Colonial Acres Residential Care Home
What is an RCFE with Memory Care?
A Residential Care Facility for the Elderly (RCFE) is a non-medical residential care home licensed by California CDSS under Health & Safety Code §1560. Residents receive help with daily living activities such as bathing, dressing, and medication management. An RCFE with a Memory Care designation is additionally required by California Title 22 (§87705 and §87706) to provide specialized staff training in dementia care, individualized care plans for residents with cognitive impairment, and appropriate supervision protocols — requirements that go beyond a standard RCFE license.
18905 Standish Avenue · Hayward, 94541
Record last updated April 20, 2026.
© Google Street View
Quick facts
Memory care context
Colonial Acres Residential Care Home is a California-licensed RCFE with 20 beds and a memory care designation, operated by John Ronald Olivarez. California Title 22 requires facilities serving dementia residents to meet specific standards under §87705 and §87706, covering individualized care plans, staff training in dementia care, and appropriate supervision. CDSS has cited Colonial Acres under §87705 or §87706 on four occasions, indicating regulatory scrutiny of its dementia care practices. State records show 20 inspection reports on file with 44 total deficiencies: 18 Type A citations (actual harm to residents) and 26 Type B citations (potential for harm). Five complaints have also been investigated. The most recent inspection occurred on November 13, 2025.
Questions to ask on your tour
Based on Colonial Acres Residential Care Home's state inspection record.
State records show 18 Type A deficiencies indicating actual harm to residents — what were the specific circumstances of these citations, and what corrective actions were implemented?
Four citations under §87705 or §87706 relate to dementia care requirements — what specific deficiencies were identified, and how has staff training or supervision changed as a result?
Five complaints have been filed with CDSS — what were the subjects of those complaints, and which were substantiated by state investigators?
With 44 total deficiencies across 20 inspection reports, what systemic changes has the facility made to address recurring compliance issues?
California Title 22 §87705 requires dementia-specific staff training — how do you verify that all caregivers working with your 20 residents have completed required training, including overnight staff?
State records
California CDSS · Community Care Licensing Division- License number
- 019200664
- License type
- RESIDENTIAL CARE ELDERLY
- License status
- LICENSED
- License expires
- Not yet indexed
- Licensed beds
- 20
- Operator
- Olivarez, John Ronald
Inspections & citations
20
reports on file
47
total deficiencies
18
Type A (actual harm)
4
dementia-care citations
InspectionNovember 13, 2025No deficiencies
Inspector: Alicia Delmundo
Inspector notes
Facility submitted an Unusual Incident Report (UIR) for resident R1 late last year. UIR indicated R1 had an un-witnessed fall at the front door of the facility. Staff called ambulance and R1's responsible person was informed. Hospital staff called the facility and informed that R1 sustained injury. On this day, LPA conducted case management visit and met with staff, Maria Dolores Floriza, John Ronald Olivarez, licensee, and Celeste Olivarez, facility consultant. LPA conducted interviews. R1 did not return to the facility. LPA requested for R1's records, and licensee and facility consultant were not able to find R1's file. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Deficiency and plan and proof of correction were discussed with facility consultant. Exit interview conducted. Appeal Rights. LIC9098 Proof of Correction form and copy of this report.
ComplaintDecember 20, 2024Type A1 deficiency
Inspector: Alicia Delmundo
Inspector notes
Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with John Ronald Olivarez, licensee. LPA also met with Celeste Olivarez, facility staff/consultant. LPA later met with Sarah Balingit, administrator. LPA informed the purpose of visit. Facility has completed COVID-19 mitigation plan and submitted to Community Care Licensing (CCL). LPA observed a hand sanitizer and a box of disposable gloves located close to the entrance door and visitor's log close to the office. Staff were observed wearing mask. Supplies of centrally stored PPEs inspected. LPA inspected the facility inside out with Sarah. LPA randomly selected 5 residents and staff rooms for inspection. LPA also inspected 3 common bathrooms, staff bathroom, dining area, kitchen, front and backyard. There were at least 7 days of nonperishable and 2 days of perishable food supplies.. Fire extinguishers were observed fully charge and tags showed serviced August 2, 2021. Hot water temperature in the 1 of the bathroom sinks was tested and measured at 118.4 degrees Fahrenheit. LPA observed the following: 1. Three bedrooms inside the staff room. Each of these rooms have door and permanent walls. 2. No COVID-19 signages through out the facility. No hand washing posters in the kitchen and bathroom sinks. No 6 feet physical distancing signs. 3. No visitor and no "Wear mask" posters on the entrance door. ....continued on 809C 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 4. Trash cans without lids in all 3 bathrooms and trash can's lid in the kitchen not "touch free". 5. Supplies of N95 respirators and surgical masks not sufficient for 30 days. No disposable gowns and face shields. 6. Staff were not fit tested for N95 respirators. Administrator to submit the following updated documents to CCL by November 23, 2021: 1. LIC500 Personnel Report 2. LIC610E Emergency Disaster Plan 3. Proof of $3M liability insurance LPA reminded that the annual fee is due by November 16, 2021. Deficiency is cited from Title 22 California Code of Regulations (see 809D). A $500.00 civil penalty is assessed for section 87202(a) and will continue for $100.00/day until corrected. Deficiency and plan and proof of correction were discussed with Sarah Balingit. Exit interview conducted. Appeal Rights, LIC421IM, LIC9098 Proof of Correction form and copy of this report provided.
