Love and Serenity of Elk Grove III.
A small home, reviewed on public record.
Compared to 68 California facilities with a similar number of beds.
RCFE · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
among peers to rank.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
Citation history, plotted month by month.
7 deficiencies on record. Each bar is a month with a citation.
Finding distribution
7 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility.
State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.
Plain language
Because a facility markets dementia or Alzheimer's care, state law mandates higher training standards: 12 hours of initial dementia training (6 hours before a staff member works independently with residents, 6 more within the first 4 weeks), 8 hours of annual dementia in-service every year thereafter, and an administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle. Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour
“Can you show me each direct-care staffer's most recent dementia training certificate, and tell me when their next refresher is due?”
Every inspection visit, verbatim.
12 inspections in the public record, most recent first. Plain-language summaries open first — click into any row for the full citation text.
2025-07-08Other VisitType A · 3 findings
“Based on interview and record review, the licensee did not comply with the section cited above. One staff on duty (S1) did not have current 1st aid/CPR certificate (expired 3/6/25); Also, S2 did not have any records available for review during this visit. This poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 07/09/2025 Plan of Correction 1 2 3 4 Per discussion, S1 will obtain their first aid/CPR certificate and submit proof by POC due date.”
“Based on record review and interview, the licensee did not comply with the section cited above. Staff on duty (S2) did not have their personnel records at the facility avaialble for review. This poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/15/2025 Plan of Correction 1 2 3 4 Per discussion facility representative (S1), licensee agreed to submit a written statement of understanding of the regulation related to personnel records. Per discussion, licensee agreed to ensure personnel records are maintained at the facility and available for review at any time.”
“Based on record review, the licensee did not comply with the section cited above. Resident R1 did not have updated Needs and Services Plan and was last updated 4/4/23. This poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/15/2025 Plan of Correction 1 2 3 4 Per discussion with facility representative (S1), the licensee will submit a written statement of understanding regarding the regulation cited by POC due date. Per discussion with facility representative (S1), licensee will ensure all residents in care have updated/current Needs and Services Plan.”
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On 7/8/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced at this facility to conduct their annual inspection visit. LPA met with Staff on duty, Omar Slypher (S1), and stated the purpose of the visit. LPA also met with another staff on duty, Felipe Naikaso (S2) who is being trained by S1 during this visit. Present during this visit were 4 residents in care with 2 staff on duty. Overview : Facility is a one-story home located in a residential neighborhood. Facility is cleared to serve up to 6 ambulatory and non-ambulatory residents, may be diagnosed with dementia/neurocognitive disorder. Facility is approved to serve one resident receiving hospice. Initial Observation: Upon arrival LPA noted 2 staff on duty (S1 and S2). LPA also noted that one resident in care was having their morning meal at the second living room by the fireplace. Other residents was in their rooms. One resident was observed to be listening to music while lying down. S1 was orienting S2 during this visit. Physical Inspection : Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the inside of the facility to be clean and in good repair at this time. LPA inspected 3 of 5 resident bedrooms and were observed to be equipped with the required furniture and sufficient lighting throughout. LPA measured the hot water temperature in 2 resident bathrooms between 115 and 116 degrees Fahrenheit. In 1 of 2 bathroom, LPA observed the towel holder to be falling off. Room temperature was observed at 68 degrees Fahrenheit. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguisher was observed at the medication area and were last inspected on 1/8/2025. Smoke and carbon monoxide detectors were observed. {Con't to 809-C} 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 {Con't from 809} LPA observed centrally stored medications, toxins, and sharp objects were kept locked and inaccessible to residents in care. No bodies of water was observed at this time. Fireplace was observed to be screened and non-operational at this time. Outdoor area was inspected. Facility has a covered patio and outdoor furniture for resident use. Ramps were observed to be in good repair at this time. Emergency walkways were observed to be unobstructed. Facility has 1 side gate exit. The gate is self locking and in good repair at this time. Part of the fence at the right side of the facility was observed to be slightly wobbly and in need of repair as soon as possible. Record Reviews: Review of 2 of 4 resident files (R1, R2) was conducted, include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. R1 did not have updated Needs and Services Plan on file; it was last updated 4/4/23. Medication review of 2 residents (R1, R2) include review of physician orders for over-the-counter medications. No issues were noted at this time. Review of 2 staff files (S1, S2) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. S1's First Aid/CPR certificate expired on 3/6/2025. S1's ongoing training records were not available for review during this visit. S2's records were not available for review during this visit, except for a documentation for background clearance. Per review of Guardian, both S1 and S2 are associated to this facility. Administrator to submit current Liability Insurance Certificate, LIC500 and LIC308 to the Department. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during today's visit. Exit interview was conducted with S1. A copy of the report and appeal rights information were provided upon exit.
