Beloved Home Retreat

Type of visit: Required - 1 Year

On 05/27/2026 at 12:50 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Mirriam Para and explained the purpose of the visit. Administrator certificate is current. LPA toured facility with Administrator inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 4 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. There are no bodies of water observed. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 75 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower pans. The hot water temperature in the residents’ shared bathroom was measured at 120 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 04/09/2026. Emergency disaster drill was last conducted on 02/08/2026. At 1:10 PM, LPA reviewed 4 residents records. At 1:29 PM, LPA reviewed 4 staff records and 3 of 4 current first aid training and 3 of 4 are associated to the facility. At 4:00 PM, LPA reviewed resident’s medications. LPA and Administrator discussed that the licensing annual fees are due on 05/28/2026. Proof of payment will be sent to CCLD for review. Continue to LIC809-C... Continued from LIC809... Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/04/2026: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan LIC9020 Register of Facility Clients/ Residents THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 1:00 PM, LPA observed that S4 is not associated with the facility. At 2:26 PM, LPA observed unlocked scissors in R2's room, prescribed mouthwash in R3's room, and paint in the living room. Repeat Civil Penalty of $250 is assessed. At 2:30 PM, LPA observed rotten bananas and cucumber. At 3:10 PM, LPA observed that 4 of 4 residents have half bed rails without a doctors order. At 3:23 PM, LPA observed that S1 does not have a first aid certification. At 3:45 PM, LPA observed that the facility doesn't have a first aid manual book. At 4:06 PM, LPA observed that the facility does not have 2 medications of R4's in the facility. Record review revealed that the facility does not have doctor's order for 4 medications for R4. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. Appeal Rights, LIC421FC, and a copy of this report provided.the state’s words, verbatim · CDSS document, May 27, 2026

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 10/22/2025 at 8:35 AM, Licensing Program Analyst (LPA) P. Manalo conducted an unannounced Case Management visit regarding the annual fees that were overdue and late fee assessment. LPA met with Direct Care Staff, Mike Mejia, and explained the purpose of the visit. The Administrator gave authorization on the phone for staff to sign the report. During the visit, LPA spoke with Administrator via phone call and Administrator stated that they will pay the annual fees online. LPA received via email the payment confirmation that the annual fees have been paid. No deficiencies cited. Exit interview conducted with staff and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 22, 2025

Type of visit: Case Management - Other

On 10/22/2025 at 9:05 AM, Licensing Program Analyst (LPA) P. Manalo conducted an unannounced Case Management visit. LPA met with Direct Care Staff, Mike Mejia, and explained the purpose of the visit. The Administrator gave authorization on the phone for staff to sign the report. While LPA was at the facility for another visit, LPA observed the following deficiency: At 8:59 AM, LPA observed Clorox wipes and Lysol Spray in the living room. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Staff. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Oct 23, 2025

87309(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions...are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having the Clorox wipes and Lysol spray unlocked in the living room which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 22, 2025

Plan of correction: The Administrator agrees to self certify the regulation with staff and locked the items. Proof of correction will be sent to CCLD by POC date.

Type of visit: Required - 1 Year

On 04/01/2025 at 12:40 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Mirriam Para and explained the purpose of the visit. Administrator certificate is current. The facility’s fire clearance was approved for capacity of six (6) all may be non-ambulatory and hospice waiver of four (4). LPA toured facility with Administrator inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 05/26/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 01/16/2025. At 12:54 PM, LPA reviewed 2 residents records. At 1:15 PM, LPA reviewed 3 staff records and all have current first aid training and associated to the facility. At 3:20 PM, LPA reviewed resident’s medications. Continue to LIC809-C... Continue from LIC809... Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/05/2025: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 1:30 PM, LPA observed that alterations were done without a building permit. At 2:00 PM, LPA observed the medication cart unlocked. At 2:30 PM, LPA observed the hot water temperature measured at 124.8 degrees F. At 3:25 PM, LPA observed resident's medication without a doctor's order. At 3:38 PM, LPA observed that both residents did not have a doctor's order for their half bed rails. At 4:30 PM, during record review, LPA observed that the facility has not paid their annual dues. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 1, 2025

The state marks this report as 13 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 05/30/24 at 11:40AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. At 11:55AM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 73 deg F. Hot water temperature was measured at 116 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 2 staff and 2 resident files. LPA also conducted 2 staff and 2 resident interviews during visit. LPA observed the following deficiency during visit: · Open trash bins with no foot operated lids in bathrooms & bedrooms Continued on next page, LIC 809-C Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance Exit interview conducted, appeal rights and a copy of this report provided.the state’s words, verbatim · CDSS document, May 30, 2024

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Jul 1, 2024

All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof. This requirement was not met as evidenced by open trash bins without foot operated lids observed in bathrooms and bedrooms which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, May 30, 2024