87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal
Based on observation, the licensee did not comply with the section cited above by adding 3 bedrooms inside the staff rooms. License failed to submit updated facility sketch so CCL can request for fire safety inspection. This poses an immediate safety risk to persons in care. A $500.00 civil penalty is assessed. POC Due Date: 11/10/2021 Plan of Correction 1 2 3 4 Administrator to submit the following by November 10, 2021: 1. Updated facility sketch showing the follwing: exit doors and windows; …
InspectionNovember 14, 2024Type A16 deficiencies
Inspector notes
On this day, November 13, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Maria Dolores Floriza, and informed the reason for visit. John Ronald Olivarez, licensee, arrived at around 10:56 am. Licensee left at around 4:30 pm. LPA started inspection with Maria Dolores Floriza and continued with licensee. LPA inspected the kitchen, dining area, living/tv room, common areas, bathrooms and staff room. LPA randomly selected 5 residents rooms for inspection. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Hot water temperature in lavatory in one of the resident's rooms was tested. Fire extinguishers were observed fully charge with tags showed serviced September 23, 2025. Disaster drill records reviewed. LPA reviewed 5 staff and 5 residents files, and interviewed 1 resident. Medications checked, and compared with LIC622 Centrally Stored Medication and Destruction Records and doctor's orders. Facility does not handle residents' cash resources. Copies of the following updated/current documents were obtained on this same day: 1. LIC610E Emergency Disaster Plan (9 pages) 2. $3M Liability insurance certificate ....continued on 809C 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 Licensee to submit copies of the following updated documents by November 27, 2025: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report The following deficiencies were observed, cited from Title 22 California Code of Regulations, and listed on 809Ds: -at 10:45 am and 11:26 am, front and back entrance/exit doors with locks operable with code. -at 11:00 am, resident's medication in the refrigerator. -at 11:02 am to 11:04 am, knives, kitchen shears, razor, lighter in kitchen drawers without locks. -at 11:05 am, knives and cleaning agents in unlocked kitchen cabinets and Vit D3 on kitchen counter. -at 11:23 am, loose light switch cover in one the residents' rooms. -at 11:25 am, hot water temperature at 121.3 degrees Fahrenheit. -at 11:27 am, dowels in another entrance/exit door. -at 11:30 am, unlocked utility room where cleaning supplies are kept. -at 11:40 am, 2 in one smoke/carbon monoxide detector not working due to no battery. -at 12:30 pm, facility does not conduct disaster drill every quarter; records showed last conducted 01/2025 and 04/2025. -at 1:25 pm and 1:50 pm, staff (S2 and S5) CPR/First Aid/AED certificates expired 11/11/25. -at 1:35, to 1:55 pm, staff, S3 & S4, do not have the required total 40 hours required training for 2024 and 2025 respectively. No TB test and LIC503 Health Screening on file. -at 2:30 pm, residents, R1 and R2, half bed rails have no doctor's order on file. -at 2:40, residents, R2 and R3, Physician's Reports/medical assessments are over a year old. -at 2:50 pm, resident, R4, LIC625 Appraisal/Needs and Services Plan is more than 2 years old. -at 3:25 pm, resident, R5, has doctor's order for a medication to be administered daily but facility does not have this medication. Facility does not have LIC622 Centrally Stored Medication and Destruction for all the medications received by the facility nor have complete record for medications administered. A $500.00 immediate civil penalty is assessed for deficiency section 87203 and $250.00 each for repeat violations of the following sections: 87309(a); 87303(a); 87303(e)(2); 1569.695(c); 87565(a)(4); 87608(a)(3). Failure to submit proof of corrections by plan of correction due dates may result in addtional civil penalties. ....continued on 809C 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 Deficiencies and plan and proof of corrections were discussed with licensee over the phone, and authorized Maria Dolores Floriza. Exit interview conducted. Appeal Rights, LIC421IM, LIC421FC Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
Based on observation, the licensee did not comply with the section cited above in carbon monoxide not working due to no battery which poses an immediate safety and/or personal rights risk to persons in care. POC Due Date: 11/14/2025 Plan of Correction 1 2 3 4 Corrected. Licensee put battery while LPA was at the facility.
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate safety and/or personal rights risk to persons in care: unlocked knives, kitchen shears, lighter, razor, cleaning agents in the kitchen. THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD. POC Due Date: 11/14/2025 Plan of Correction 1 2 3 4 Staff removed and locked all the items. In addition, licensee to in-service the staff and stated he will have lock installed on the kitc…
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutio…
Based on observation, the licensee did not comply with the section cited above inunlocked utility room where cleaning supplies are kep which poses an immediate safety and/or personal rights risk to persons in care. POC Due Date: 11/14/2025 Plan of Correction 1 2 3 4 Licensee locked the room. In addition, licensee to in-service the staff.
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications ........(1) Medications shall be centrally stored........ (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medicati…
Based on observation, the licensee did not comply with the section cited above in medication on the kitchen counter and resident's medications unlocked in the refrigerator which pose an immediate health, safety and/or personal rights risk to persons in care. POC Due Date: 11/14/2025 Plan of Correction 1 2 3 4 Staff locked the items. Licensee to in-service the staff and submit proof by 11/14/25.
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
Based on observation, the licensee did not comply with the section cited above in loose light switch cover in resident's room which poses a potential safety and/or personal rights risks to persons in care. THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD. POC Due Date: 11/27/2025 Plan of Correction 1 2 3 4 Licensee to have the switch cover fixed and submit picture by 11/27/25.
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degre…
Based on observation, the licensee did not comply with the section cited above in hot water temperature at 121.3 degrees Fahrenheit which poses a potential health and/or personal rights risks to persons in care. THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD. POC Due Date: 11/27/2025 Plan of Correction 1 2 3 4 Licensee to have the water temperature adjusted to a temperature within Regulations range and submit proof by 11/27/25.
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.
Based on records review, the licensee did not comply with the section cited above in R2 and R3's medical assessments (Physician's Report) over a year old which pose a potential health and/or personal rights risks to persons in care. POC Due Date: 11/27/2025 Plan of Correction 1 2 3 4 Licensee to have a medical assessment schedule for R2 and R3 and submit copies of LIC602A by 11/27/25.
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as speci…
Based on record review)], the licensee did not comply with the section cited above in R4's LIC625 Appraisal/Needs and Services Plan more than 2 years old which poses a potential health and/or personal rights risks to persons in care. POC Due Date: 11/27/2025 Plan of Correction 1 2 3 4 Licensee to have the re-appraisal performed and submit copy of LIC625 by 11/27/25.
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill,…
Based on record review, the licensee did not comply with the section cited above in not conducting drills every quarter which poses a potential safety and/or personal rights risks to persons in care. THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD. POC Due Date: 11/27/2025 Plan of Correction 1 2 3 4 Licensee to have drills conducted and submit copy by 11/27/25,
87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as th…
Based on records review, the licensee did not comply with the section cited above in staff (S2 and S5) certificates expired which pose a potential health, safety and/or personal rights risks to persons in care. POC Due Date: 11/27/2025 Plan of Correction 1 2 3 4 Licensee to have S2 and S5 register for training and submit copies of certificates by 11/27/25.