2025-04-08Complaint InvestigationNo findings
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On 4/8/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to conduct a case management visit. LPA met with staff on duty, Omar Slypher (S1) and stated the purpose of this visit. Administrator, Bianca Castro, was notified of this visit. Present during this visit were 4 residents in care with 1 staff on duty (S1). Overview: During a Non-Compliance Conference (NCC) meeting with Bianca Castro, Licensee, on 11/6/2024, regarding another facility under her administration, the Department determined that increased monitoring was required to ensure the facility's compliance. The Department has also determined that licensee is not to admit new residents until further notice and to appoint new administrator. Licensee has agreed to these terms. LPA conducted a physical inspection of the facility. Room temperature was measured at 76*F and hot water temperature was measured at 115.9 degrees Fahrenheit in one of the resident bathrooms located near the laundry room by the garage door. 3 resident bedrooms were inspected and were observed to be clean and good repair. 2 resident bathrooms were inspected and was observed to be maintained and in good repair. Kitchen was observed to be clean and in good repair. Facility continues to maintain at least 2-day perishables and 7-day nonperishables food items. Medications, sharp objects, cleaning supplies, and other dangerous materials were observed to be locked and inaccessible to residents in care. Bianca remains the current administrator; no new administrator has been hired. However, a change of ownership is currently in the process. Per interview with S1, no new residents have been admitted since the last visit on 3/5/2025. Exit interview was conducted with Omar and a copy of this report was provided.
2025-03-05Other VisitNo findings
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On 3/5/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to conduct a case management visit. LPA met with staff on duty, Omar Slypher (S1) and stated the purpose of this visit. Administrator, Bianca Castro, was notified of this visit. Present during this visit were 3 residents in care with 1 staff on duty (S1). 1 of 4 resident was out in the community. Overview: During a Non-Compliance Conference (NCC) meeting with Bianca Castro, Licensee, on 11/6/2024, regarding another facility under her administration, the Department determined that increased monitoring was required to ensure the facility's compliance. The Department has also determined that licensee is not to admit new residents until further notice and to appoint new administrator. Licensee has agreed to these terms. LPA conducted a physical inspection of the facility. Room temperature was measured at 76*F and hot water temperature was measured at 116.8*F in one of the bathrooms. 2 resident bedrooms were inspected and were observed to be clean and good repair. 1 resident bathrooms was inspected and were observed to be maintained and in good repair. Kitchen was observed to be clean and in good repair. Facility continues to maintain at least 2-day perishables and 7-day nonperishables food items. Medications, sharp objects, cleaning supplies, and other dangerous materials were observed to be locked and inaccessible to residents in care. Bianca remains the current administrator; no new administrator has been hired. Per interview with S1, no new residents have been admitted since the last visit on 2/11/2025. Per interview with S1, no new staff have been associated to the facility since the previous visit on 2/11/2025. Per Bianca, she will provided 60-day notice to all residents in care on 3/6/2025 regarding the change of ownership that is currently in process. Exit interview was conducted with Omar and a copy of this report was provided.
