Pepper Tree Assisted Living II

Type of visit: Required - 1 Year

On 03/04/2026 at 01:00 pm, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Pepper Tree Assisted Living 2 Facility. LPA Calderon was allowed entry into the facility by Staff Ricarde Lapuz. Facility is to operate a Residential Care Facility for 6 Elderly residents 60 years or older. Currently, there are five (5) residents residing in the facility, 60 and older. LPA Calderon explained to Staff Ricarde Lapuz, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Five (5) client service records, five (5) client medication administration records (MAR), two (2) staff records, and inspected the inside facility and outside grounds. The facility’s last fire drill was conducted on 01/24/2026. The two-story residential home consists of five (5) client bedrooms, four (4) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored on the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage and kitchen area. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 110 degrees Fahrenheit, bathroom #2 hot water temperature properly measured at 114 degrees Fahrenheit, Bathroom #3 hot water temperature properly measured at 109 degrees Fahrenheit, and bathroom #4 hot water temperature properly measured at 112 degrees Fahrenheit. Kitchen hot water temperature properly measured at 115 degrees Fahrenheit. Facility two (2) Carbon Monoxide and nine (9) Smoke Detectors, hard wired operated and connected were tested and working properly. Fire (3) Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. The facility has a working landline telephone. All toxins and knives are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility 2 first aid kit is fully stocked with manuals checked and in order. Outside grounds were toured and there is no water feature observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Five (5) client files were reviewed and found to be complete. LPA Calderon reviewed five (5) resident medications (MAR) and they were all found to be administered according to doctor's orders. Two (2) staff files were checked and have the required documents. LPA Calderon noted the Administrator Marhlyn Sapugay Certification # 7033660740 expiration date of 10/03/2026 was valid at time of inspection. Commercial General Liability Policy #PCI2983118801 policy period from 03/03/2026 to 03/03/2027 underwritten by Primary Care Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. All the required documents are posted in the facility in a clearly visible area. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did observe deficiencies therefore citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Staff Ricarde Lapuz.the state’s words, verbatim · CDSS document, Mar 4, 2026

Allegation investigated: Staff did not ensure medications were dispensed as prescribed

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 6/6/25. On 6/6/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Administrator, Marhlyn Sapugay and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 6/6/25 LPA requested and reviewed copies of the following records: Residents file, Resident Roster, Staff roster, Identification and Emergency Contact Information, Physician’s Report, Medication Administration Record, (MAR), emailed communications, responsible party’s text message, Activities Calendar, Administrators Medication Certifications, and Special Incident Report dated 6/6/25. LPA Shirley interviewed Staff 1 – Staff 3 and Resident 1 – Resident 5, R6 was not available for interview. LPA Shirley spoke to a visitor, W1 that was at the facility at the time of investigation. Con'd on 9099-C Substantiated The investigation revealed the following: Allegation: Staff did not ensure medications were dispensed as prescribed On 6/6/25, LPA Shirley observed R1’s responsible party’s text dated, 5/13/25 sent to S1 regarding the reduction in medication indicated from R1’s doctor. During record review, LPA Felisa Shirley observed an email from R1’s doctor dated 5/13/25, regarding reducing divalproex to every other day for 2 weeks and to discontinue after. Per further review, LPA Shirley reviewed R1’s Medication Administration Record, (MAR), for May 2025 and the record shows that R1 received 500 mg of divalproex 2 times a day, daily from 5/1/25 through 5/31/25. During the course of the investigation, LPA Shirley received a copy of the Special Incident Report dated 6/6/25 stating that there was a medication error that occurred May 19 thru May 30, 2025. LPA interviewed staff, staff 1 – staff 3 (S-1 – S-3). LPA asked, does staff ensure that medications are dispensed as prescribed. Of those interviewed 3 out of 3 stated yes. LPA interviewed Resident 1 – Resident 5 (R-1 – R-5). LPA asked residents, does staff give you your medications as prescribed. Of those interviewed, 5 out of 5 answered, yes. Based on observations, information gathered and reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Based on CCLD staff's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6), is being cited, please see attached LIC-9099D. Deficiencies were cited during today's visit. An exit interview was conducted, and plans of corrections were developed, with Anna Leeza DeGuzman, Caregiver. A copy of this report and appeals rights were provided. The investigation revealed the following: Allegation: Staff did not ensure planned activities were conducted for residents in care On 6/6/25, LPA Shirley observed the activities calendar that was posted on the refrigerator. On 6/6/25, LPA Shirley observed, Dominos, the board game Scrabble and crossword puzzles. LPA observed 2 videos of residents doing chair yoga and exercises. On 6/6/25, LPA Shirley spoke with a visitor, W1 was visiting with a relative at the facility at the time of the investigation. W1 stated that she loved the facility because the staff had a genuine concern for the residents. W1 stated that staff helps the residents celebrate birthdays and different holidays. LPA interviewed staff, staff 1 – staff 3 (S-1 – S-3). LPA asked, does staff ensure that planned activities are conducted for residents in care. Of those interviewed 3 out of 3 stated yes. LPA interviewed Resident 1 – Resident 5 (R-1 – R-5). LPA asked residents, does staff offer activities for the residents in care to enjoy. Of those interviewed, 5 out of 5 answered, yes. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to Anna Leeza DeGuzman, Caregiver.the state’s words, verbatim · CDSS document, Jul 30, 2025 · control 11-AS-20250602144808

