The Shining Light RCFE

Type of visit: Required - 1 Year

On 5/20/26 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Aloma Tonel and Staff (S1) Edna Tonel, LPA was granted entry. 4 residents were present during inspection. Administrator (A1) Carlo Santos arrived shortly after LPA’s arrival. LPA toured facility with S2. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. A roach and a bug was observed crawling in kitchen cabinets. Samples of resident’s medications were checked and observed locked in kitchen cabinet. Clients’ MARS was reviewed. Fire extinguisher reviewed with a service date of: 7/7/25. Fire drill completed on 4/15/26. Clients' bedrooms were toured and reviewed. Cleaning chemicals were observed stored and locked in kitchen cabinet. Resident’s bedrooms observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 116.7 to 118.2 degrees in 3 bathrooms. Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature observed at 0 degrees F and refrigerator temperature maintained at 23 degrees F. Smoke detectors and carbon monoxide were tested and observed to be operational. All client’s and samples of staff files reviewed to have all the required documents. The following deficiencies is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 6/3/26: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A) A copy of this report, 9102 and Appeal Rights were provided to A1, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, May 20, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff hit resident. Staff did not assist resident with care needs.

On 9/9/25 at 11:30 am Licensing Program Analyst (LPA) J. Leffall conducted a subsequent complaint visit to open and to deliver findings on above allegations. LPA met with Staff (S1) Rene Valencia and stated purpos of the visit. Administrator (A1) Carlo Santos was contacted by phone. The Department conducted an interviews with facility staff, reviewed facility records, resident files and hospital discharge records. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is Unsubstantiated. No deficiencies were issued. Exit interview conducted. A copy of this report was distributed to Administrator which confirms signature of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 9, 2025 · control 24-AS-20250812114532

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 10, 2025

a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. Based on records reviewed and interviews conducted, R1’s evening medications were missed which poses an immediate Health & Safety risk to the residents.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: Licensee agrees to have staff complete medication training and submit completion documents to CCLD by POC due date.

Type of visit: Case Management - Deficiencies

On 9/9/25, Licensing Program Analyst (LPA) J. Leffall conducted a case management visit to follow up and confirm details of an interview that LPA conducted with a Social Worker (SW) Joslyn Davis, located at Fresno PACE. Fresno PACE is the day program that Resident (R1) Rigoberto Garcia Zamora attends. SW reported to LPA that on 9/3/25 R1 had a Urinary Tract Infection (UTI) and reported to Licensee Delia Galvez. LPA met with Staff (S1) Rene Valencia and contacted Licensee (L1) Delia Galvez by phone. LPA asked L1 to confirm the UTI. L1 cofirmed the UTI and R1 has been prescribed antibiotics. LPA asked, was UTI reported to CCLD? L1 states was busy and did not report incident timely. A citation is issued on the attached 809-D wtih appeal rights regarding timely incident reporting both by phone and in writing. A copy of this report with appeal rights was issued to S1 whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Sep 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 23, 2025

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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. Based on records reviewed and interviews conducted, the Licensee did not report timely of R1's Unirary Tract Infection, which poses a potential Health & Safety risk to the residents.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: The Licensee agrees to conduct an inservice with all staff at facility and read all of the steps in regulation 87211 on timely report writing and submit either a sign in sheet or completion document to CCLD by POC due date.

Type of visit: Required - 1 Year

On 5/15/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Mylene Valencia, LPA was granted entry. 5 residents were present during inspection. Administrator (A1) Carlo Santos arrived shortly after LPA’s arrival. LPA toured facility with S1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Samples of resident’s medications were checked and observed locked in kitchen cabinet. Clients’ MARS was reviewed. Fire extinguisher reviewed with a service date of: 7/15/24. Fire drill completed on 4/10/25. Clients' bedrooms were toured and reviewed. Cleaning chemicals were observed stored and locked in kitchen cabinet. Resident’s bedrooms observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 105.9 to 108.6 degrees in 3 bathrooms. Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature observed at 0 degrees F and refrigerator temperature maintained at 25 degrees F. Smoke detectors and carbon monoxide were tested and observed to be operational. Client’s and samples of staff files reviewed to have all the required documents. No deficiencies issued during this inspection. Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 5/29/25: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A) A copy of this report was provided to A1, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, May 15, 2025

Type of visit: Required - 1 Year

On 7/15/2024 Licensing Program Analyst (LPA) K.Kaur arrived at facility unannounced to complete an Annual inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Direct Care Staff. Designee Administrator Carlo Santos was contacted and arrived a short time later. The facility has 5 residents, of which all were present during the inspection. LPA toured the facility with the staff. Facility postings observed at entry. Tour started at Bedroom # 1. Fire extinguisher did not have a service date. Tour continued down the hallway and observed two staff rooms. Two Bathrooms toured LPA observed grab bars installed by toilet and showers and non-skid mats in place. Three additional resident rooms toured at the end of the hallway. Residents' bedrooms were observed to be adequately furnished with beds, dresser, and adequate lighting. Mattresses and linen were in good condition. The dining room is equipped with a table and chairs, the living room is equipped with adequate sofas and recliners for seating. Extra linen and towels are available in the hallway closet. Knives were locked in the kitchen cabinet. LPA observed a 7-day supply of non-perishable foods and 2-day supply of perishable foods. Medications, first aid kit observed locked in cabinet in kitchen area. Cleaning supplies observed locked in the cabinet next in the laundry cabinets. The laundry area toured and observed with locks on all cabinets. Bedroom # 5 toured next to laundry and garage. Garage observed with locked cabinets for chemicals. Smoke alarm detectors and Carbon monoxide detectors installed and operational. Adequate outside space for rest and recreational. Sufficient seating observed under a covered patio. Backyard gate is self-closing and self-latching. Resident's records contained signed Admission Agreement, Personal Rights, and Physician's Report and ID Documentation. All residents Physician's Report were two to four years old. During Medication review LPA observed Centrally Stored Medication and destruction record (CSMDR) was incomplete. PRN medication that came with resident was not logged in CSMDR. Residents’ response to PRN medication was not noted. Staff files were reviewed for good health. Staff files had health screenings/ TB Clearance. It was verified that current staff on duty are CPR certified. Last Fire Drill conducted on 4/10/2024. Continued to 809C... Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22 Division 6. LPA is requesting the following documents be submitted to the Fresno CCL office by 7/22/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted with Administrator. Report signed on-site; a copy of this report, 809D with appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 15, 2024

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff prevented resident from having visitors

The Department conducted interviews and reviewed records. Facility staff stated R1’s family member was allowed visitation and family member was asked to leave and not return after being disruptive. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is Unsubstantiated. Exit interview was conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 6, 2024 · control 24-AS-20231012114355