2025-02-11Other VisitNo findings
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On 1/23/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct a case management visit. LPA met with staff on duty, Omar Slypher, and stated the purpose of the visit. The administrator, Bianca Castro, was notified of the visit and gave permission to Omar to sign this report. Present during this visit were 3 residents in care with 1 staff on duty. LPA conducted a physical inspection of the facility. Room temperature was measured at 75*F and hot water temperature was measured at 115*F in one of the bathrooms. 2 resident bedrooms were inspected and were observed to be clean and good repair. 2 resident bathrooms was inspected and were observed to be maintained and in good repair. Kitchen was observed to be clean and in good repair. Facility maintains adequate amount of food items. Medications, sharp objects and toxic chemicals were observed to be locked and inaccessible to residents in care. Fire extinguisher was observed to be maintained and was last serviced on 1/8/2025. LPA noted that two residents were in their bedroom watching TV, while one was in the living room watching squirrels in the backyard. The other resident was out in the community for an appointment. The outdoor area appeared to be well-maintained at the time. The staff on duty was observed cleaning and preparing dinner. Bianca remains the current administrator, and no new administrator has been hired. No new residents have been admitted since the last visit on 1/23/25. According to the staff on duty, no new staff have been associated to the facility since the previous visit on 1/23/25. Exit interview was conducted with Omar and a copy of this report was provided.
2025-01-23Other VisitNo findings
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On 1/23/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct a case management visit. LPA met with staff on duty, Omar Slypher, and stated the purpose of the visit. The administrator, Bianca Castro, was notified of the visit and gave permission to Omar to sign this report. Present during this visit were 4 residents in care with 1 staff on duty. Case Management Visit - Health Checks During today’s visit, LPA conducted a physical tour of the facility. Upon arrival, LPA observed one resident in the family room watching squirrels play on the fence and interacting with LPA. Other residents were in their bedrooms. The room temperature was noted to be 76°F, and the hot water temperature in one hallway bathroom was measured at 115°F. The kitchen was found to be clean and in good repair, and food supplies appeared to be adequate. LPA also reviewed the files of 2 residents, including their admission agreements, needs and services plans, medical assessments, and ambulatory statuses. LPA noted that no new admissions have occurred since the Non-Compliance Conference (NCC) on 11/6/24, with the most recent admission being on 10/25/24. At present, no residents are receiving hospice services, and the bedrooms are being used appropriately according to the residents' ambulatory clearance. Case Management Visit - Death Report Death report stated that resident (R1) passed away of natural causes. Additionally, R1 was receiving hospice services. Prior to this, R1 was hospitalized on 10/9/2024 due to unwitnessed fall occurred at this facility which resulted in wound on the face and hospitalization. Per interview with facility staff, Omar, after hospitalization, R1 was discharged to a skilled facility for rehabilitation. Interview with Omar revealed that after being discharged from skilled facility, R1 returned to this facility on hospice care. R1 was on hospice care until their death. Death report was received timely on 12/23/2024. Copy of death report, incident report and discharge document from skilled facility was obtained. Exit interview was conducted with Omar and a copy of this report was provided.
2025-01-02Other VisitNo findings
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On 1/2/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit. LPA met with Omar Slypher, staff on duty (S1). The administrator, Bianca Castro, was notified of this visit and gave permission to S1 to sign this report. Present during this visit were 4 residents in care with 1 staff on duty (S1). During a Non-Compliance Conference (NCC) meeting with Bianca Castro, Administrator, on 11/6/2024, regarding another facility under her administration, the Department determined that increased monitoring was required to ensure the facility's compliance. The Department has also determined that licensee is not to admit new residents and to appoint new administrator. Licensee has agreed to these terms. Per observation, upon LPA's arrival to this facility, one resident was dropped off by a driver (S2) from their appointment. S2 also picked up another resident for another appointment. S2 is currently associated to this facility. LPA conducted physical inspection of the facility including but not limited to living room, resident bedrooms, bathrooms, kitchen and outdoor area. Room temperature was observed at 72 degrees F. Hot water temperature was taken in one of the bathrooms and was measured at 114 degrees F. Facility maintains 2-day perishable and 7-day non perishable food supplies. Fence and gate were observed to be in good repair at this time. LPA conducted a record review of one resident (R1) who was admitted prior to the NCC meeting held on 11/6/2024, which include review of admission agreement, medical assessment, and needs and services plan. According to an interview with Bianca, she has not yet identified a new administrator for this facility at this time as she stated she has having difficulties with recruiting. No deficiencies are being cited at this time. Exit interview was conducted with S1 and a copy of this report was provided.