87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) m…
Based on records review, the licensee did not comply with the section cited above in S3 and S4 not having TB test and LIC503 Health Screening on file which pose a potential health and/or personal rights risks to persons in care. POC Due Date: 11/27/2025 Plan of Correction 1 2 3 4 Licensee to have the staff undergo health screening and submit proof by 11/27/25.
§1569.625 Staff training; legislative findings; contents : (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall com…
Based on records review, the licensee did not comply with the section cited above in S3 & S4 not have the required total 40 hours required training which pose a potential health, safety and/or personal rights risks to persons in care. POC Due Date: 11/27/2025 Plan of Correction 1 2 3 4 Licensee to have the staff complete training and submit proof by 11/27/25.
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A)to(F).
Based on records review, the licensee did not comply with the section cited above for not having LIC622 Centrally Stored Medication and Destruction for all the medications received by the facility nor have complete record for medications administered for R5 which pose a potential health and/or personal rights risks to persons in care. POC Due Date: 11/27/2025 Plan of Correction 1 2 3 4 Licensee to have the records completed and submit proof by 11/27/25.
87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A writt…
Based on records review, the licensee did not comply with the section cited above in not having doctor's orders for R1 and R2's half bed rails which pose a potential health, safety andor personal rights risks to persons in care. THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD. POC Due Date: 11/27/2025 Plan of Correction 1 2 3 4 Licensee to obtain doctor's orders and submit copies by 11/27/25.
87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic
Based on observation, the licensee did not comply with the section cited above in Installing a door hardware operable with code in 2 entrance/exit doors and having dowels in the other entrance/exit door which poses an immediate health, safety or personal rights risk to persons in care. A $500.00 civil penalty is assessed. POC Due Date: 11/14/2025 Plan of Correction 1 2 3 4 Corrected. Licensee removed and replaced the door hardwares and replaced with a 'no-knowledge' type and removed the dowels…
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as n…
Based on record review, the licensee did not comply with the section cited above in not having one of R5's prescribed medications which poses an immediate health and/or personal rights risks to persons in care. POC Due Date: 11/14/2025 Plan of Correction 1 2 3 4 Licensee to have the medication obtained and submit picture by 11/14/25.
ComplaintJune 20, 2024· SubstantiatedCitation on file
Inspector: Alicia Delmundo
Substantiated — CDSS found a violation and issued a citation. Full citation details are on file with the state.
Inspector notes
Page 2 Allegation: Resident (R1) developed stage 4 pressure injury while in care. R1 was admitted to the facility on 1/08/22, and the Pre-placement Appraisal did not indicate that R1 had a pressure injury, however, the LIC602A Physician’s Report indicated that R1 had contractures to the upper and lower extremities, required continuous bed care, had fragile skin and needed to be repositioned every 2 to 3 hours. John Olivarez, licensee, stated that R1 has dementia, was bed bound and fully contractured when admitted to the facility and that R1 was always in fetal position. Licensee stated R1 was admitted to the facility as it was their hope that R1 could get to the point where R1 could sit up on her own. R1’s pressure injury was reported to him by staff which at the time he believes it was stage 1. The pressure injury worsened Staff (S3) stated she does not believe R1 should be admitted to the facility because S3 felt that R1 needed a higher level of care. R1 has dementia and needed assistance with all activities of daily living, with both feet and hands being contractured, and R1 was difficult to reposition. S3 also stated that the first person to notice the pressure injury was R1’s previous caregiver - when this private caregiver visited R1 and changed R1’s diaper and reported the pressure injury to her. S2 stated having noticed the wound which was approximately the size of a quarter. R1 had home health but S2 was not able to report anything because she never saw them, or she was busy assisting other residents. Between the time R1’s home health was terminated to the time R1 was hospitalized, S2 was cleaning R1’s wound. In September 2022, S2 noticed R1’s wound grown to about the size of a golf ball with soft center and had some pus. Two out of 3 residents interviewed did not know or remember R1 while the other 1 stated R1 can walk but R1’s documents and staff interviewed stated R1 is bedridden. Previous administrator (S1) stated R1’s daughter requested ambulance transportation on September 2022 to the hospital per advice nurse and R1’s doctor. Medical records showed R1 was admitted to the hospital on 9/16/22 and diagnosed with stage 4 sacral pressure injury and unstageable pressure injury at right lateral pelvis. .....continued on 9099C (page 3) 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 Page 3 FM1 stated when R1 was admitted to the facility, R1’s pressure injury in the sacrum was superficial and eventually healed after home health services for 1 to 2 months. In May 2022, the pressure injury came back and R1 was placed on home health again and was discharged when the wound was not completely healed because the home health nurse felt it was okay to discharge R1 so long as the staff continue to change the dressing and reposition R1. FM1 and FM2 stated that they visited R1 several times a week for 30 minutes to 3 hours and staff did not check R1 unless they asked. FM1 stated she visited R1 on September 2022 on R1’s birthday and R1 was lethargic, unresponsive and barely able to eat. FM1 discussed the pressure injury with R1’s physician and requested for home health service. After 2 days, R1 was visited by a home health nurse and said that the injury was too advanced to treat with home health. FM1 called 9-1-1. Medical records showed R1 was admitted to the hospital on September 16, 2022 and was diagnosed with stage 4 pressure injury in the sacrum and unstageable pressure at right lateral pelvis. Based on interviews and records review, the allegation is substantiated. Allegation: Staff allowed resident to become severely dehydrated while in care. Staff (S2, S3 and S4) interviewed provided differing information in regard to R1 eating and drinking. S3 stated R1’s eating habits were inconsistent and that at the time of admission, R1 ate well and able to drink Ensure and water. S3 stated R1 ate a little, didn’t drink much, and noticed that R1 was dehydrated. S4 stated R1’s appetite and liquid intake were good, and that R1 was able to drink half a glass of water without issue. W1 and W2 stated that when they visited R1 and requested the staff to assist in transferring to wheelchair so that W1 can feed R1, the staff responded with an assumption that R1 will not eat. W1 stated that on their last visit prior to R1’s hospitalization, R1 appeared dehydrated. R1’s family members FM1 and FM2 stated that during heat wave, the facility has electric fans spread out in the facility blowing hot air around. R1 was sweaty, hot and lethargic. FM2 stated she brought misting fan that blows water to keep R1 cool; however, when FM2 visited R1 the fan was off and R1 was sweaty. The staff blamed each other for turning off the fan. R1 was sent out to the hospital and was diagnosed with hypernatremia and septic shock due to UTI among others. Based on information obtained, the allegation is substantiated. ........continued on 9099C (page 4) 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 Page 4 Allegation: Staff did not seek timely medical attention for resident. Medical records showed R1 developed stage 4 pressure injury in the sacrum and unstageable pressure injury at right lateral pelvis and staff did not seek medical attention. It was R1’s family member who called 9-1-1. Allegation: Staff left resident soiled in urine for an unreasonable period of time. FM1, FM2, W1 and W2 stated they observed R1 soaked in urine. W1 stated that on 2 out of the 3 visits to R1, W1 observed R1 wet with urine and on one of these 2 visits, R1 was soaking wet up to the waist and W1 asked S3 for assistance when W1 changed R1. Based on interviews, the allegation is closed as substantiated. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. A $500.00 civil is assessed for deficiency section # 1569.269(a)(6) and will continue for $100.00/day until corrected. Deficiencies, plan and proof of corrections and civil penalty were discussed with ADM and licensee. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form, and copy of this report provided.
