Anastasia

On 9/26/2024 at 12:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Caregiver, Vanesia Duhaney and explained the purpose for the visit. LPA spoke with administrator, Lacy Vincent who stated caregiver can sign CCLD reports. While LPA G. Luk was at the facility for a complaint investigation (#15-AS-20230825120429), the following deficiency was observed. After reviewing Guardian system, LPA G. Luk observed staff (S1) was not fingerprint cleared or associated to the facility. LPA spoke with Administrator, Lacy Vincent over the phone and informed her that S1 cannot be at the facility or have interactions with residents until fingerprint clearance is completed. LPA observed S1 left the licensed portion of the facility during visit. Civil penalty of $200 is being assessed. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.

COMP II by CAB successfully completed Facility Type: RCFE Application Type: INC Capacity: 6 Census (if any clients in care): NO Method: Telephone at CAB COMP II Participants: Octavian Mahler (Applicant/Administrator) Applicant/Administrator participated in COMP II at CAB via telephone with analyst at CAB. Identification of the Applicant and Administrator was verified by providing California Driver License number. During COMP II, Applicant and Administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and Administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property

R2's physician's report dated 10/21/2022 shows that R2's weight was168.8 pounds. However, the facility did not have records of R2's weight after admission to the facility. Staff did not assist resident in transferring out of bed. Interview with residents revealed that staff are assisting residents in transferring out of bed. R2 stated that staff would assist R2 in transferring to wheelchair when asked. Interview with staff indicated that R2 doesn't want to be transferred out of bed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED . No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

On 5/28/2025 at 10:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Christine Sevier and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and purchased on 4/25/2025. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 115.5 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete. The facility has a written emergency disaster plan. Last disaster drill was conducted on 5/2/2025. LPA reviewed 6 residents and 3 staff files starting at 11:40AM. LPA reviewed a sample of resident's medications during inspection. No deficiencies are being cited on this date. Exit interview conducted with Christine Sevier. A copy of this report was provided.

On 5/13/2022 at 1:00PM, Licensing Program Analyst (LPA) G. Luk conducted a face to face Component III presentation. LPA met with Licensee/Administrator, Octavian Mahler. LPA presented Component III power point and discussed the regulations embodied in the presentation. LPA observed Licensee/Administrator gained knowledge about running and maintaining the facility in accordance with Title 22 regulations. LPA concluded Component III. Exit interview conducted and a copy of this report provided.

On 6/9/2022 at 9:00AM, Licensing Program Analyst (LPA) G. Luk conducted a Pre-licensing Inspection to verify corrections were made. LPA met with Licensee/Administrator, Octavian Mahler. The facility's fire clearance was approved for 6 bedridden residents. LPA toured facility including but not limited to resident's bedrooms, bathrooms, living room, kitchen, and outdoor area. LPA observed fire extinguisher to be full and purchase receipt attached dated 5/16/2022. Carbon monoxide detector observed in operating condition. Hallway bathroom toilet has grab bar. LPA observed room 4's door handle has been repaired with no exposed hole. LPA observed knives drawer and kitchen sink cabinet had magnetic locks installed. LPA advised Licensee/Administrator that magnet key should not be accessible to residents. CCLD complaint poster was observed to be 20"x26". LIC610E has been updated to include two temporary shelter locations. Front gate lock has been changed and gate is able to open from the inside. Side gate has a self closing latch. LPA observed a small fence was built parallel to the back fence between the two shed in the backyard for storing additional items (wheelchairs, wheel barrow, shovel, and extra equipment). LPA advised that Licensee/Administrator to update yard sketch to indicate a fence was created and send a copy to CAB analyst. No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required. Exit interview conducted and a copy of this report provided.

On 5/13/2022 at 8:45AM, Licensing Program Analyst (LPA) G. Luk conducted a Pre-licensing Inspection. LPA met with Licensee/Administrator, Octavian Mahler. The facility's fire clearance was approved for 6 bedridden residents. LPA toured facility including but not limited to resident's bedrooms, bathrooms, living room, kitchen, garage, and outdoor area. Resident's rooms were fully furnished and clean. Hot water was measured at 112.8 degrees F in the kitchen sink. LPA observed lighting in all rooms. LPA observed facility had some non-perishable and perishable food supply. Licensee will purchase additional food supplies once facility is licensed. Smoke detectors were observed in operating conditions. First aid kit was complete. Emergency disaster plan was complete. The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB): 1. Fire extinguisher was observed to be full, but unknown when it was last purchased or serviced. Licensee agreed to either provide a copy of the purchase receipt or have it serviced. 2. LPA observed front gate has a mechanical lock and facility does not have a fire clearance with locked perimeter. LPA requested licensee to either obtain property fire clearance or remove the mechanical lock on front gate. (Continue on LIC809C...) 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 3. LPA observed facility only had smoke detectors and did not have carbon monoxide detector(s). 4. The toilet in the hallway bathroom does not have a grab bar. 5. No latch on side gate (right side of the building - front view). Room 4's door handle installed improperly which exposed the hole. 6. Backyard has some items that needs to be removed including exercise equipment, additional storage, wheelchairs, wheel barrow, shovel, and extra furniture in bedroom 1. 7. LPA observed knives were locked in the drawer with child lock only. 8. Facility currently only have 1 temporary shelter location. Per guidelines, facility must have two temporary shelter locations. 9. CCLD Complaint poster size was 10''x16'' and should be 20''x26''. Licensee/Administrator will submit proof of corrections to CCLD on/before 5/30/2022. Exit interview conducted and a copy of this report provided.