SENIOR GUEST HOME

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary... The Licensee did not ensure that the above regulation was met as evidenced by: Per the House Manager, R1 eloped form the back yard. This posed an immediate threat to the health, safety and personal rights of residents in care.

Official plan of correction

Nawasa stated that they would develop a new training program that woudl follow the regulations and retrain all staff. An outline of the training and a schedule will be submitted to licensing by the close of business tomorrow 06/05/26. These materials will be sent to CCLASCPSacramentoSouthRO@dss.ca.gov or Fax to (916) 263-4744

Deadline recorded: Jun 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

Reappraisals (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. The Licensee did not meet this requirement as evidenced by: Based on record review, R1's last LIC 602 was dated May or 2024. This poses/ed an immediate threat to the heatlh, safety, and personal rights of residents in care.

Official plan of correction

Licensee will provide documentation by the close of business tomorrow on securing a primary care physician for R1 and scheduling an appointment. This information will sent to CCLASCPSacramentoSouthRO@dss.ca.gov or faxed to: (916) 263-4744

Deadline recorded: Jun 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, ...and that appropriate assistance is provided... The Licensee did not ensure that the above requirement was met as evidenced by: Licensee did not provide appropriate assistence to R1 when they noted change in R1's mental state or deterioration of mental ability the licensee did not ensure that these changes were documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

Official plan of correction

The Licensee will conduct a training on this area and the materials and a date for training will be submitted to licensing by the close of business on 6/5/26 the email or fax above.

Deadline recorded: Jun 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements: All RCFE staff who assist residents... shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 The Licensee did not ensure that the above regulation was met as evidenced by: requirement was met as evidence by: Based on document review and and interview with the House Manager, training was incomplete and not documented properly. This poses a potential threat to the health, safety, and personal rights of residents in care.

Official plan of correction

Licensee will ensure that all training will be completed and all necessary documents will be on fie for Licensing to review by 07/16/26. Licensee to send training materials and signature sheets for all participants but the date above. These will be faxed to (916) 263 4744.

Deadline recorded: Jul 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(d)

Regulation authority

CCR

What the official deficiency says

Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative... The Licensee did not ensure that the This requirement was not met as evidence by: Based on document review, R1 did not have a signed agreement to be living in this facility. This posed a potential threat to the health safety and personal rights of residents in care.

Official plan of correction

Licensee will ensure that each resident has a signed admission agreement with all necessary components. This will be completed and copies of each will be faxed to (916) 263 4744. by the close of business on 6/19/26

Deadline recorded: Jun 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This is not met was evidenced by: Based on interview and record review, the licensee did not ensure that they assisted R1 with medical are appropriate to their current condition and needs of the resident. This poses a potential health, safety, and personal rights risks to persons in care.

Official plan of correction

Per discussion, the facility manager agreed to create a plan in place to ensure their residents’ medical needs are met. Submit the plan by end of business day on May 29, 2026 to Arielle.Pascua@dss.ca.gov

Deadline recorded: May 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

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 is not met as evidenced by: Based on interviews and record review. The Licensee did not ensure adequate supervision of residents in care. R1 has eloped from the facility approximately 8 times within this year and is not able to leave unassisted. This poses an immediate health and safety risk to the R1 in care.

Official plan of correction

An immediate civil penalty of $500 was issued for violation of this Section. Licensee will provide a statement of correction, along with proof of training from an outside vendor for no less that one hour in duration regarding AWOL procedures. Licensee shall also update AWOL procedures. A copy of training and these procedures shall be provided to to the LPA by POC date.

Deadline recorded: May 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

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. This it not met as evidenced by: Based on observation the facility did not ensure that exit gate and bedroom door were not locked. This poses an immediate health, safety, and personal rights risks to persons in care.

Official plan of correction

The facility shall remove the locks from the back gate and bedroom door. The licensee shall also submit a written statement of correction and ensure that staff complete at least one hour of fire safety training conducted by an outside vendor. Documentation of the completed training shall be provided to LPA Pascua by the plan of correction (POC) due date.

Deadline recorded: May 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

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. This is not met as evidenced by: Based on observation, the Licensee did not ensure that the facility garage was cleared for staff use. LPA Pascua observed an air mattress along with personal items in the garage. This poses a potential health, safety, and personal rights risks to persons in care.

Official plan of correction

The facility shall remove the air mattress from the garage. The licensee shall submit a fire clearance request to the Department to update the facility’s fire clearance, reflecting changes to the garage and staff occupancy. The licensee shall also provide a written statement of correction and ensure that staff complete a minimum of one hour of fire safety training conducted by an outside vendor. Documentation of the completed training shall be submitted to LPA Pascua by the POC due date.

Deadline recorded: May 5, 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

(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 is not met as evidenced by: The licensee did not ensure there was a sufficient 2 day perishable food supply at the facility at the time of this LPAs visit. This poses an immediate, health,safety, and personal rights risks to persons in care.

Official plan of correction

The licensee shall submit to LPA Pascua a plan to ensure the facility maintains an adequate two-day supply of perishable food. Copies of receipts and photographs verifying compliance shall be provided to the LPA by the (POC) due date. Photographs and receipts shall be sent to the LPA weekly until 06/04/2026.

Deadline recorded: May 5, 2026. 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 is not met as evidenced by: Based on observation, the liensee did not ensure that the toilets used for resident used were unclogged. This poses a potential health,safety, and personal rights risks to persons in care.

Official plan of correction

The licensee unclogged the toilet at the time of this visit. The licensee shall submit to LPA Pascua a written acknowledgment of this regulation, along with a plan to ensure that the facility maintains fully functioning toilets.

Deadline recorded: May 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not comply with the regulation cited above. Staff did not properly supervised resident with known substance abuse history and did not implement plan to manage this behavior which allowed drug possession and distribution in the facility. This poses an immediate health, safety and personal rights risks to persons in care.

Official plan of correction

Per discussion, Administrator agreed to submit the following written plan: (1) Risk Mitigation on Substance Use and Contraband Policy; (2) Plan for Incident Reporting that includes suspected illegal drug possession/distributioin; (3) Conduct staff training for Care & Supervision requirements under Title 22, Recognizing substance use behaviors, notifying law enforcement and documentation standards. Plan to be submitted by POC due date.

Deadline recorded: Mar 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.312(e)

Regulation authority

HSC

What the official deficiency says

Basic services requirements Being aware of the resident’s general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not comply with the regulation cited. Multiple elopements. One staff did not follow resident when he eloped. Staff left facility to look for eloped resident, leaving the facility without staff supervision. Resident is able to obtain illegal drugs when out in the community This poses an immediate health, safety and personal rights risks to persons in care.

Official plan of correction

Per discussion, Administrator agreed to submit the following written plan: (1) Risk Mitigation on Substance Use and Contraband Policy; (2) Plan for Incident Reporting that includes suspected illegal drug possession/distributioin; (3) Conduct staff training for Care & Supervision requirements under Title 22, Recognizing substance use behaviors, notifying law enforcement and documentation standards. Plan to be submitted by POC due date.

Deadline recorded: Mar 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Created this page by mistake. See 9099-D dated 1/9/2026. This page was not provided to facility.

Deadline recorded: Jan 17, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above. Staff are still placing a door knob cover equipped with combination lock on the knob of the front door to prevent residents from leaving without supervision.This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Corrected on site: Administrator discarded the door knob lock in the trash can. Facility administrator agrees to retrain staff. Proof of retraining shall be submitted to the Department by 1/16/26.

Deadline recorded: Jan 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D)…\This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the regulation cited above. LPA discovered that a resident (R3) had a hospitalization on 12/1/25 due to psychiatric issue and same resident eloped on 12/15/25. The Department did not receive incident reports for these incidents. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to submit a written statement of understanding of the regulation related to reporting requirement. Statement shall be submitted tomorrow 1/10/26.

Deadline recorded: Jan 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Based on interviews, by admission of the facility manager, there were 2 instances where resident was not adequately supervised: one was when was reported by neighbor urinating on the street; and another instance where resident eloped, and staff did not follow. Record reviews showed is not able to leave the facility unassisted. This poses immediate health, safety and personal rights risks to persons in care.

Official plan of correction

Per discussion, the licensee or its designee will submit a statement of understanding regarding the cited regulation. Written statement must be submitted by tomorrow, 1/10/2026

Deadline recorded: Jan 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This is not met as evidenced by: Based on interviews, by admission of facility manager, staff yelled at residents and deemed it inappropriate. This poses a potential health, safety and personal rights risks to persons in care.

