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13 | Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint investigation visit to deliver findings regarding the above allegations. LPA met with Lakeisha Ogesby and explained the reason for the visit. LPA spoke with Cheryl Dallas (Administrator) via phone call and delivered findings.
The investigation consisted of the following:
On 4/22/25 LPA Mary Flores conducted an initial investigation visit, requested copies of resident/staff roster, conducted a tour of the home, interviewed 6 residents and 2 staff. LPA Flores requested copies the following documents: resident/staff roster, menu, activity calendar, training for 2 staff, designee notification, physician’s report, appraisal, identification and emergency information sheet for resident #1-2(R1-R2), and hospital discharge documents for Resident #3(R3), pest control records to be emailed by 4/23/25. On 5/6/25 LPA Flores received requested documents. On 6/28/25 LPA Herrera delivered findings for allegations.
(continued on the LIC9099-C)
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| Substantiated | Estimated Days of Completion: |
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NARRATIVE |
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32 | The investigation revealed the following:
Regarding allegation: Licensee does not ensure that staff are adequately trained. It is alleged staff do not receive initial training or yearly training. Interviews conducted with residents revealed 6 out of 6 residents were unable to provide an answer due to cognitive skills. Interviews with staff revealed training is provided prior starting to work at the facility. Documents reviewed revealed; administrator provided copies of training material via pictures. However, there were no training logs that record the date and time of yearly or initial training provided to staff #2(S2).
Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Regarding allegation: Licensee does not ensure that there is a designated substitute at the facility when the administrator is not at the facility. It is alleged administrator left on vacation in December 2024 and did not leave a responsible designee. Interviews conducted with residents revealed 6 out of 6 residents were unable to answer due to cognitive skills. Interviews conducted with staff revealed there is a designated person when the administrator is out. Per administrator, administrator took a vacation in December and left staff #3(S3) as the designee of responsibility and they should have submitted the Designation of Responsibility LIC 308 to the department. LPA reviewed documents submitted to the department between December 2024 and May 2025, there was no record of appointing S3 or other staff as the designee for responsibility. Administrator did not provide a copy of document submitted to the department with transmittal sheet.
Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.
Exit interview was conducted with Lakeisha Ogesby and a copy of this report, LIC 9099D, and appeal rights were provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
07/05/2025
Section Cited
CCR
87411(C) | 1
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7 | 87411 Personnel Requirements - General (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 evidence by: | 1
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7 | Administrator will provide training to facility’s staff and will provide a copy of training logs, with date, duration of training, and staff signatures to the department by POC due date |
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14 | Based on observations and document review licensee did not ensure that S2 received, and records were maintained for training provided which poses a potential risk to the health, safety, or personal rights of the persons in care. | 8
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Type B
07/05/2025
Section Cited
CCR
87405(a) | 1
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7 | 87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management … | 1
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7 | Administrator will certify in writing that will appoint and notify the department whenever is out of the facility for an extended period of time and submit a copy to the department by POC due date |
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14 | Based on observation and document review licensee did not ensure to notify or appoint via LIC 308 a designee of responsibility before going on vacation which poses a potential risk to the health, safety, or personal rights of the persons in care. | 8
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13 | Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint investigation visit to deliver findings regarding the above allegations. LPA met with Lakeisha Ogesby - Caregiver and explained the reason for the visit. LPA spoke with Cheryl Dallas (Administrator) via phone call and delivered findings.
The investigation consisted of the following:
On 4/22/25 LPA Mary Flores conducted an initial investigation visit, requested copies of resident/staff roster, conducted a tour of the home, interviewed 6 residents and 2 staff. LPA Flores requested copies the following documents: resident/staff roster, menu, activity calendar, training for 2 staff, designee notification, physician’s report, appraisal, identification and emergency information sheet for resident #1-2(R1-R2), and hospital discharge documents for Resident #3(R3), pest control records to be emailed by 4/23/25. On 5/6/25 LPA Flores received requested documents. On 6/28/25 LPA Herrera delivered findings for allegations.
(Continued on LIC9099-C) |
| Unsubstantiated | Estimated Days of Completion: |
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