Non-compliance follow-up·January 27, 2025

Licensing Program Analysts (LPAs) Manuel Monter, Kenneth Madrigal & Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced Case Management- Legal/Non-compliance(NCC). LPAs met with Administrator (ADM) Bernelette Taa and stated the purpose of the visit. The purpose of this inspection was to ensure that the facility is in compliance with Title 22 Regulations and the compliance plan stated on LIC9111 NCC on 7/262024. LPA conducted a random review of 4 resident (R1 to R4) and 2 (S1 to S2) staff files, and toured the facility inside and out. During visit, LPA observed the staff room directly across to the dining area has been converted into two bedrooms/partition [1 for a resident and 1 for a staff (S1)]. On 11/18/2024, LPA observed 1 of the converted bedroom was occupied 1 male resident (R1) wherein a citation was not issued at the time of visit due to time constraint but discussed it with Administrator/licensee. Based on a review of STD850 issued on 1/30/2020 by the SJ Fire clearance and facility floor plan approved for 5 bedrooms including staff designated bedroom. ADM stated she did not obtain building permit prior to the building alterations. ADM stated R1 just no longer resides in the staff bedroom, as of January 26, 2025. In addition, while touring bedroom #3 and master bedroom , LPA observed a partition wall inside bedroom#3 and a little office (Photographs were taken) with no building permit including converting master bedroom into bedroom and a main master bedroom door was removed to expand as a hallway. These building alterations are not reflected on the submitted and approved fire clearance and physical plant in 2020. Further review of the STD850, the facility does not have a 'delayed egress,' a secure perimeter or is a locked perimeter with an exception of the swimming pool inaccessible to residents with 5 foot fence and is padlocked. CCLD will clarify and resubmit facility fire clearance to SJFD. Page 1 Out of 3. LPA conducted a staff file review for S1 to S5 S1's file was reviewed. S2's 1st Aid and CPR training has expired since 06/24/2024. health screening. S2 does not have a completed health screening signed by a physician. S3, S4 and S5 does not have a file. ADM stated that staff training on mental illness was conducted in 2024. ADM stated that staff training for 2025 is in progress. LPAs/LPM also review facility staffing. ADM (S3) stated that she has 1 full-time staff (S1) who works 5 days a week (730am to 12pm and 2pm to 6pm) with 3 hours break (12-2pm) during and is live-in. ADM stated that she lives in the facility, M to F from 12pm to 8am and on weekends 7pm to 7am; ADM's daughter visits once or twice a week; daughter is not an employee and her brother who comes to sleep once a week. Both ADM's daughter and brother has criminal background clearance. ADM stated that her husband (S4), who is a co-licensee, who works only on Fri and Sat 730am to 7pm, and 1 staff (S2) who works only on the weekends, 7am to 7pm. ADM's designated on-call administrator (referred as S5), does not have a file in the facility. ADM stated she will update CCL with any changes to the LIC500. During visit, LPAs/LPM assessed staff knowledge such as but not limited to mental illness, neurocognitve disorder and responding to emergency situation. S1 is able to respond to some of the questions. LPAs/LPM informed licensee to ensure that staff are provided in-service in the level that they understand. Also, the importance of maintaining staff files including training log (i.e., hours, date, trainees, topic). LPAs/LPM reviewed R1 to R4's LIC625 Appraisal Needs and Services Plan with ADM, LPAs/LPM advised ADM to have a method of evaluating residents' progress, such as data tracking. LPAs informed ADM to complete and update all the residents Appraisal Needs and Services Plans; detailing the residents care needs & what the facility is doing to meet their needs, and to ensure that residents' LIC625 is signed by the resident or residents' responsible party and licensee. During today's visit, LPAs/LPM observed two surveillance camera located, in the kitchen and living room area. ADM stated the video camera has the ability to record audio and video, but ADM clarified that the cameras are not recording audio. ADM removed cameras during visit. LPAs' informed licensee about, infringement of residents personal rights. LPAs' advised ADM to submit a program plan if she wishes to continue using video surveillance inside the facility. Page 2 Out of 3. LPAs' advised ADM if she requires a POC extension,she must send a written request to CCLD on or before the POC date by providing the following the reason and new POC date. Failure to complete/submit POC before due date may result to Civil Penalty. Deficiencies were cited during today's inspection and an exit interview was conducted with the licensee/ administrator Bernelett Taa. A copy of the report was provided. Appeal Rights were provided.