2024-11-21Other VisitNo findings
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski spoke with facility administrator Bianca Castro over the phone. Castro said caregiver Omar Slypher could sign this report in her absence. This visit is to confirm immediate exclusion orders for a staff member (S1). Castro acknowledged that S1 is excluded effective immediately, which means that S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders this facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Castro said that S1 never worked at this facility. Castro said S1 had been working at another facility for which she is administrator, but Castro said S1 has not been working there for over a month. Castro agreed to remove S1 from all facility Guardian rosters as soon as possible. No deficiencies were cited during this visit. An exit interview was held with Slypher. A copy of this report and the immediate exclusion notice were left with Slypher. A signature on this report acknowledges receipt of these documents.
2024-10-29Other VisitNo findings
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On 10/29/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit. LPA Villanueva met with one of the staff on duty and explained the purpose of the visit. The Administrator Bianca Castro was notified of the visit and gave permission to S1 to sign this report. Present during today's visit were 5 residents in care with 1 staff on duty (S1). During this visit, S1 was assisting residents and preparing resident meal for dinner. During this visit, LPA obtained copy of resident files (R1, R2, R3, R4, R5 and R6), including their Identification and Emergency Information, current Physician Report and current Needs and Services Plan. Per Administrator, this facility is not certified Assisted Living Waiver Program at this time. No deficiencies are being cited during today's visit. Exit interview was conducted with S1 and a copy of this report was provided.
2024-10-24Complaint InvestigationMixedType B · 1 finding
“Based on interviews and record reviews, facility did not initiate a fall prevention measures after R1’s multiple fall incidents. This posed a potential health and safety risk to residents in care.”
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A review of incident reports revealed multiple falls involving R1. On 11/15/23 , R1 fell after lunch, hitting their forehead. The incident was unwitnessed, and Alpha One was notified. On 2/22/24 , R1 fell while attempting to reach the dining room; it was unclear if the fall was witnessed. Staff found R1 on the floor, and Alpha One was called. On 4/18/24 , R1 experienced two falls in one day. These falls were witnessed by outside agency visiting that day. Additionally, R1 was displaying combative behavior not typical of their baseline which prompted facility staff to send R1 to emergency hospital. Staff were present, yet no preventive measures were documented post-incident. Note that additional incidents of falls involving other residents in care were reviewed, specifically those dated 7/17/24, 5/28/24, 12/10/23, 11/12/23, and 10/18/23. Review of the facility's policies and procedures, provided by Administrator Bianca Castro, outline actions to take after a fall occurs but fail to include proactive measures to prevent falls. The document emphasizes the need for timely medical care but does not address risk mitigation strategies. There is a clear gap in compliance with the expectation that facilities develop and implement a fall prevention plan, especially for high-risk residents like R1, who was assessed as a fall risk. Resident R1 was noted to have several risk factors, including: abnormal gait and mobility; non-ambulatory status, requiring the use of a front-wheel walker; and history of a medical condition (C1), which may contribute to instability. Despite these factors being documented, there is no evidence that staff are following a systematic approach to monitor or mitigate these risks, further substantiating the allegation of non-compliance. As a result of the investigation, the preponderance of evidence standards has been met, therefore, the allegation that facility staff are not following facility procedures for resident falls was SUBSTANTIATED due to the absence of a fall prevention plan and the documented incidents highlighting the facility’s lack of proactive measures to prevent future falls. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. LPA discussed Plan of Correction with Administrator and gave permission to S1 to sign this report. Exit interview was conducted with S1 and a copy of this report and appeal rights were provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Upon reviewing R1’s Medication Administration Record from September 2022 to June 2024, LPA found that staff were administering R1's medications as prescribed. While the PRN Authorization Letter dated February 26, 2024, was incomplete—lacking a physician's signature and not clearly indicating R1's ability to communicate their needs—the overall administration of medications followed the prescribed guidelines. Staff member (S1) confirmed that R1 could express their needs regarding PRN medications, particularly for sleep. For the M1, it was noted that the dosage varied between one and two tablets, in line with the prescription allowing for this flexibility. Despite some oversights, such as the lack of documentation indicating that the physician or nurse was consulted before administering PRN medications, the actual administration of R1's medications, including M3 and M1, was consistent with the prescribed orders. For M2, multiple administrations were documented, reflecting adherence to the prescription aimed at managing R1's agitation. Although there are concerns regarding the thoroughness of documentation and communication with healthcare providers, the evidence does not have preponderance of evidence that the allegation that staff are not administering medications as prescribed by doctor. Therefore, the allegation is UNSUBSTANTIATED. Exit interview was conducted with S1 and a copy of this report was provided.
