MOM BOARD AND CARE SERVICES, INC.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review . . . shall prior to working . . . in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by: Based on record review, licensee did not comply with the section cited above. Staff S1 was not fingerprint cleared and Staff S2 was not associated with the facility, which poses an immediate safety risk to persons in care.

Official plan of correction

On or before the due date, the Licensee has agreed to inform LPA Sampair of the fingerprint clearance and association status of Staff S1 and S2. Further, the Licensee has agreed to not allow S1 or S2 to enter the facility until their fingerprint clearance and association process has been completed. Civil penalty of $1,000 is being assessed.

Deadline recorded: Jun 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

The following food service requirements shall apply:...(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by observation of only 1 package of ground beef in freezer which poses an potential health and safety risk to persons in care.

Official plan of correction

Licensee to purchase one week supply of non-perishable food for four residents, and send LPA the reciept by POC date.

Deadline recorded: Nov 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87467(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored:...(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by observation of unlocked medication in the refrigiator which poses an potential health and safety risk to persons in care.

Official plan of correction

Licensee to purchase a lockedbox for the medication that needs refrigiation and send the picture to LPA by the POC date.

Deadline recorded: Nov 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...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. This requirement was not met as evidenced by observation of the cabinet under the sink which contains the cleaning supplies is not locked which poses an immediate health and safety risk to persons in care.

Official plan of correction

Licensee to repair lock and send the letter of self attestation to LPA by POC date.

Deadline recorded: Nov 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by observation of having staff upstairs and not present in the facility which poses an potential health and safety risk to persons in care.

Official plan of correction

Licensee to submit an updated LIC500 with hours the administrator and care staff are physically in the facility working to LPA by POC date.

Deadline recorded: Nov 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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. This requirement was not met as evidenced by observation of toilet seat in the bathroom in disrepair which poses an potential health and safety risk to persons in care.

Official plan of correction

Licensee to replace toilet seat and submit a picture and reciept by the POC date.

Deadline recorded: Nov 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80076(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. This requirement was not met as evidenced by observation of numerous expirered food items in the refrigerator which pose an potential health and safety risk to persons in care.

Official plan of correction

Licensee to discard expired food items. Licensee to set a schedule of food inspection and send to LPA monthly.

Deadline recorded: Nov 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: Job application, health screening -TB test, and LIC508. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 2 out of 2 files were incomplete which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/17/2025 Plan of Correction Licensee shall ensure files are complete by POC date and maintained in the facility.

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident’s record shall contain at least the following information: Admission agreement, MA-TB test, LIC627C, LIC601, Appraisal and needs and services plan, and LIC 613. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 4 out of 4 resident files were incomplete which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/17/2025 Plan of Correction Licensee shall ensure that resident files are complete and maintained in the facility by the POC date.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2025 Plan of Correction Licensee shall send the picture of a fully stocked refrigerator and antry by POC date.

Official classification

Type B

Official code

87303(2)

Regulation authority

CCR

What the official deficiency says

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 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: water in the shared bathroom measured 97.2 degrees Deficient Practice Statement Based on observation the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/15/2025 Plan of Correction Liicensee to send photo proof of correction to LPA by POC date.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: LPAs observed no food in the kitchen. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/15/2025 Plan of Correction Licensee to send a photo of a fully stocked refrigerator by the POC date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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. This requirement is not met as evidenced by: LPAs observed kife on kitchen counter and Draino in under kitchen sink. Deficient Practice Statement Based on observation , the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/15/2025 Plan of Correction Licensee to submit a picture of locked cabinet by the POC date.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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. This requirement is not met as evidenced by: LPAs observed kitchen sink to be unsanitary, filthy, and filled with dirty, mostly plastic utensils. Deficient Practice Statement Based on observation the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/17/2025 Plan of Correction Licensee to submit a picture of a clean sink to LPA by the POC date.