Other visitJune 20, 2024Type A12 deficiencies
Inspector: Alicia Delmundo
Inspector notes
At 12:30 pm on this day, November 14, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with John Ronald Olivarez, licensee, and informed the reason for visit. LPA also met with staff, Maria Dolores Floriza, Macario Balingit, Jackylen Mendoza and Celeste Olivarez. LPA toured the facility inside out with licensee. LPA inspected the kitchen, dining area, living/tv room, common areas, staff and laundry room, bathrooms, side and backyard. LPA randomly selected 6 residents rooms for inspection. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Facility has 2 in 1 carbon monoxide detector that was tested and observed in operating condition. Hot water temperature in the common bathroom was tested. Disaster drill records reviewed. Fire extinguishers were observed fully charge with tags showed serviced September 17, 2024. LPA reviewed 5 staff and 5 residents files, and interviewed 2 residents. Medications checked, and compared with LIC622 Centrally Stored Medication and Destruction Records and doctor's orders. Facility does not handle residents' cash resources. The following updated/current documents were obtained on this same day: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) Licensee or administrator to submit by November 28, 2024 a copy of $3M Liability insurance certificate. ....continued on 809C (page 2) 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 Page 2 The following deficiencies were observed, cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties. -at 12:35 pm, the 3 entrance/exit doors with no auditory signals. -at 12:39 pm, residents medications in 2 refrigerators unlocked. -at 12:44 pm, cleaning supplies/agents in unlocked cabinet in the kitchen. -at 12:47 pm, peritoneal cleanser and broken drawer in residents' room. -at 12:50 pm, wound cleanser in the cabinet under the sink in another resident's room. -at 12:55 pm, wound dressing, saline solution, grooming kit in the night stand drawer in another resident's room. -at 1:01 to 1:03 pm, insect killer, wound cleanser, staff medications, liquid laundry soap, Clorox spray in unlocked staff's room. -at 1:12 pm, water temperature at 127.4 degrees Fahrenheit. -facility has new administrator who took over the position when Adeliza Magallones resigned in September 13, 2024 and licensee failed to notify the Department. -at 2:30 pm, records showed disaster drills last conducted July 6 and 9, 2024. -at 4:00 pm. resident (R2) was discharged back to the facility on 7/2024 with LIC602A Physician's Report indicated stage 3 pressure injury and dependent on others with all activities of daily living (ADLs); however, R2 is able to feed self. LIC625 not updated. -at 5:00 pm, all 5 resident's half bed rails do not have doctor's order on file. -at 5:45 pm, resident (R1) doctor's order for Acetaminophen is 650 mg tablet, 2 tablets PRN but the medication in facility's hand is 325 mg tablet, 2 tablet PRN. Has doctor's order for Vascepa but facility does not have this medication. Order for ducosate sodium is 50 mg 1 capsule daily but medication on hand is 100 mg twice daily. Order for Atorvastatin is 20 mg 1 tablet at bedtime but medication on hand is 10 mg 1 tablet at bedtime and facility administers 10 mg. Order for Amlodipine is 5 mg once daily and the medication on hand is 10 mg once daily. ...continued on 809C (page 3) 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 Page 3 -at 7:00 pm, resident (R5) doctor's order for prenisolone is 1 mg, 3 tablets daily but medication on hand is 1 mg, 1 tablet daily and facility administers only 1 mg 1 tablet daily. Has PRN order for Senna and Lorazepam and facility does not have these medications. Deficiencies and plan and proof of corrections were discussed with licensee. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degre…
Based on observation, the licensee did not comply with the section cited above in hot water at 127.4 degrees Fahrenheit which poses an immediate health and/or personal rights risks to persons in care. POC Due Date: 11/15/2024 Plan of Correction 1 2 3 4 Licensee to have the temperature adjusted within Regulations range and submit proof by 11/15/24.
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate safety and/or personal right risks to persons in care: unlocked kitchen cabinet where cleaning supplies are kept; insect killer, laundry soap, Clorox spray, wound cleanser, staff's medications in unlocked staff room POC Due Date: 11/15/2024 Plan of Correction 1 2 3 4 License locked the items and the staff room. In addition, licensee and/or administrator to in-service the s…
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
Based on observation, the licensee did not comply with the section cited above in all 3 entrance/exit doors' auditory signals/device turned off & not working which pose an immediate safety and/or personal rights risk to persons in care. POC Due Date: 11/15/2024 Plan of Correction 1 2 3 4 Corrected. Staff fixed and turned on the auditory signals.
