Non-compliance follow-up·August 19, 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. All rooms are currently occupied. There were no observation of bed bugs. ADM states the facility does not have any active cases of bed bugs. ADM states in July 2025 the pest control company found 1 bed bug on the mouse trap behind the refrigerator in the hallway. Upon discovery, the ADM inspected all resident beds and did not observe any beg bugs. ADM also followed-up with the residents who denied any case of bed bugs in their rooms. ADM states the pest control company last visited on 08/11/2025. ADM states the pest control company comes at least 2 times a month. LPA observed the facility has a cleaning and maintenance log. During visit, LPA observed staff actively mopping the floors of the facility. 2 staff files (S1 - S2) was reviewed. 2 out of 2 staff were provided training by the ADM and Relias on January 2025 and 04/08/2025 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. 3 out of 3 residents is a new admissions to the facility as of June and July 2025. 3 out of 3 files contained a TB result, pre-appraisal, and progress notes. The 3 residents does not have a special diet per their physician's report. 3 resident's appraisal/needs and services plan are not completed as of today's visit (08/19/2025). A type B deficiency was cited today per Section 87467(a) - Resident Participation in Decision Making wherein 3 resident's reappraisals are not completed. 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. On 08/18/2025, ADM emailed LPA Kabariti confirmation of the outstanding annual fee payment. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Nicolas Inneh and a copy of the report and appeal rights was provided.