StarlynnCare

California · Pleasant Hill

Cordial Care Home

RCFE · 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.

2957 Hannan Drive · Pleasant Hill, 94523

Quick facts

Licensed beds6
Memory careYes
Last inspectionJun 2025
Last citationMay 2025
Operated byCordial Care Home Inc
Map showing location of Cordial Care Home

Quality snapshot

Updated April 25, 2026

Compared to 182 California RCFE memory care facilities of similar size, over the last 36 months.

Source: California Department of Social Services, Community Care Licensing Division. View raw inspection records →

Quality grade· click to show how this was calculated

Severity
39th

Weighted citations per bed

Repeats
100th

Repeat deficiencies as share of total

Frequency
30th

Deficiencies per inspection

Tick mark at 50% = peer median · higher percentile = better facility

Cordial Care Home scores C. Better than 56% of comparable California RESIDENTIAL CARE ELDERLY facilities. Severity: 39th percentile. Repeats: top 0%. Frequency: 30th percentile.

Each metric is converted to a 0–100 percentile within the peer set (higher = better). The composite grade averages all four. Peer set: CA / rcfe_memory_care / small beds (182 facilities).

Citation severity over time

↓ improving

Weighted severity score per month · 24 months

May 24peer medianApr 26

Weighted score (24mo)

43

Last citation

May 25

Finding distribution

15 total · 36 months

Scope × Severity (CMS A–L)

IsolatedPatternWidespreadJKLG1HID14EFABCSev 4 · IJSev 3Sev 2Sev 1

View inspections & citations

The rules that apply to this facility

California Title 22 requirements for this facility, with the specific regulation and a suggested question for each.Rules this facility has been cited for are shown first.

What dementia-care training must staff complete?Cited Aug 202422 CCR §87705 / HSC §1569.625

Because this facility markets dementia or Alzheimer's care, state law mandates higher training standards:

  • 12 hours initial dementia training — 6 hours before a staff member works independently with residents, 6 more within the first 4 weeks.
  • 8 hours annual dementia in-service — required every year thereafter.
  • Administrator CE — the 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: Ask how dementia training records are kept — families may request documentation.

What must this facility report to the state — and how fast?Cited Aug 202322 CCR §87211 / WIC §15630
  • ImmediateElopement, fire, epidemic outbreak, or poisoningImmediately
  • 2 hoursAbuse with serious bodily injury2-hour phone report + 2-hour written report — to the California Department of Social Services (CDSS), Adult Protective Services, and law enforcement
  • 24 hrsAbuse without serious bodily injuryWithin 24 hours
  • Next dayDeath of a residentPhone by next working day; written within 7 days
  • Next dayInjury requiring medical treatment beyond first aidPhone by next working day; written within 7 days
  • WrittenBankruptcy, foreclosure, eviction, or utility shutoff noticeWritten notice to CDSS and residents — $100/day penalty (max $2,000) for failure

Your enforcement lever:Incidents that aren't reported on time are themselves a separate violation. If you believe a reportable event wasn't filed, you can submit a complaint directly to the California Department of Social Services (CDSS).

How many staff must be on duty overnight?22 CCR §87415

Based on 6 licensed beds:

One qualified staff member must be on call and physically on premises at all times overnight.

Violation pattern to watch for:A facility that documents a staff member as "on call" but with that person physically off-site — when the law requires on-premises presence — is in violation of this section.

Ask on tour: Ask the facility to walk you through their overnight staffing plan and confirm whether on-call staff are on premises or off-site.

What health conditions can this facility legally accept or refuse?22 CCR §87612–87615

Restricted — allowed with physician order + care plan

  • Supplemental oxygen
  • Insulin and injectable medications
  • Indwelling or intermittent catheters
  • Colostomy / ileostomy
  • Stage 1 and Stage 2 pressure injuries
  • Wound care (non-complex)
  • Incontinence
  • Contractures

Prohibited — facility must refuse or discharge

  • Stage 3 or Stage 4 pressure injuries
  • Feeding tubes (PEG, NG, or J-tube)
  • Tracheostomies
  • Active MRSA or communicable infections requiring isolation
  • 24-hour skilled nursing needs
  • Total ADL dependence with inability to communicate needs

A hospice waiver (HSC §1569.73) can allow continued care for residents on hospice who would otherwise fall into a prohibited category.