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health, safety and/or personal rights risk to persons in care: residents medications unlocked in the refrigerator; saline solution, wound and peritoneal cleansers, grooming kit in residents' rooms POC Due Date: 11/15/2024 Plan of Correction 1 2 3 4 Licensee locked all the items. In addition, licensee and/or administrator to in-service the staff and submit copy of training top…
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
Based on observation, the licensee did not comply with the section cited above in broken drawer in resident's room which poses a potential safety and/or personal rights risks to persons in care. POC Due Date: 11/28/2024 Plan of Correction 1 2 3 4 Licensee and/or administrator to have the drawer fixed and submit picture by 11/28/24.
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, …
Based on observation, the licensee did not comply with the section cited above in R2 who had change in condition and admitted back to the facility and LIC625 not updated which poses a potential health, safety and/ or personal rights risks to persons in care. POC Due Date: 11/28/2024 Plan of Correction 1 2 3 4 Administrator to update R2's LIC625 and submit copy by 11/28/24.
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill,…
Based on record review, the licensee did not comply with the section cited above in not conducting the disaster drill every quarter which poses a potential safety risk to persons in care. POC Due Date: 11/28/2024 Plan of Correction 1 2 3 4 Administrator to have the drill conducted and submit copy by 11/28/24.
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physicia…
Based on records review, the licensee did not comply with the section cited above in 5 out of 5 residents' half bed rails not having doctor's orders on file which pose a potential safety and/or personal rights risks to persons in care. POC Due Date: 11/28/2024 Plan of Correction 1 2 3 4 Administrator to obtain doctor's order and submit copies by 11/28/24.
87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
Based on records review, the licensee did not comply with the section cited above In R2 who has stage 3 pressure injury was admitted back to the facility. which poses a potential health and/or personal rights risk to persons in care. POC Due Date: 11/28/2024 Plan of Correction 1 2 3 4 Licensee to obtain an updated stage of pressure injury from a wound doctor or wound nurse. If stage is still stage 3, licensee stated he'll submit exception request; otherwise submit an updated copy of wound ass…
87458 Medical Assessment (c) The licensee shall obtain an updated medical assessment when required by the Department.
Based on record review, the licensee did not comply with the section cited above in R2's LIC602A indicating R2 needs assistance with all ADLs but R2 can feed self. This poses a potential personal rights risk to persons in care. POC Due Date: 11/28/2024 Plan of Correction 1 2 3 4 Administrator to obtain updated LIC602A and submit copy by 11/28/24
87211 Reporting Requirements (g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator.
Based on interview and record review, the licensee did not comply with the section cited above in not notifying the Department when a new administrator was hired poses a potential health and/ or personal rights risks to persons in care. POC Due Date: 11/28/2024 Plan of Correction 1 2 3 4 Licensee to submit a signed letter along with copies of the new administrator's certificate, LIC501 Personnel Record by 11/28/24.
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as n…
Based on observation and records review, the licensee did not comply with the section cited above in R1 and R5 not having the right medication dosages, not having certain medications, and facility not administering the dosage as precribed which pose an immediate health and/or personal rights risk to persons in care. POC Due Date: 11/15/2024 Plan of Correction 1 2 3 4 Licensee and/or administrator to check with R1 and R5’s physicians for updated doctor’s orders and administer the medications …
Other visitApril 19, 2024No deficiencies
Inspector: Alicia Delmundo
Inspector notes
On this day, June 20, 2024, an LIC9102 Technical Advisory is being issued resulting from investigation of complaint (15-AS-20240617080839) conducted by Licensing Program Analyst (LPA) Delmundo. The license admitted to disclosing health information of prospective resident to prospective roommate (facility resident). LPA discussed the above with the licensee and administrator. No deficiency cited. Exit interview conducted, and copy of this report provided.
Other visitApril 11, 2024No deficiencies
Inspector: Alicia Delmundo
Inspector notes
On this day, April 19, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit. LPA m et with Adeliza Magallones, administrator, and informed the reason for visit. On 4/11/24, LPA conducted the first POC visit for the citations issued on 3/21/24 with POCs to be submitted by 4/04/24. Licensee failed to submit the POCs by the due and civil penalties were assessed on 4/11/24. Most of the documents (POC) requested for one of the deficiencies, section # 1569.269(a)(3), were only submitted by the licensee on 4/16/24. Additional civil penalty is assessed for deficiency section # 1569.269(a)(3). Civil penalty = $100.00/day x 5 days (from 4/12/24 to 4/16/24)= $500.00 Civil penalty was discussed with t he Adeliza Magallones. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, and copy of this report provided.
ComplaintMarch 21, 2024· UnsubstantiatedNo deficiencies
Inspector: Alicia Delmundo
Unsubstantiated — CDSS investigated and did not find violations.
Other visitMarch 21, 2024No deficiencies
Inspector: Alicia Delmundo
Inspector notes
On this day, 12/20/24, at 4:10 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management resulting from the investigation of a complaint (15-AS-20220927100258) by the Department. LPA met with Mary Eileen Legados, administrator (ADM), and informed the purpose of visit. John Ronald Olivarez, licensee, arrived after about an hour. During investigation, the Department observed the following: 1. Resident's (R1) LIC602A Physician's Report dated 1/25/2 2 i ndicated the following: non-ambulatory and bedridden; contractures on lower & upper extremities; advanced frontotemporal dementia; fractured pelvis (unable to rehabilitate). The staff interviewed indicated R1 needs to be repositioned. LIC9020 Register of Facility Clients/Resident was bedridden. 2. LIC602A showed R1 was dependent on others with all activities of daily living (ADLs). 3. R1's LIC9172 Functional Capability Assessment was incompletely filled-up. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil is assessed for deficiency section # 87202(a)(2) and will continue for $100.00/day until corrected. Deficiencies, plan and proof of corrections and civil penalty were discussed with licensee and ADM. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form, and copy of this report provided.