2024-09-20Annual Compliance VisitNo findings
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On 9/20/2024, at 4:51 pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit and return a resident (R1)'s file. LPA met with staff on duty (S1) and explained the purpose of the visit. The Administrator, Bianca Castro, was made aware of this visit and gave permission for S1 to sign this report. Today’s visit there were 5 residents in care with 1 staff on duty (S1). On 9/19/24, this facility was visited by this LPA and requested to remove R1's file for the purpose of copying relevant documents at the Regional Office. Administrator was made aware of this request. During this visit, LPA Villanueva returned R1’s file and was received by S1. Per California Code of Regulations, Title 22, no citations were issued during this visit. An exit interview was held with S1a nd a copy of this report was provided.
2024-08-14Complaint InvestigationUnsubstantiatedNo findings
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Additionally, resident interviews affirmed their satisfaction with the food provided. One resident stated the food as nutritious. Inspection of food supply: On several visits on 8/14/24, 7/18/24, and 5/9/24, conducted by this LPA revealed facility to have a well-stocked refrigerator and freezer containing different vegetables, meats, breakfast items, fruits, eggs, milk, juices and snacks. Inspection of their pantry include Included non-perishable items such as canned foods, boxed pastas, cereals, and rice, as well as fresh potatoes and onions. Meal observations: LPA observed the meal preparations on different visits. One observation where ground meat and a variety of fresh vegetables were being cooked. During the same visit, residents' lunch was observed with a balanced meal including a bologna sandwich, salad, chips, and juice. Residents (R4 and R5) expressed satisfaction with the food quality, describing it as nutritious and enjoyable. Also during today's visit, LPA observed S1 prepared chicken burger for residents' lunch along with chips and pudding and choice of beverages. Based on interviews, observations of food preparation and supply, and feedback from residents, there was not preponderance of evidence to substantiate the allegation that staff do not ensure that residents receive adequate quality and quantity of food and liquid. The facility appears to be meeting residents' dietary needs, with appropriate food supplies and positive feedback from residents. However, LPA is unable to determine if this practice is sustained daily, therefore, the allegation is deemed UNSUBSTANTIATED. Note that a finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with S1 and a copy of this report was provided. {2 of 2}
2024-07-18Annual Compliance VisitType A · 3 findings
“Based on interview and record review, the licensee did not comply with the section cited above. 1of 6 resident who is non-ambulatory (per review of LIC602A) was placed in a bedroom (labeled #4 on the facility sketch) which was not fire cleared with non-ambulatory use. Additionally, staff confirmed resident is non-ambulatory and needs assistance with ambulating. this poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 07/19/2024 Plan of Correction 1 2 3 4 Licensee/Administrator agreed to submit a plan on how the citation will be corrected to the Department by the POC due date.”