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 20, 2025

87465 Incidental Medical and Dental Care (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. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and records reviewed, records revealed that a medication error regarding R1 occurred, 5/19/25 thru 5/30/25 in which the wrong medication was discontinued. This action poses as an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: Licensee will submit plan informing the department medication training has been performed with all staff. A written proof of correction must included along with date, time and participants names. Correction must be submitted by due date: 6/20/25 to LPA's email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016. **Corrective action received 6/13/25

Allegation investigated: Staff did not ensure medications were dispensed as prescribed

On 6/6/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Administrator, Marhlyn Sapugay and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 6/6/25 LPA requested and reviewed copies of the following records: Residents file, Resident Roster, Staff roster, Activities Calendar, Administrators Medication Certifications, and Special Incident Report dated 6/6/25. LPA Shirley interviewed Staff 1 – Staff 3 and Resident 1 – Resident 5, R6 was not available for interview. LPA Shirley spoke to a visitor,W1 that was at the facility at the time of investigation. Con'd on 9099-C Substantiated The investigation revealed the following: Allegation: Staff did not ensure medications were dispensed as prescribed On 6/6/25, LPA Felisa Shirley observed an email from R1’s doctor regarding administering medication changes forwarded to the facility’s Administrator instructing the caregivers to follow the directions of the doctor and to document and monitor for changes. LPA Shirley reviewed the email dated 5/31/25, from facility’s owner informing R1’s responsible party that R1 was may have been given the wrong medication. On 6/6/25, during the course of the investigation, LPA Shirley received a copy of the Special Incident Report dated 6/6/25 stating that there was a medication error that occurred May 19 thru 30, 2025. LPA interviewed staff, staff 1 – staff 3 (S-1 – S-3). LPA asked, does staff ensure that medications are dispensed as prescribed. Of those interviewed 3 out of 3 stated yes. LPA interviewed Resident 1 – Resident 5 (R-1 – R-5). LPA asked residents, does staff give you your medications as prescribed. Of those interviewed, 5 out of 5 answered, yes. Based on observations, information gathered and reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Based on CCLD staff's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6), is being cited, please see attached LIC-9099D. Deficiencies were cited during today's visit. An exit interview was conducted, and plans of corrections were developed with the Administrator, Marhlyn Sapugay . A copy of this report and appeals rights were provided. The investigation revealed the following: Allegation: Staff did not ensure planned activities were conducted for residents in care On 6/6/25, LPA Shirley observed the activities calendar that was posted on the refrigerator. On 6/6/25, LPA Shirley observed, Dominos, the board game Scrabble and crossword puzzles. LPA observed 2 videos of residents doing chair yoga and exercises. On 6/6/25, LPA Shirley spoke with a visitor, W1 was visiting with a relative at the facility at the time of the investigation. W1 stated that she loved the facility because the staff had a genuine concern for the residents. W1 stated that staff helps the residents celebrate birthdays and different holidays. LPA interviewed staff, staff 1 – staff 3 (S-1 – S-3). LPA asked, does staff ensure that planned activities are conducted for residents in care. Of those interviewed 3 out of 3 stated yes. LPA interviewed Resident 1 – Resident 5 (R-1 – R-5). LPA asked residents, does staff offer activities for the residents in care to enjoy. Of those interviewed, 5 out of 5 answered, yes. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Administrator,Marhlyn Sapugay .the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 11-AS-20250602144808