InspectionNovember 9, 2023No deficiencies
Inspector: Alicia Delmundo
Inspector notes
Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit. LPA met with Celeste Olivarez, facility consultant, and Adeliza Magallones, administrator, and informed the reason for visit. On 3/21/24, LPA issued citations for the following deficiencies with POCs to be submitted by 4/04/24. Licensee failed to submit the POCs up to this day. Civil penalties are assessed on this day, 4/11/24, and will continue for $100.00/day until POCs are submitted:. 1. Complaint Investigation deficiency section # 1569.269(a)(3). Licensee has not submitted proof that documents were released. nor responded to the reporting party's request and follow-ups. Civil penalty = $100.00/day x 7 days (from 4/05/24 to 4/11/24)= $700.00 2. Case management deficiency section 87405(a). Magallones who stated she quit as administrator on 12/31/23 and came back 4/03/24; however, licensee failed to submit proof that a full time administrator is hired. Civil penalty = $100.00/day x 7 days (from 4/05/24 to 4/11/24)= $700.00. In order to satisfy the POC, licensee to submit the following: signed letter indicating Magallones has been re-hired with effective date she took the position; copy of current administrator certificate; LIC500 Personnel Report POCs and civil penalties were discussed with the Celeste Olivarez and Adeliza Magallones. Exit interview conducted. Appeal Rights, LIC421FCs Civil Penalty Assessments, LIC9098 Proof of Correction form, and copy of this report provided.
Other visitJune 21, 2023Type A15 deficiencies
Inspector: Alicia Delmundo
Inspector notes
Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Adeliza Magallones, administrator, and informed the purpose of the visit. LPA also met with Celeste Olivarez, facility consultant, and staff, Mary Eileen Olivarez-Legados, Ethel David, Bonifacio Flores and Maria Dolores Floriza. Facility has Infection Control Plan that was submitted on June 30, 2022. LPA toured the facility inside out with Adeliza Magallones and Mary Eileen Olivarez-Legados. LPA inspected the kitchen, dining area, living/tv room, common areas, staff and laundry room. bathrooms, side and backyard. LPA randomly selected 5 residents rooms for inspection. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Facility has 2 in 1 carbon monoxide detector that was tested and observed in operating condition. Hot water temperature in one of the common bathrooms was tested and measured at 119.2 degrees Fahrenheit. LPA reviewed 5 staff and 5 residents files, and interviewed 3 staff and 3 residents. Medications checked, and compared with records and doctor's orders. Facility does not handle residents' cash resources. The following updated/current documents were obtained on this same day: 1. LIC308 Designation of Facility Responsibility 2. Proof of $3M liability insurance coverage Administrator to submit the following updated documents by November 23, 2023 : 1. LIC500 Personnel Report 2. LIC601E Emergency Disaster Plan (9 pages) ......continued on 809C 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 Page 2 The following deficiencies were observed and cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections (POCs) by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties. -at 11:04 am, medicines in the medicine box with broken lock in the refrigerator. -at 11:06 am, expired sour cream with mold. -at 11:19 am Albuterol inhaler solution in the drawer in one of residents rooms. -at 11:24 am, shave cream, shaver glucose lancets, ointment in another resident's room. -at 11:42 am unlocked utility room where bleach and cleaning supplies are kept. -at 11:52 am, unlocked storage in the backyard where bleach and other cleaning supplies are kept. -at 12:30 pm, LPA asked the administrator who stated they haven't conducted disaster drill since last year. -at 2:15 pm, S1's first aid certificate expired 6/05/23 -at 2:50 pm, S3 has no first aid training, no annual training record and no LIC503 Health Screening and TB test record on file -at 3:15 pm. S4 and S5's first aid certificate expired 11/26/21 -at 5:00 pm, R1's LIC602A Physician's Report indicated needs assistance with all ADLs. -at 5:20 pm, R3's LIC602A is over a year old -at 5:30 pm, 5 out of 5 residents' LIC625 AppraisalNeeds and Services Plan do have residents' representative signatures. -at 6:05 pm, R1 has order for 4 medications but facility does not have on hand. Medications filled on 2023 and dates started not recorded on LIC622 Centrally Stored Medication and Destruction Record. No doctor's order on file for half bed rails. Deficiencies and plan and proof of corrections were discussed with the administrator and Mary Eileen Olivarez-Legados. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.
Based on observation, the licensee did not comply with the section cited above for the shower area in the 2 bathrooms with not non-skid mats or strips which pose an immediate safety and/or personal rights risk to persons in care. POC Due Date: 11/10/2023 Plan of Correction 1 2 3 4 Administrator to purchase non-skid mats or have strips inslalled. Pictures to be submitted by 11/10/23.
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
Based on observation, the licensee did not comply with the section cited above for the expired sour cream which poses an immediate health risk to persons in care. POC Due Date: 11/10/2023 Plan of Correction 1 2 3 4 Staff discarded the item. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures bu 11/10/23.
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the …
Based on observation, the licensee did not comply with the section cited above for mediications in the storage box with broken lock and Albuterol soltuon in one of ther residents' rooms which pose an immediate health, safety and/or personal rights risk to persons in care. POC Due Date: 11/10/2023 Plan of Correction 1 2 3 4 Staff locked the items. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures bu 11/10/23.
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as n…
Based on record review, the licensee did not comply with the section cited above for facility not having the 4 medications for resident (R1) which were on the list of order which poses an immediate health risk to person in care. POC Due Date: 11/10/2023 Plan of Correction 1 2 3 4 Administrator to check with the doctor and if no llonger needed. to obtain discontinued order. Otherwise, obtain the medicaitons. Proof to be submitted by 11/10/23.
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivisi…
Based on record review, the licensee did not comply with the section cited above for S3 not having the required annual training on file which poses/posed a potential safety and/orpersonal rights risk to persons in care. POC Due Date: 11/23/2023 Plan of Correction 1 2 3 4 Administrator to have the staff complete the training and submit proof by 11/23/23.
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Parti…
Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents' LIC625 with no signatures of residents' responsible person; it's not clear whether or not the assessment been discussed which pose a potential personal rights risk to persons in care. POC Due Date: 11/23/2023 Plan of Correction 1 2 3 4 Administrator to meet with the residents' responsible persons and have the LIC625 signed. Self-certificattion to be submitted by 11/23/23.
