Medication handling and storage
Cited in 2 reports, with 2 deficiencies in total.
AGING IN THE BAY 2
1325 POTRERO CIRCLE, Suisun City CA 94585
6 bedsLatest official report Oct 27, 2025Licensed
Additional info
- Telephone
- (510) 388-7352
- Licensee
- C & M HEALTH CARE, LLC
- Administrator
- MENDAROS, CHARMAINE
- Contact
- MENDAROS, CHARMAINE
- License first date
- Dec 15, 2021
- License effective date
- Dec 15, 2021
- District office
- SANTA ROSA RO · (707) 588-5026
- Regional office
- 21
- Clients served
- 935 - ELDERLY, 983 - RCFE / DEMENTIA, 985 - RCFE / HOSPICE
Summary
The available records show 4 Type A and 8 Type B deficiencies for this facility.
- Most recent inspection
- Oct 27, 2025
- Most recent deficiency
- Oct 27, 2025
No later report is available, so the records do not show what happened afterward.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 147 Solano County facilities licensed for 6 or fewer beds.
In the available public five-year record, CCLD published 10 reports for this facility: 6 inspections, 0 complaint investigations, and 4 licensing or administrative records.
Those records contain 4 Type A and 8 Type B deficiencies.
1 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 6
- Recorded deficiencies
- 12
- Type A deficiencies
- 4
- Type B deficiencies
- 8
- Substantiated complaints
- 0
- Repeated topics
- 1
More than the typical 5
1 in the last 12 months
Well above the typical 1
2 in the last 12 months
Most this size have none
1 in the last 12 months
Well above the typical 1
1 in the last 12 months
Most this size also have none
0 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Inspection
Fire safety and emergency preparednessType A
- Official classification
- Type A
- 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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate 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 requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and admin observation], the licensee did not comply with the section cited above in that shared resident room #1 and #2 closet is being occupied as a living space for staff which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/28/2025 Plan of Correction Licensee to submit LIC 9098 self certifying that mattress will no longer be placed in closet and no staff to be sleeping in resident closet or other areas in facility without a fire clearance or permit. *** Immediate Civil Penalty assessed in the amount of $500 due to fire clearance violation.
Plan of correction recorded
Correction not verified in available records
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.618(c)(3)
- Regulation authority
- HSC
What the official deficiency says
(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 staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review , the licensee did not comply with the section cited above in First aid/CPR Certifications for Staff 2,Staff 3,Staff 4 not verifiable and contained the same certification number. Staff 5 certification not verifiable and Staff 6 expired CPR. which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/03/2025 Plan of Correction Licensee to submit CPR/First aid training for S2,S3,S4,S5,S6 by plan of correction due date 11/03/2025.
Plan of correction recorded
Correction not verified in available records
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Inspection
Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87307(d)(2)
- Regulation authority
- CCR
What the official deficiency says
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in ensuring the facility window screen are in place and in good repair, and that the facility is free from rodents as evidenced by a mouse trap set in bedroom number 3 and mouse droppings observed in the facility pantry which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/23/2024 Plan of Correction Licensee to submit a self certification to CCL that they will ensure facility window screens are in place and in good repair and that the facility is free from rodents to CCL by POC due date 12/23/2024.
Plan of correction recorded
Correction not verified in available records
Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in ensuring that keys used to unlock cabinets containing item which could pose a risk to residents in care remains inaccessible to resident in care which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/23/2024 Plan of Correction Licensee to submit a self certification to CCL that they will ensure that keys for cabinets containing item which could pose a risk to rodents in care remain inaccessible to residents in care to CCL by POC due date 12/23/2024.
Plan of correction recorded
Correction not verified in available records
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(h)(4)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in ensuring that centrally stored medication records were maintained accurately and that expired medications were removed from residents' stored medications which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/20/2025 Plan of Correction Licensee to submit proof of training completed by all staff regarding the proper maintenance of centrally stored medication records to CCL by POC due date of 1/20/2025.
Plan of correction recorded
Correction not verified in available records
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(a)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above where LPAs observed at least two documents missing or not signed and dated for each resident in care which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/20/2025 Plan of Correction Licensee to submit Self certification to CCL that all resident records are current and complete with signature and date to CCL by POC due date 1/20/2025.
Plan of correction recorded
Correction not verified in available records
Dementia careType A
- Official classification
- Type A
- Official code
- 87705(l)(1)
- Regulation authority
- CCR
What the official deficiency says
Care of Persons with Dementia 87705(l)(1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in the observed instance of a lock that was installed at the top of the facility's front door which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/23/2024 Plan of Correction Licensee immediately uninstalled the lock from the door. POC cleared during inspection.
Official record says corrected or clearedRecorded in report dated Dec 20, 2024
Plan of correction recorded
Food serviceType B
- Official classification
- Type B
- Official code
- 87555(a)
- Regulation authority
- CCR
What the official deficiency says
General Food Service Requirements 87555(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an 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 in ensuring that all food in properly labeled when transferred to new storage containers/packaging which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/20/2025 Plan of Correction Licensee to submit self-certification that all food has been inspected and in labelled and stored in compliance with regulation to CCL by POC due date 1/20/2025.
Plan of correction recorded
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(c)
- Regulation authority
- CCR
What the official deficiency says
Personnel Requirements – General 87411(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above where S1 and S2 were observed missing proof of 10 or more hours of initial training, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/20/2025 Plan of Correction Licensee to submit proof of completed initial training hours for S1 and S2 to CCL by POC due date 1/20/2025.
Plan of correction recorded
Correction not verified in available records
Inspection
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(c)
- Regulation authority
- CCR
What the official deficiency says
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 4 residents did not have Reappraisals conducted yearly as outlined in Title 22 regulations which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/05/2023 Plan of Correction Plan of Correction shall include submitting an LIC 9098 understanding of this regulation. In addition, Administrator shall conduct reappraisals on ALL residents and retain those reappraisals in files. Administrator shall submit a plan for future compliance.
Plan of correction recorded
Correction not verified in available records
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(h)(4)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, a resident had the label of the medication ripped off which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/28/2023 Plan of Correction Plan of Correction shall include submitting an LIC 9098 understanding of this regulation. In addition, Administrator shall obtain an updated Medication bottle that reflects the proper documentation. Administrator shall submit a plan for future compliance.
Plan of correction recorded
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Inspection
Fire safety and emergency preparednessType B
- 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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate 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 requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above in 1 out of 1 fire extinguisher requiring inspection and servicing which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/24/2023 Plan of Correction Administrator agrees to contact the Suisun City Fire Department to inspect and recharge the facility fire extinguisher. Administrator to submit photo proof of corrections to CCLD by POC due date 1/24/2023.
Plan of correction recorded
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology