Roberta Care Home

On 11/06/2025, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator Johnny Macabasco and explained the purpose of today’s visit. Currently there is one client present in the facility and 2 staff. This is a single level facility with 4 bedrooms for clients. Facility is equipped with fire sprinklers through out the facility and in client rooms. The facility is licensed for age 60 and over and approved for 4 non-ambulatory clients. LPA Vado toured the facility both inside and outside. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. Knives are locked in the kitchen drawer across from the sink. Toxic chemicals are stored in locked cabinets located in the garage. An outdoor shed is observed to house additional cleaning supplies and chemicals including additional PPE and incontinence supplies. Medications are locked in a medication cart located in a central hallway connecting to all client rooms. Each client room observed contained the required furniture as outlined in regulations . Facility has functioning smoke detectors within the facility as well as carbon monoxide detectors. LPA observed carbon monoxide detector in the central hallway where all client rooms are located. Continued on next page... 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 facility is equipped with two full bathrooms which are in good working order. Water temperature is tested at 110F. Facility tests water daily twice a day and keeps a log posted on the refrigerator in the kitchen. Fire extinguishers are observed through out the facility. One is observed in the garage and the kitchen area of the facility. Both observed as charged and ready for use per the dial reading on the extinguishers and an inspection date of 04/12/2025. LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident bathrooms are observed as clean and in good worker order. Shower floors are equipped with non-skid mats or flooring. Garage area is observed as in good repair housing additional supplies and laundry area. Both washer and dryer are observed as in good working order. LPA inspected the medications and the P&I monies of all 4 clients in care at the facility. Based on review of all resident files, medications, and P&I monies all items are current and logged accurately. Disaster fire drill last conducted on 09/07/2025 per log reviewed. Facility administrator certificate is observed as current expiring 12/27/2026. There are no citations issued during today's visit. Report is reviewed with the Administrator and a copy is provided on this day.

On 11/12/2024, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator Johnny Macabasco and explained the purpose of today’s visit. Currently there is one client present in the facility and 4 staff. This is a single level facility with 4 bedrooms for clients. Facility is equipped with fire sprinklers through out the facility and in client rooms. The facility is licensed for age 60 and over and approved for 4 non-ambulatory clients. LPA Vado toured the facility both inside and outside. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. Knives are locked in the kitchen drawer across from the sink. Toxic chemicals are stored in locked cabinets located in the garage. An outdoor shed is observed to house additional cleaning supplies and chemicals including additional PPE and incontinence supplies. Medications are locked in a medication cart located in a central hallway connecting to all client rooms. Each client room observed contained the required furniture as outlined in regulations . Facility has functioning smoke detectors within the facility as well as carbon monoxide detectors. LPA observed carbon monoxide detector in the central hallway where all client rooms are located. The facility is equipped with two full bathrooms which are in good working order. Water temperature is tested at 112F. Facility tests water daily twice a day and keeps a log posted on the refrigerator in the kitchen. Fire extinguishers are observed through out the facility. One is observed in the garage and the kitchen area of the facility. Both observed as charged and ready for use per the dial reading on the extinguishers and an inspection date of 05/13/2024. Continued on next page... 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 LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident bathrooms are observed as clean and in good worker order. Shower floors are equipped with non-skid mats or flooring. Garage area is observed as in good repair housing additional supplies and laundry area. Both washer and dryer are observed as in good working order. LPA inspected the medications and the P&I monies of all 4 clients in care at the facility. Based on review of all resident files, medications, and P&I monies all items are current and logged accurately. Disaster fire drill last conducted on 09/06/2024 per log reviewed. Facility administrator certificate is observed as current expiring 12/24/2024. The following updated forms are requested to be submitted to CCLD by 11/19/2024 : • Copy of updated administrator certificates as there are more than one administrator • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC400 Affidavit Regarding Client/Resident Cash Resources • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease • Copy of updated surety bond There are no citations issued during today's visit. Report is reviewed with the Administrator and a copy is provided on this day.

LPA Audrey Jeung toured facility and grounds, consisting of 4 client bedrooms and 2 full bathrooms. This facility serves developmentally disabled persons. Clothes washer and dryer are located in attached 2 car garage. There is a detached storage shed in back yard where diapers, PPE and supplies are stored. No accessible bodies of water or fire safety hazards observed. Food supplies are adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. First-aid kit is inspected and complete. An updated Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, including current first aid training and health screenings. Fatollah Ghlichloo is a certified RCFE administrator (x 6/24) that oversees facility operations. The following information/forms are provided to LPA today: - Proof of current surety bond - Proof of current liability insurance No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed. See Technical Violations issued--3 pages.

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management investigation visit to deliver the exclusion letter regarding a staff person (S1). LPA met with caregiver Joseph and explained purpose of today's visit. LPA met with Joseph in private and explained purpose of the letter being delivered today. He confirmed that S1 has not worked in the facility for approximately two to three years. Joseph has worked in this facility for about 1.5 years and S1 has not worked in this facility since he's been employed here. He informed LPA that S1 did visit the outside of the facility around July 4, 2022 to deliver meat to the facility but did not enter the facility. LPA made observations of the facility's two restrooms with Joseph. There were no suspicious observations made. Report is reviewed with Joseph. Letter is hand delivered to Joseph on this day. No citations issued.