Ask on tour: Ask whether your loved one's specific care needs are restricted or prohibited, and what the facility's process is if needs change after admission.

How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58
  1. 1Notice of DeficiencyWritten citation with a correction deadline. Facility must submit a Plan of Correction.
  2. 2Civil PenaltyStarts at $50/day for non-serious; $150/day for serious deficiencies — immediately, with no grace period. Repeats escalate to $150 first day + $50/day, then $1,000 first day + $100/day.
  3. 3Suspension of AdmissionsFacility cannot accept new residents until violations are corrected.
  4. 4Temporary Suspension or RevocationEmergency suspension for imminent danger; full revocation after administrative hearing.
  5. 5Exclusion OrderAdministrator and operator can be barred from all CDSS-licensed facilities — not just this one.

See how these rules have been applied to this specific facility:

View state inspection record and citations

State records

California Dept. of Social Services · Community Care Licensing
License number
079200578
License type
RESIDENTIAL CARE ELDERLY
License status
LICENSED
License expires
Not yet indexed
Licensed beds
6
Operator
Cordial Care Home Inc

Inspections & citations

9

reports on file

18

total deficiencies

1

Type A (actual harm)

1

dementia-care citations

InspectionJune 5, 2025
No deficiencies

Plain-language summary

On June 5, 2025, inspectors returned to check whether the facility had fixed a problem found during a routine annual inspection on May 16, 2025. The facility had corrected the deficiency, and no new citations were issued.

View full inspector notes

On 6/5/2025 at 8:30 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a Plan of Correction (POC) visit. Upon arrival, the LPAs stated the purpose of the visit to Caregiver Winifred "Willy" Wepee who phoned and left a message of the visit for Licensee/Administrator Ogedi Okeigwe. On 5/16/2025, the LPA had conducted a Required 1 Year visit during which 1 deficiency was cited. During the visit, the deficiency was cleared. No citations were issued Exit interview conducted and a copy of this report provided.

InspectionMay 16, 2025Type B
1 deficiency

Plain-language summary

On May 16, 2025, an unannounced routine annual inspection found the facility met most requirements: adequate food storage, proper temperatures, working smoke and carbon monoxide detectors, current fire extinguishers, required postings, and sufficient administrator oversight. One violation was identified and cited during the inspection.

View full inspector notes

On 5/16/2025, at 8:30 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Caregiver Winifred "Willy" Wepee. Administrator Ogedi Okeigwe was informed of the inspection by phone. The LPA toured the interior and exterior of the facility, inspecting the kitchen, food and emergency supply storage areas, dining area, shared restrooms, community living spaces, client rooms, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. The maximum hot water temperature was 112 degrees Fahrenheit and the temperature in the common area was 72 degrees Fahrenheit. The carbon monoxide and smoke detectors were fully operational. The fire extinguishers were last serviced on 1/9/2025. The LPA observed postings in the facility that included a complaint poster, Ombudsman, and Personal Rights posters. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. The LPA reviewed the facility records, records of 5 staff members, and the records of 5 residents. 1 Type-B citation was issued during the inspection (refer to LIC 809-D for details). Exit interview conducted and a copy of this report provided.

Type BCCR §87507(a)

Regulation

(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.

Inspector finding

Based on record review, the licensee did not comply with the section cited above in 6 out of 6 Admission Agreements, which poses a potential personal rights risk to persons in care. POC Due Date: 05/30/2025 Plan of Correction 1 2 3 4 On or before the due date, the Licensee shall: (A) read and understand Section 87507 of Title 22, Admission Agreement, and (B) replace the LIC 604 "ADMISSION AGREEMENT GUIDE FOR RESIDENTIAL FACILITIES" with the LIC 604A "ADMISSION AGREEMENTS FOR RESIDENTIAL CARE F…

Other visitAugust 14, 2024Type A
11 deficiencies

Inspector: Lori Alexander-Washington

Plain-language summary

This was a routine annual inspection conducted in August 2024. The facility was found to be in good condition overall, with proper fire safety equipment, adequate lighting and temperature, secure medication storage, and sufficient food supplies, though the inspector noted some deficiencies that required correction (specific violations are detailed in the full report). The facility was operating within its licensed capacity and had appropriate emergency plans and first aid supplies in place.