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill,…
Based on interview and record review, the licensee did not comply with the section cited above for not conducting disaster drills which poses a potential safety risk to persons in care. POC Due Date: 11/23/2023 Plan of Correction 1 2 3 4 Administrator to have drills conducted and submit copy by 11/23/23,
87411 Personnel Requirements - General (c) (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
Based on record review, the licensee did not comply with the section cited above for S1, S4 and S5 expired first aid certificates which pose a potential safety and/or personal rights risk to persons in care. POC Due Date: 11/23/2023 Plan of Correction 1 2 3 4 Administrator to have the staff complete the training and submit copies of certificates by 11/23/23.
87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
Based on observation, the licensee did not comply with the section cited above for shave cream, shaver, glucose lancets, and ointment unlocked in resident's room which pose an immediate safety and/or personal rights risk to persons in care. POC Due Date: 11/10/2023 Plan of Correction 1 2 3 4 Staff locked all the items. In addition, administrator to add to in-service and submit copy of training topic with attendees signatures by 11/10/23.
87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
Based on observation, the licensee did not comply with the section cited above for unlocked utility room and storage where bleach and cleaning supplies are kept which pose an immediate health and safety risks to persons in care. POC Due Date: 11/10/2023 Plan of Correction 1 2 3 4 Administrator lock the room and storage. In addition, administrator to add to in-service and submit copy of training topic with attendees signaures by 11/10/23.
87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section…
Based on record review, the licensee did not comply with the section cited above for R1 who is dependent on staff with all activities of daily living which poses a potential safety and/or personal rights risk to persons in care. POC Due Date: 11/23/2023 Plan of Correction 1 2 3 4 Administrator to submit an exception request with supporting documents by 11/23/23.
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessme…
Based on record review, the licensee did not comply with the section cited above for R3's LIC602A over a year old which poses a potential health and/or personal rights risk to persons in care. POC Due Date: 11/23/2023 Plan of Correction 1 2 3 4 Administrator to arrange a doctor's appointment and submit a copy of LIC602A by 11/23/23.
87608 Postural Supports (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
Based on record review, the licensee did not comply with the section cited above for not having doctor's order on R1's file for half bed rails which poses a potential safety and/or personal rights risks to person in care. POC Due Date: 11/23/2023 Plan of Correction 1 2 3 4 Administrator to obtain doctor's order and submit copy by 11/23/23.
87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
Based on record review, the licensee did not comply with the section cited above for R1's LIC622 not recording the dates medications were filled and started which pose a potential health, safety or personal rights risk to person in care. POC Due Date: 11/23/2023 Plan of Correction 1 2 3 4 Administrator to check all the residents' LIC622 and complete accordingly. Self-certification to be submitted by 11/23/23.
87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) m…
Based on record review, the licensee did not comply with the section cited above for S3 not having LIC503 Health Screening and TB test on file which pose a potential health risk to persons in care. POC Due Date: 11/23/2023 Plan of Correction 1 2 3 4 Administrator to have the staff TB tested and have the LIC503 completed. Copy to be submitted by 11/23/23.
Other visitJanuary 10, 2023No deficiencies
Inspector: Alicia Delmundo
Inspector notes
While at the facility for other reason, Licensing Program Analyst (LPA) Delmundo conducted a case management visit to address the change in administrator. On November 29, 2022, John Olivarez, licensee, sent to LPA copy of Adeliza Magalonnes's administrator certificate. LPA responded to the licensee on November 30, 2022 requesting to submit by December 2, 2022 a signed letter indicating the effective date Magalonnes took over the position of administrator and a copy of LIC501 Personnel Record. Licensee has not submitted the requested documents as of this day. Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction (POC) by plan of correction due dates and any repeat violations within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with Celeste Olivarez and licensee. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
Other visitJanuary 10, 2023No deficiencies
Inspector: Alicia Delmundo
Inspector notes
While at the facility investigating a complaint (Control # 15-AS-20240314140353), Licensing Program Analyst (LPA) Delmundo obtained information that the facility does not have an administrator. LPA called and spoke with Adeliza Magallones who stated she quit as administrator December 31, 2023, John Ronald Olivarez, licensee, stated that they have a certified administrator, Angeline Bangi. LPA interviewed Bangi who stated she stsrted working at the facility on February 2024 and works only either Wednesday or Thursday from 1:00 p.m. or 2:00 p.m. to 5:00 p.m.. Bangi stated she does not intend to work 20 hours per week as administrator as she has other full time job. Staff (S1) was interviewed and confirmed Bangi only comes ether Wednesday or Thursday and works only 3 or 4 hours per week. Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the licensee. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
InspectionNovember 10, 2022No deficiencies
Inspector: Luisa Fontanilla
Inspector notes
On this day at around 9:15 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit to follow up on four residents who needed immediate transfer from Montgomery Springs Manor. LPA met with Administrator Adeliza Magallones and explained the purpose of visit. During the visit, LPA interviewed 3 out of 4 residents who all state they are doing fine, no issues or concerns. One resident was sleeping. LPA did not observe any immediate health and safety risk. A copy of this report was provided to Administrator.
Other visitSeptember 29, 2022No deficiencies
Inspector: Liridon Fici
Inspector notes
On 11/10/2022, at 9:12 AM, Licensing Program Analyst (LPA) Liridon Fici arrived unannounced to conduct an Annual Infection Control Visit. LPA was greeted by licensee, John Olivarez . During the inspection, LPA toured facility with licensee, including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. All sharps and toxins were locked up and inaccessible to residents in care. Common areas are disinfected frequently throughout the day. Water temperature is measured at 106.0 degrees F. Fire extinguisher was last serviced on 7/20/2023. Facilities room temperature is maintained at 75 Degrees F. First aid kit is complete. Carbon monoxide and smoke detectors are operable. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care. During record review, LPA observed facility has a copy of their Infection Control Plan and Disaster Plan on file No deficiencies cited during today's visit. Exit interview conducted with Licensee and copy of this report provided.