“Based on interview and record review, the licensee did not comply with the section cited above. 1of 6 resident who is non-ambulatory (per review of LIC602A) was placed in a bedroom (labeled #4 on the facility sketch) which was not fire cleared with non-ambulatory use. Additionally, staff confirmed resident is non-ambulatory and needs assistance with ambulating. this poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 07/19/2024 Plan of Correction 1 2 3 4 Licensee/Administrator agreed to submit a plan on how the citation will be corrected to the Department by the POC due date.”
“Based on observation, the licensee did not comply with the section cited above. During an inspection of the garage, LPA observed paint containers on the floor and are accessible to residents. Although the door to the garage was locked, residents can still unlock it from the inside, which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/25/2024 Plan of Correction 1 2 3 4 Licensee/Administrator agreed to submit a plan on how they will correct the citation to the Department by the POC due date.”
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On 7/18/24 at 10 am Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct their required annual visit. LPA met initially with staff on duty (S1). The Administrator, Bianca Castro (ADM) was notified of the visit. Per S1, facility is COVID-free status. Present during this visit are 5 residents in care and 1 staff members on duty. At 10:30am LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, other common areas, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a single-story home with a fire clearance to serve elderly residents and hospice approved for one (1). Facility has 5 resident bedrooms, one staff bedroom and 3 bathrooms for resident use. Bedroom #3 is a shared bedroom and has its own bathroom. Bedroom #4 on the facility sketch is fire cleared for ambulatory resident only. LPA observed 2 bathrooms to contain grab bars, non-skid flooring, shower chairs, close lid trash containers and hygiene supplies. Resident bedrooms were sanitary, furnished, well-lit and had adequate space for resident’s belongings. The facility common areas are cleaned and furnished. Facility has a dining area off the kitchen and a formal living room. Fireplace was observed to be screened and not in use. In the kitchen area, LPA observed the kitchen to be sanitary and free of clutter. Additionally, the kitchen knives and other sharp objects are kept locked under the kitchen sink and not accessible to residents. Toxins and cleaning supplies are also kept locked under the kitchen sink. LPA observed the facility to have adequate food supply with at least 2 days’ worth of perishables and 7 days’ worth of non-perishables. LPA observed the laundry room to be sanitary and observed cleaning detergents to be locked and inaccessible to residents. Inside the garage, LPA observed paint containers accessible to residents. However, the garage door was observed to be locked but residents can unlock and access it from the inside. {Page 1} 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The front yard and the backyard are observed to be free of obstruction and maintained. LPA observed the ramp on the front to be in need of repair soon as evidenced by the chipped wood in the middle of the ramp. Additionally, the backyard has a covered patio and furnished with outdoor furniture for outdoor activities. LPA observed part of the fence (right side of facility) was leaning. Technical assistance was provided to repair (or replace) the ramp and the fence. Water temperature reads 118*F and room temperature reads 76*F. Smoke and carbon detectors were tested and operable. Fire extinguisher was serviced on 4/5/24. Medication storage area was observed to be locked and inaccessible to residents in care. Medication records were reviewed and in compliance with regulation. First aid kit was observed to have adequate supplies and accessible to staff. During this inspection 6 resident records and 3 personnel records were reviewed for regulatory compliance. Staff records contained required contents including staff training requirements. Staff noted on LIC 500 contained criminal background clearances. Resident records reviewed contained required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Through record review, it was revealed that a resident with non-ambulatory status was placed in a bedroom that was not fire cleared for non-ambulatory resident. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Evidence of quarterly fire drills was Immediately not available for review during this visit. ADM faxed a copy of the last 2 fire drill log to the facility. Technical assistance was provided to document quarterly drills and always maintain documents in the facility and readily available for review upon request. Note that LPA conducted the inspection using the CARE tool. The facility has an approved infection control plan in place. LPM requested an updated copy of current Liability Insurance, LIC 308, LIC610D and LIC 500. Per California Code of Regulations, Title 22 and Health and Safety Codes, the following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Note that a civil penalty was assessed during this visit in the amount of $ _____ due to fire clearance violation. Interview was held with S1 and a copy of this report and appeal rights were provided. {Page 2}
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