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 20, 2025

87465 Incidental Medical and Dental Care (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. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and records reviewed, records revealed that a medication error regarding R1 occurred, 5/19/25 thru 5/30/25 in which the wrong medication was discontinued. This action poses as an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 6, 2025

Plan of correction: Licensee will submit plan informing the department medication training has been performed with all staff. A written proof of correction must included along with date, time and participants names. Correction must be submitted by due date: 6/20/25 to LPA's email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Ricarte Lapuz, House Manager and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents age 60 and over . The facility has an approved hospice waiver for 6 residents. None of the residents are diagnosed with dementia or receiving home health. One (1) resident is receiving hospice care services. The facility does not handle any of the residents’ money. This home is a single story home consisting of: (5) resident bedrooms, (3) Full bathroom, living room, kitchen, with dining area, laundry room (located in the attached garage) and an outdoor shaded patio area. LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 115.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. During todays visit LPA did not observe any deficiencies. Exit interview conducted with Ricarte Lapuz, House Manager and a copy of this report was provided..the state’s words, verbatim · CDSS document, Jan 29, 2025

Type of visit: Required - 1 Year

On 02/01/2024 at 12:00 PM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Pepper Tree Assisted Living 2 Facility. LPA Calderon was allowed entry into the facility by Staff Mario Pangan. Staff Mario Pangan was asked questions regarding the full care tools control package (13) sections. Staff Mario Pangan took LPA Calderon temperature prior to entrance into the facility. Facility is licensed for (6) non-ambulatory residents. LPA Calderon explained to Staff Mario Pangan, the purpose of the one-year (1) Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: six (6) resident service records, six (6) resident medication records, two (2) staff records. LPA Calderon interviewed six (6) residents and two (2) staff members for visit. LPA Calderon inspected the inside facility and outside grounds to include all common areas. The facilities’ last fire drill was conducted on 11/03/2023. The two-story residential home consists of five (5) resident bedrooms, three (3) resident bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day (2) supply perishable and seven-day (7) supply of non-perishable foods are present in the facility. Emergency Water seven-day (7) supply is found in the garage. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 109 degrees Fahrenheit. Bathroom #2 hot water temperature properly measured at 110 degrees Fahrenheit. Bathroom #3 hot water temperature properly measured at 112 degrees Fahrenheit. Kitchen hot water temperature properly measured at 116 degrees Fahrenheit. Facility (2) carbon Monoxide and (10) Smoke Detectors hard wired and were tested and are working properly. The facility two (2) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit (1) is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. LPA Calderon noted the Administrator Marhlyn Sapugay Certification # 6018525740 expiration date of 10/03/2024 was valid at time of visit. The facility does NOT handle resident's money/cash resources and a NO Surety bond is needed. Commercial General Liability Policy #01002294880 policy period from 03/03/2023 to 03/03/2024 underwritten by Kinsale Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Marhlyn J Sapugay who will email full copy of insurance contact which shows all coverages to LPA Calderon no later than 02/28/2023. All the required documents are posted in the facility in a clearly visible area to all staff, clients, and guests. LPA Calderon reviewed LIC500 and noted all staff associated to facility per LIS. LPA Calderon reviewed the resident roster, LPA Calderon confirmed residents’ interview are on resident roster. During the visit, LPA Calderon observed the facility infection control practices. LPA Calderon observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA Calderon observed staff and residents were NOT wearing face coverings. LPA Calderon observed the facility has a thirty-day (30) supply of Personal Protective Equipment (PPE). LPA Calderon advised the Staff Mario Pangan to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe any deficiencies therefore NO citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Staff Mario Pangan.the state’s words, verbatim · CDSS document, Feb 1, 2024