View full inspector notes

On 08/14/2024 at 3:15 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Winifred Wepee and explained the purpose of the visit. Winifred phoned Licensee/Administrator, Ogedi Okeigwe and informed. The facility’s fire clearance was approved for capacity six (6) non-ambulatory of which one (1) may be bedridden. Bedridden is granted for Bedroom #6. Hospice waiver for two (2). Administrator Certificate #6041025740 expires 09/01/2024. LPA toured facility with Winifred including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms which 6 bedrooms are occupied by the residents and 2 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 116.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/08/2024. Emergency Disaster Plan was last posted on 08/14/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 08/03/2024. LIC809-C Continued... 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 LPA reviewed six (6) residents records. LPA reviewed 8 staff records and 6 of 8 have current first aid training and 5 out of 8 were associated to the facility. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/21/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Copy of Liability Insurance Policy Exit interview conducted. Appeal Rights and a copy of this report provided.

Type ACCR §87618(b)(3)(A)

Regulation

(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.

Inspector finding

Based on observation, record review, the licensee did not comply with the section cited above in by not reporting to the local fire dept that oxygen is in use for R1 in Bedroom #1 which poses an immediate health and safety risk to persons in care. POC Due Date: 08/15/2024 Plan of Correction 1 2 3 4 Administrator agree to submit a copy of letter to CCLD by POC date.

Type B

Regulation

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staf…

Inspector finding

Based on interview and record review the licensee did not comply with the section cited above in by not having First Aid and CPR for S1 and S2 which poses a potential health and safety risk to persons in care. POC Due Date: 08/28/2024 Plan of Correction 1 2 3 4 Administrator agree to submit coppies of First Aid/CPR and/or health professional license/certification to CCLD by POC date.

Type BCCR §87533(e)(2)

Inspector finding

Based on observation, interview and record review, the licensee did not comply with the section cited above in by not having S6, S7 and S8 associated to facilicity in Guardian which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 08/21/2024 Plan of Correction 1 2 3 4 Administrator agree to submit LIC9182 with valid U.S. issued picture ID to CCLD by POC date

Type BCCR §87468(c)(2)(A)

Regulation

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (…

Inspector finding

Based on observation, the licensee did not comply with the section cited above in by not having 20x26 poster sized PUB 475 which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 08/28/2024 Plan of Correction 1 2 3 4 Administrator agree to submit a photo to CCLD by POC date.

Type BCCR §87458(b)(5)

Regulation

(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or …

Inspector finding

Based on record review, the licensee did not comply with the section cited above in by not having an updated Physician's report for R1 which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 08/28/2024 Plan of Correction 1 2 3 4 Administrator agree to submit an updated Physician's Report (LIC602A) for R1 by POC date.

Type BCCR §87463(a)(3)

Regulation

(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, …

Inspector finding

Based on record review, the licensee did not comply with the section cited above in by not having an updated Appraisal Needs and Services (ANS) Plan for R1 which poses a potential health and safety risk to persons in care. POC Due Date: 08/28/2024 Plan of Correction 1 2 3 4 Administrator agree to submit an updated ANS for R1 to CCLD by POC date.

Type B

Regulation

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

Inspector finding

Based on observation and record review, the licensee did not comply with the section cited above in by not having updated review of Emergency Disaster Plan LIC610E (P.9) signed and dated which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 08/28/2024 Plan of Correction 1 2 3 4 Administrator agree to submit copy of updated reviewed LIC610E to CCLD by POC date. While at the facility S2 updated and signed LIC610E. Deficiency cleared.

Type BCCR §87608(a)(5)(A)

Regulation

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

Inspector finding

Based on observation, interview and record review, the licensee did not comply with the section cited above in by not having doctor's orders on file for R2-R4,R6 which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 08/28/2024 Plan of Correction 1 2 3 4 Administrator agree to submit copies of doctor's orders for 1/2 rail beds for R2-R4,R6 to CCLD by POC date.

Type BCCR §87608(a)(5)(B)

Regulation

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

Inspector finding

Based on observation, interview and record review, the licensee did not comply with the section cited above in by not having an doctor's order for R1 which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 08/28/2024 Plan of Correction 1 2 3 4 Administrator agree to submit an copy of doctor's order for hospital bed for R1 to CCLD by POC date.