Official plan of correction

Per discussion, the administrator will conduct a staff training related to Personal Rights and proper communication with residents. Proof of training must be submitted to the Department by 1/16/2026.

Deadline recorded: Jan 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

A plan for incidental medical and dental care shall be developed by each facility…The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observations, record reviews and interviews, the licensee did not comply with the regulation cited above. Facility staff did not ensure that R4 received their medication refills on time, including their seizure medication, which resulted in R4 sustaining a seizure and fall during today’s visit. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to submit a written plan to ensure all residents in care receive their medication on time and ensure residents' medications do not run out. Plan shall be submitted by 1/10/2026.

Deadline recorded: Jan 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews, by admission of the facility manager, there were 2 instances where resident (R2) was not adequately supervised: one was when R2 was reported by neighbor urinating on the street; and another instance where R2 eloped, and staff did not follow R2. Record reviews showed R2 is not able to leave the facility unassisted. This poses immediate health, safety and personal rights risks to persons in care.

Official plan of correction

Per discussion, the licensee or its designee will submit a statement of understanding regarding the cited regulation. Written statement must be submitted by POC due date.

Deadline recorded: Dec 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(2) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This is not met as evidenced by: Based on interviews, by admission of facility manager, staff yelled at residents and deemed it inappropriate. This poses a potential health, safety and personal rights risks to persons in care.

Official plan of correction

Per facility manager, he immediately conducts in-service training to staff whenever he observes staff yelling at residents inappropriately. Per discussion, the facility manager will conduct a staff training related to Personal Rights and proper communication with residents. Proof of training must be submitted to the Department by POC due date.

Deadline recorded: Dec 24, 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

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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. During physical observation, LPA observed a cleaning chemical on a shelf inside the hallway closet. This poses/posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/12/2025 Plan of Correction Corrected on site: Staff on duty immediately removed the cleaning chemical out of the closet and placed it in a locked storage.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

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 is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. During the inspection of the garage area, LPAs observed a medication inside a cupboard. Note that this garage was not locked and accessible to residents in care at the time of the inspection. This poses/posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/12/2025 Plan of Correction Corrected on site: Staff immediately removed the medication from the cupboard.

Official classification

Type A

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above. LPA observed staff on duty placing a door knob cover equipped with combination lock on the knob of the front door. Through interview, staff stated that he place the door cover because one resident has an elopement behavior. Staff stated that this is not their daily practice. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/12/2025 Plan of Correction Per discussion, licensee will submit a written letter of understading of the regulaiton related to resident rights. Submit letter to the department by POC due date. Per discussioin, licensee will conduct staff training relating to personal rights, and proper care and supervision and submit proof of training to the Department once completed, but no later than end of business day on 9/18/2025.

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: Deficient Practice Statement Based on [(observation) (record review)], the licensee did not comply with the section cited above. Scissors and knives were observed to be accessible to residents in care inside one of the ktichen drawers; grooming and hygiene products were accessible to residents who are at risks if given direct access to these items; two wooden items with nails sticking out were found inside a resident drawer. These pose an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/27/2025 Plan of Correction Corrected on site: facility representative (S5) immediately removed these items and place them in locked areas. Per discussion, licensee will submit a waiver to the Department for locking hygiene and grooming products. Waiver will include how they ensure other residents have access to these products. Waiver to be submitted by 7/4/25 to the Department.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Staff on duty (S1) was initially present during the visit and was observed to provide care and supervision to residents in care. It was discovered through record reviews and interviews that S1 was not associated to this facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/27/2025 Plan of Correction Corrected on site: S1 was asked to immediately remove themselves from this facility and a replacement staff arrived shortly after. Per discussion with facility representative (S5), licensee will submit a transfer request to associate S1 to this facility before S1 returning to work.

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements: (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(interview) (record review)], the licensee did not comply with the section cited above. Licensee did not provide a written report of resident's death in a timely manner as required, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/27/2025 Plan of Correction Corrected on site: facility representative (S5) provided the death report to licensee during this visit. S5 stated she forgot to submit and ensure adherence to timely reporting requirement moving forward.