observing and documenting resident changes, and communication & working with difficult behaviors. Administrator states they continue to implement regular check-in with staff every Friday for deep cleaning parts of the facility, monthly meeting with every staff, and daily meeting with the staff as part of their communication. 3 resident files (R1 - R3) was reviewed. 1 out of 3 residents is a new admissions to the facility as of March 2025. 3 out of 3 files were completed and up to date. ADM states they do not have any residents with a special diet per the physician. The Administrator was advised regarding the importance of adhering to the facility's corrective action plan that was developed on 10/23/2024 to ensure the facility's stays within compliance of Title 22 regulations. During visit, ADM signed the LIC809-D from the annual inspection on 04/24/2025, which was inadvertently amended. A copy of the LIC809-D was provided. On 05/23/2025, LPA emailed the Licensee and ADM regarding the outstanding civil penalty payment due. This was sent to the Licensee on 10/30/2024. During today's visit, ADM was again reminded of the outstanding civil penalty payment due to the Department. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Nicolas Inneh and a copy of the report was provided.