Type BCCR §87616(b)(2)

Regulation

(b) Written requests shall include, but are not limited to, the following: (2) The licensee's plan for ensuring that the resident's health related needs can be met by the facility.

Inspector finding

Based on observation, interview and record review, the licensee did not comply with the section cited above in by not having an exception request for R1's foley catheter which poses a potential healt and safety risk to persons in care. POC Due Date: 08/28/2024 Plan of Correction 1 2 3 4 Administrator agree to submit an exception request for foley catheter with all supporting documents to CCLD by POC date. Deficiency will not be cleared until all documents are received and approved.

Type BCCR §87705(c)(5)

Regulation

(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 reassessment of the resident's dementia care …

Inspector finding

Based on record review, the licensee did not comply with the section cited above in by not having an updated Physician's Report for R2 which poses a potential health and safety risk to persons in care. POC Due Date: 08/28/2024 Plan of Correction 1 2 3 4 Administrator agree to submit updated Physician's Report for R2 to CCLD by POC date.

InspectionAugust 24, 2023Type B
3 deficiencies

Inspector: Lori Alexander-Washington

Plain-language summary

This was a follow-up inspection in August 2023 at a residential care facility. Inspectors found that the administrator had been out of the country for about a month without notifying the state or naming a substitute administrator, three staff members were missing required health screenings and tuberculosis tests, and the facility failed to report the death of a resident in August 2023 and did not notify the state when another resident was admitted to hospice care in July 2023.

View full inspector notes

On 08/24/2023 at 11:00 AM, Licensing Program Analysts (LPAs) L. Alexander and L. Hall arrived unannounced to conduct an continued 1-Year Annual Required inspection from previous visit on 07/26/2023. LPAs met with Caregiver, Marilin "Lin" Alegria and explained the purpose of the visit. LPA spoke with Administrator, Ogedi Okeigwe, via telephone. LPAs reviewed 4 resident files from previous visit on 07/26/23. LPAs reviewed 1 resident file on today's visit. LPAs reviewed 6 staff files and 5 of 6 staff had CPR/AED/First Aid training and associated to the facility. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: LPAs observed during visit on 7/26/2023, that Licensee/Administrator was out of the country and had been for approximately a month and did not notified CCLD of their absence. There was no substitute Administrator notified. LPAs observed during record review that S4, S5 and S6 was missing health screening and TB tests. LPAs observed during record review and interview that R4 expired on 8/17/2023. Facility did not submit a death report to CCLD. LIC 809C Continued 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 LIC 809 Continued... LPAs observed R1 was admitted into hospice services on 7/13/2023. Facility did not notify CCLD of hospice services. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 08/31/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Exit interview conducted. Appeal Rights and a copy of this report provided.

Type BCCR §87211(a)

Regulation

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to...

Inspector finding

Based on observation, interview, record review, the licensee did not comply with the section cited above in by notifying Licensing of hospitalizations, and death which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 08/28/2023 Plan of Correction 1 2 3 4 Licensee/Administrator agreed to read section 87211 and submit self- certification that the regulation has been reviewed and he will abide by the regulation going forward. Self-certification will be su…

Type BCCR §87411(f)

Regulation

87411 Personnel Requirements – General (f) All personnel, including the licensee and administrator, shall be in good health...health screening...chest x-ray

Inspector finding

Based on observation, interview, record review, the licensee did not comply with the section cited above in by not having health screening and TB tests for S4, S5 and S6 which poses a potential health and safety risk to residents in care. POC Due Date: 08/31/2023 Plan of Correction 1 2 3 4 Licensee/Administrator will complete a health screening and TB test for S4, S5 and S6 and will submit copies of completed results to CCLD by POC Due Date.

Type BCCR §87632(d)(2)

Regulation

87632 Hospice Care Waiver (d) If the Department grants a hospice care waiver it shall stipulate terms...(2)The licensee shall notify the Department in writing within five working days of the initiation of hospice care services...

Inspector finding

Based on observation, interview, record review, the licensee did not comply with the section cited above in by not notifying Licensing of residents that have started hospice services which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 08/28/2023 Plan of Correction 1 2 3 4 Licensee/Administrator shall review section 87632 and self-certify that they have read the regulation. Self-certification will be submitted to CCLD by POC Due Date.

