Routine inspection·August 14, 2025

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a required Annual inspection and was greeted by caregiver Edwin Taitano. Administrator Lily Alcones was in the Phillipines and staff called back up Administrator, Arthur Alcones to come to the facility. However, Mr. Alcones arrived at 10:17am. LPA requested a written plan from Licensee to address how they will ensure that back up administrator spends a reasonable amount of time in the facility, while Licensee/Administrator Lily Alcones is in the Phillipines to ensure resident's care needs will be met in case of an emergency and Community Care Licensing inspections. Facility contact information was reviewed. Annual fees are outstanding in the amount of $495. At approximately 9:00am LPA toured the building and grounds. The facility was found to be at a comfortable temperature. All bedrooms were equipped with required furniture. Fire extinguisher charged and serviced as of December 2024. Smoke detectors and carbon monoxide were tested and operational. Auditory alarms were found operational. Last disaster drill was conducted on 7/8/25. Extra hygiene products and linens were available. LPA observed at least a two day supply of perishable and seven day supply of non-perishable food. Kitchen drawer with sharp knives locked. Cabinets containing cleaning supplies locked. Resident's bathrooms had required bath mat and grab bar, but one out of two bathrooms did not have paper towels available for residents in care (technical advisory issued). At approximately 9:05am, LPA/staff observed a lock in the exit gate, during last annual conducted on 8/14/24, LPA reviewed fire clearance facility sketch and it was clarified with back up administrator to be an exit gate identified as an emergency exit. LPA have a conversation with back up administrator to remind them of this exit is identified as a fire clearance exit, and it must offer access for residents as an escape in emergency situations, the lock was removed by back up administrator. Continued on 809C... Continued from 809... Also, it was observed in resident's rooms cracks on the wall that needed to be repaired. Back up administrator showed LPA written communication with LPM Bertozzi dated June 2025 outlining their intentions to start a construction project where adobe clay of the foundation is settle causing the cracks on the walls. According to back up administrator, they are fully permitted to start the construction from the city of Santa Rosa to raise the foundation on the right side of the house by 4 to 6 inches, which according to the contractor it will be completely safe for the residents to stay in their rooms without a need to relocation. However, as described per the drill down will be around 20 feet and LPA has concerns of potential disruption due to noise that this project could cause to residents in care. LPA requested written plan to be submitted to CCL prior to start the expected construction September 14, 2025 along with copy of building permit from the City of Santa Rosa. The written plan should address how the facility will ensure the health and safety of residents in care while the construction occurs, as well as materials and equipment handling inaccessible to residents in care. Staff will be required to continuously remind and check all residents to make sure that they are not going to the construction site and notify their responsible parties. During tour of the facility, LPA inquired with staff regarding bed rails documentation been posted on the walls of resident's rooms. Upon inquire with staff (S1) who entered the room made an inappropriate comment to R1, by referring to them as "this one" and R1 stare at them. LPA raised the concern about staff needs to be respectful with resident's personal rights to back up administrator who addressed with S1 this incident. At approximately 9:10am, LPA/staff measured water temperature in faucets used by residents 129.2 and 126.5, which is not within the allowable range of 105 to 120 degrees F. Back up administrator adjusted water heater. **Civil Penalty assessed in total amount of $250.00 for repeated violation within 12 months. At approximately 9:15am LPA/staff observed a bag of ten carrots sitting on the kitchen counter it was spoiled and 18 cans of thick and easy were expired as of 1/31/25. Food was not been stored in a safe manner as indicated by regulation. Food was discarded by staff. During LPA's visit, there were no activities to be conducted with residents in care. LPA had a conversation with back up administrator who stated that residents are not engaged in any of the activities been offered. LPA suggested to review current activity calendar and update it to offer more engaging activities (technical violation issued). Continued on LIC809C... Continued from LIC809C... At approximately 9:20am, LPA/staff attempted to flush the toilet in the bathroom across from room number six and it was not working. Electric face plate located in the kitchen is broken and it needs to be replaced, During last annual visit conducted on 8/14/24, LPA cited fence in backyard needed to be repaired, handrails broken and base of handrails cracked. There was a frame of wood with nails exposed. Per back up Administrator it was agreed to be repaired, but it wasn't fully repaired. **Civil Penalty assessed in total amount of $250.00 for repeated violation within 12 months. LPA initiated file review at 10:00 am. LPA reviewed four residents files and three staff files. One out of four residents (R2) needs medical assessment to be updated and it was requested to their physician on 7/15/25 and facility is waiting on their response (technical violation issued). Resident's needs service plans are updated. The facility has implemented a computerized system to update resident's care plans and is maintained in the facility computer for accessibility. LPA/back up administrator discussed Dementia regulation changes including focus on person-centered care and provided resources including LIC602A form for their review. All three out of three staff do have current First Aid/CPR certificates and 20 hours of additional required training. Administrator Certificate for Lily Alcones, 7003673740, expires on 3/9/2026. Medications and medication records were reviewed. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report, LIC308- Designation of Responsibility and Liability Insurance. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. **Civil Penalties assessed in total amount of $250.00 each for repeated violation within 12 months. Exit interview conducted with Back up Administrator and a copy of this report was given.