Other visitSeptember 29, 2022No deficiencies
Inspector: Alicia Delmundo
Inspector notes
Licensing Program Analyst (LPA) Delmundo conducted an unannounced health & safety inspection as a result of the Department receiving a complaint (15-AS-20220927100258). LPA met with John Ronald Olivarez, licensee, and Celeste Olivarez, facility consultant, LPA toured facility with Celeste Olivarez. LPA inspected the kitchen, dining area, residents bedrooms, staff room, bathrooms, hallway. tv room. There's sufficient food supplies good for 7 days of non-perishable and 2 days of perishables. Facility has running water and electricity. LPA observed the following: 1. Entrance door's auditory signal was disabled. Review of resident (R1) records and interview of staff revealed R1 has wandering and sundowning behavior. 2. Oxygen concentrator in one of the resident's bedroom. LPA reviewed records and interviewed and R2 who indicated he uses the oxygen. There's no "No smoking. Oxygen in Use" posters posted by the entrance and exit doors and resident's bedroom door, 3. Resident's medications unlocked in the refrigerator, and knives and cleaning supplies in drawers without lock in unlocked kitchen. 4. Unlocked utility room where cleaning supplies are kept. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with facility consultant. Exit interview conducted. Appeal Rights. LIC9098 Proof of Correction form and copy of this report provided.
Other visitSeptember 29, 2022No deficiencies
Inspector: Alicia Delmundo
Inspector notes
Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to information received from Adeliza Magalonnes. Magallones submitted a copy of facility's Narrative Report for resident (R1) indicating R1 AWOLed on 12/30/22. LPA responded to Magalonnes informing her to use the Departments' LIC624 Unusual Incident Report (UIR) when reporting an incident and requested for copy of LIC602A Physician's Report. Report indicated that at 4:15 am on 12/30/22, R1 was found not in R1's room. Staff searched the facility and neighborhood and called the police. R1 was found and returned to the facility by the police officer. On this day, 1/10/23, LPA met with Celeste Olivarez, facility consultant, and staff, Maria Dolores Floriza, and informed the purpose of visit. John Olivarez, licensee, arrived after about an hour, Review of R1's LIC602A Physician’s Report revealed R1 has dementia, confused/disoriented, has wandering and sundowning behaviors, needs assistance with bathing. dressing and grooming. However, LIC625 Appraisal/Needs and Services Plan not updated to reflect and meet R1's current needs, LPA conducted interviews, and obtained copy of LIC Personnel Report. LPA conducted inspection with Olivarez and Floriza. LPA checked the front door entrance and sliding exit door at the back of the facility. LPA observed the sliding door's auditory signal not working properly. LPA further observed the sound of the signal is barely heard in staff's room and in other common areas of the facility, ......continued on 809C 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 Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections (POCs) by plan of corrections due dates and any repeat violations within 12 month period may result in civil penalties. Deficiencies and plan and proof of correction were discussed with Celeste Olivarez and licensee. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
ComplaintNovember 17, 2021· SubstantiatedCitation on file
Inspector: Alicia Delmundo
Substantiated — CDSS found a violation and issued a citation. Full citation details are on file with the state.
Inspector notes
2. Facility has inadequate record keeping It was alleged that staff were not able to provide any details of the R1's medical situation and that S1 was not able provide R1's hospital discharge document when asked by medical transport person. LPA interviewed S1 who stated he looked for the document and was not able to locate it. 3. Staff did not properly assist R1 while in care It was alleged that R1 wanted to go to hospital due to abdominal pain. R1 was found in great distress at 2 a.m. on March 7, 2021 with staff reporting that R1 had been in "10 out of 10 pain" for the full afternoon and evening prior. S1, S2 and administrator indicated that R1 was hospitalized and discharged back to the facility on March 6, 2021 in the afternoon. S1 indicated that R1 has been yelling from the time he was discharged from the hospital and they called non-emergency transport around 12:00 midnight, 1:00 pm the following day. LPA interviewed FM1 who stated that when she called R1 two, three times in evening on March 6, 2021, R1 complained of stomach pain. FM1 spoke with S2 who told FM1 that they (staff) will call non-emergency transport. FM1 stated what she did not understand was why it took 2:00 am for the responder to arrive if the staff called right after FM1 spoke with S2. Based on the information gathered, the preponderance of evidence were met, therefore all 3 allegations are substantiated. Deficiencies are cited from Title 22 California Code of Regulations (see 9099D), Failure to submit proof of corrections by plan of correction due dates may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with licensee over the phone who authorized Maria Dolores Floriza to sign and receive this report. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
ComplaintNovember 17, 2021· SubstantiatedCitation on file
Inspector: Alicia Delmundo
Substantiated — CDSS found a violation and issued a citation. Full citation details are on file with the state.
Inspector notes
RP stated several attempts were made starting from February 2, 2024 to March 5, 2024 requesting for R1's documents. Requests via mail and e-mails were made with signed authorization from FM to release the documents to RP. Phone calls were also made by RP, and licensee has not responded to the request. LPA interviewed FM who confirmed she signed the document for the release of the documents to RP. LPA interviewed S1 and S2 who confirmed receiving calls and/or emails from RP and licensee was informed. Licensee stated he received the request but has not responded to the request and emails nor returned RP's calls. Based on information obtained, the preponderance standard has been met, therefore the allegation of "Licensee not providing prompt access to or photocopies of resident (R1) records" is substantiated. Deficiency is cited per Title 22 California Code of Regulations, and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the licensee. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
InspectionNovember 9, 2021No deficiencies
Inspector: Alicia Delmundo
Inspector notes
Licensing Program Analyst (LPA) Delmundo conducted a POC visit for the type A deficiency that was cited on November 9, 2021 for adding 3 rooms inside the staff bedroom. Licensee submitted the LIC9054 and updated sketch on January 3, 2022. LPA submitted the STD850 Fire Safety Inspection Request and updated sketch to the fire department; however, LPA has not receive the STD850 back. LPA followed-up with John Olivarez, licensee, who in-turn sent to LPA picture of the staff bedroom. On this day, September 29, 2022, LPA met with John Ronald Olivarez, licensee, and Celeste Olivarez, facility consultant. LPA conducted inspection with Celeste Olivarez. LPA observed the 3 rooms that were added were removed and the staff bedroom were returned to it's original layout. Exit interview conducted and copy of this report provided.
Federal summary
CMS Care CompareNot a CMS-certified facility
California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.
Family reviews
No reviews yet — be the first to share your experience
No published reviews yet. Use the button above to share your experience.