Other visitJuly 26, 2023
No deficiencies

Inspector: Lori Alexander-Washington

Plain-language summary

An unannounced routine annual inspection was conducted on July 26, 2023, and found the facility in compliance with state requirements, including safe water temperatures, working smoke and carbon monoxide detectors, secure medication storage, and adequate food supplies. The inspector toured the bedrooms, bathrooms, kitchen, and common areas, and confirmed that passageways were clear and the facility maintained comfortable temperature and lighting. No violations were found.

View full inspector notes

On 07/26/2023 at 2:55 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Raynardo "Leon" Stewart and explained the purpose of the visit. The Acting Administrator, Winifred Wepee, was called and arrived shortly after. Hospice waiver for 2. The facility’s fire clearance was approved for 6 Non-Ambulatory of which 1 may be bedridden only in Bedroom #6. Hospice waiver for 2. LPA toured facility with Leon including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms which 6 bedrooms are occupied by the residents and 2 bedrooms is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 116.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/06/2023. First aid kit was observed to be complete. During visit LPA reviewed resident records but LPA will have to return at a later date to continue annual inspection. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

Other visitNovember 16, 2022Type B
1 deficiency

Inspector: Alicia Delmundo

Plain-language summary

During an investigation in November 2022, inspectors found that the facility failed to document a resident's pre-existing injury (a bandage on the resident's back) when the resident arrived from the hospital in March 2021, and did not keep progress notes or document changes in the resident's condition during their stay. The facility was cited for inadequate record-keeping practices. The facility was notified of the violation and required to submit a plan to correct the problem.

View full inspector notes

During investigation of complaint (Complaint Control # 15-AS-20210629164337) and upon review of documents, the Department learned that u pon admission of resident (R1), the facility did not conduct an intake evaluation and document any pre-existing marks or injuries on resident. Staff (S1) stated R1 had a bandage on backside when R1 arrived to the facility from the Emergency Department on 3/10/2021, but it was not documented anywhere. The facility keeps limited records and did not document a change in condition or keep progress notes on R1’s condition. On this day, November 16, 2022, Licensing Program Analyst (LPA) Delmundo arrived to the facility unannounced and met with staff, Winifred 'Willie' Wepee, facility manager, and informed the reason for visit. LPA called and spoke with Ogedi Okeigwe, administrator, over the phone and informed of the above. 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 the administrator over the phone in the presence of the facility manager. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

Type BCCR §87466

Regulation

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning, and that appropriate assistance is provided when such observation reveals unmet needs. ..... the licensee shall ensure that such changes

Inspector finding

Based on interview and records review, the licensee did not comply with the section above for not properly observing and documenting resident's changes in condition.

ComplaintNovember 16, 2022· Substantiated
Citation on file

Inspector: Alicia Delmundo

Substantiated — CDSS found a violation and issued a citation. Full citation details are on file with the state.

Plain-language summary

A complaint investigation found that a resident developed pressure injuries while at the facility and that the facility failed to meet the resident's care needs. The resident was admitted to the hospital in March 2021 with skin breakdown and fecal matter on the skin, then returned to the hospital weeks later with severe sepsis and an unstageable pressure injury; staff had difficulty recalling details about the resident's condition and the home health nurse noted the resident may have developed the first pressure injury from spending a night in a wheelchair due to the facility's lack of an appropriate bed. The facility was assessed a $500 civil penalty and required to submit a plan of correction.

View full inspector notes

Page 2 During the course of investigation, the Department obtained copies of R1’s documents including but not limited to the following: medical records; LIC601 Identification and Emergency Information; Admission Agreement; LIC602A Physician's Report; Pre-placement Appraisal; hospital documents. Copies of LIC9020 Register of Facility Clients/Residents and LIC500 Personnel Report were obtained, and interviews conducted. Medical records showed R1 was admitted to the hospital on 3/09/2021 with generalized buttocks pain. R1 was observed with skin breakdown but no pressure injury, wounds or incision. Medical records also revealed R1 had large amount of soft stool that appears to have been on R1’s skin for some time as it was difficult to remove and dried in some areas. R1 indicated that he tell the facility staff that he had bowel movement but sometimes it takes a while for them to clean him up. Staff (S1) stated when R1 moved-in, R1’s hospital bed and lift was not delivered that night and R1 slept in a wheelchair all night, because the facility didn’t have a lift. R1 was discharged back to the facility on 3/10/2021 with after care instructions on how to care for non-specific dermatitis. On 03/30/2021, R1 was visited by Home Health at the facility and was observed with altered mental state. R1 was sent out and admitted to the hospital with final diagnosis of severe sepsis with acute organ dysfunction and unstageable pressure injury of sacrum/buttocks. Staff interviews were conducted, and staff (S1 & S2) had a hard time recalling if R1 had pressure injury. S1 indicated that on the day of admission to the facility, R1’s hospital bed was delivered but not accepted by the facility due to bed was not electric. .......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 Director for Home Health and Hospice (HHD) stated R1 receives home health care for catheter care and seen by home health nurse twice a week. HHD stated that on 03/09/2021, home health called the facility to schedule a visit but was notified that R1 was at the hospital. Home Health nurse (HH) was interviewed who stated that R1 had stage 1 pressure injury and unstageable deep tissue pressure injury while at the facility’s care. HH indicated that R1 could have developed the first pressure injury for spending the night at R1’s wheelchair. HH went over the care of pressure wounds with the staff. Based on records review and interviews, allegations of “Resident (R1) developed pressure injury while in care”, and “Facility failed to meet resident's (R1) care needs.” are substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099D. A $500.00 civil penalty is assessed. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties. Deficiencies, plan and proof of corrections and civil penalty were discussed with the administrator over the phone in the presence of the facility manager. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty, LIC9098 Proof of Correction form and copy of this report provided.

InspectionJuly 8, 2021
No deficiencies

Inspector: Alicia Delmundo

Plain-language summary

A health and safety inspection was conducted following a complaint received by the state. The inspector toured the entire facility including bedrooms, bathrooms, kitchen, and outdoor areas, and found the building well-lit with clear hallways and kitchen knives properly secured in a locked cabinet.

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Licensing Program Analyst (LPA) Delmundo conducted a health and safety inspection as a result of the Department receiving a complaint (Control # 15-AS-20210629164337 ) . LPA called and informed Ogedi Okeigwe, administrator, the purpose of visit and inspection. Ogedi authorized Winifred Wepee to be with LPA during inspection. Ogedi arrived after about 2 hours. LPA toured the facility inside out with Winifred Wepee LPA inspected the living room, kitchen, dining area, bedrooms, bathrooms, side and backyards. There were 3 staff on-duty and 2 residents present. Facility has 8 bedrooms, 6 designated for residents use and 2 for staff. Facility has sufficient lighting. Hallways and passageways were observed free of obstructions. Knives were observed in a locked cabinet in the kitchen. Exit interview conducted and copy of this report provided to Ogedi Okeigwe.

ComplaintJune 16, 2021Type B
1 deficiency

Inspector: Leslie Ibo

Plain-language summary

An unannounced annual inspection on June 16, 2021 found that while the facility maintained adequate food and hygiene supplies and had a screening station at the entrance, it was missing required documentation for COVID-19 screening of staff and residents, had insufficient protective equipment on hand, had not completed required fit-testing for respirators, and had not conducted staff training on infection prevention and disease transmission. The administrator was informed of these deficiencies and discussed correction plans with the inspector.

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On 6/16/2021 at 10AM Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an annual required inspection. LPA met with staff Joyce Carter and informed the purpose of visit. LPA called Administrator Ogedi Okeigwe to inform the purpose of visit, Administrator gave permission to staff to give tour to LPA. Facility has census of 3. LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and backyard. Facility has enough supplies of paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every 30 days. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. LPA observed the following: Facility Administrator has not submitted LIC808. Insufficient PPE (gowns, n95s, face shields)- Administrator ordered supplies NO documentation for staff and residents covid19 screening NO log for daily temperature and Covid19 symptom checks Facility haven’t start FIT (N95) testing procedure Facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use Deficiency and plan and proof of corrections were discussed with Administrator. Exit interview conducted. Appeal Rights and copy of this report provided.

Type BCCR §87411(d)(5)

Regulation

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early si…

Inspector finding

Based on interview & record review, the licensee did not comply with the section cited above in facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control which poses/posed a potential health, safety risk to persons in care. POC Due Date: 06/25/2021 Plan of Correction 1 2 3 4 Facility Administrator will conduct training for all staff regarding infection prevention, symptoms, transmission and PPE use. Copy …

Federal summary

CMS Care Compare

Not 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.

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