Fil-Am Home for Seniors III

Allegation investigated: Staff do not ensure resident is bathed. Staff do not meet resident's incontinence care needs. Staff do not reposition resident.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/13/2026 regarding the above allegations. During today’s visit LPA Ramirez was greeted by House Manager Claudia Orozco and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff#1 - 4 interviews (S1 – S4), Resident#1- 5 interviews (R1- R5), attempted interview with resident#6 (R6), observation notes, physician’s report, Medication Administration Record (MAR), Resident Appraisal for Resident#1 (R1), and physical plant tour. See 9099-C Unsubstantiated The investigation revealed the following: regarding the allegation “Staff do not ensure resident is bathed.” It is alleged that staff did not bathe R1 for several weeks. Four (4) out of the four (4) staff interviewed denied this allegation. Staff interviewed revealed that R1 is given bed baths every other day. Staff revealed that due to R1’s limited mobility and diagnosis, it is unsafe to move R1 into a shower chair. Staff revealed they document when all residents get bathed. During record review, LPA observed staffing notes that indicated R1 was provided bed baths regularly. Five (5) out of the five (5) residents interviewed denied this allegation. Residents interviewed revealed that staff assist them with bathing on a regular basis. R6 was unavailable to be interviewed during LPA’s visit. During tour of the facility LPA observed residents to be well groomed and did not observe residents to malodorous. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. “Staff do not meet resident's incontinence care needs.” It is alleged that staff are not meeting R1’s incontinence care needs. Four (4) out of the four (4) staff interviewed denied this allegation. Staff interviewed revealed that any residents that require assistance with toileting and incontinence, are assisted and changed at least every 2 hours. During record review, LPA observed staffing notes that indicated R1 is provided incontinence care on a regular basis. Five (5) out of the five (5) residents interviewed denied this allegation. Residents interviewed revealed staff assist them with toileting and changing their incontinence briefs. During tour of the facility LPA observed residents to be well groomed and did not observe residents to malodorous. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. “Staff do not reposition resident.” It is alleged that staff do not reposition R1. Four (4) out of the four (4) staff interviewed denied this allegation. Staff interviewed revealed that R1 is checked at least every 2 hours and always reposition every 2 hours. Staff revealed that they make attempts to bring R1 into the living room but R1 declines to be moved due to pain R1 experiences when they are moved. Five (5) out of the five (5) residents interviewed denied this allegation. Interview with R1 revealed that they don’t want to be moved too much due to pain in their lower back when moved out of their bed. R1 revealed staff does reposition them often. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted. A copy of this report was provided. No deficiencies were cited for this complaint investigation.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 28-AS-20260807164958

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management-Deficiencies visit on 08/13/2026. LPA was met by House Manager Claudia Orozco and explained the purpose of the visit. Administrator Toby Miclat was notified via phone of LPA’s visit. During record review, LPA discovered that staff#1 (S1) and staff #2 (S2), who were present at the facility during LPA’s visit did not have proof of criminal clearance. Interview with S1 revealed that they are a volunteer and do not provide direct care and supervision to residents. S1 revealed that they began volunteering to assist with cooking and cleaning the facility only. S1 revealed that they do not have proof of criminal clearance and they began volunteering effective 08/06/2026 and only on Thursdays, Fridays and Saturdays. Interview with S2 revealed they provide direct care and supervision to residents. S2 revealed that they started working at the facility 3 weeks ago and they have not obtained criminal clearance. Based on interviews and records reviewed, LPA issued one (1) deficiency and two (2) civil penalties in the amounts of $500 & $400. Exit interview was conducted. A copy of this report, 809-D, LIC 421BG and appeals rights was provided.the state’s words, verbatim · CDSS document, Aug 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Aug 14, 2026

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department This requirement was not met as evidenced by: S1 and S2 did not obtain a California clearance or exemption as required. This poses an immediate risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Administrator Miclat will draft a plan on how future staff/and or volunteers will obtain criminal clearance or exemption prior to working or volunteering at the facility. Plan must be received by 08/14/2026, via email.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Ana Aparicio and explained the reason for the visit. Maxson Raharuhi, Assistant Administrator arrived shortly thereafter. The facility is licensed to serve residents ages sixty (60) and older. The approved capacity is six (6) non-ambulatory residents. The facility is approved to retain no more than two (2) residents receiving hospice care. There were two (2) residents under hospice care during inspection. Facility Tour & Observations Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Oxygen was observed in use in the facility. Required “Oxygen in Use / No Smoking” signs were posted throughout the facility in visible locations. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present. Physical Plant The facility is in a residential area and is a one-story home consisting of four (4) resident bedrooms, one (2) restroom one being a guest restroom, living room, kitchen, laundry room, dining area, laundry room, garage, front yard, and backyard. Property includes a caregiver corridor near bedroom four (4). LPA observed four (4) resident bedrooms, and all contained the required furniture (bed, mattress, linens, dresser, chair, and lighting). Cleaning supplies and toxic substances were accessible to residents in a kitchen cabinet under sink. (continued on 809C) Bathrooms were clean and equipped with required grab bars in showers and near toilets, as well as non-skid mats; hot water measured in bathroom (1) 113.2°F, bathroom (2) 111.5°F which is within the required 105–120°F. Extra linens and towels were available in a hallway cabinet. Smoke/carbon monoxide detectors were functional; fire extinguisher mounted in the kitchen. There were no bodies of water present. Backyard provided shaded seating. Passageways and exits were observed to be clear and unobstructed. Food Service Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees °F and freezer 0-degree °C) with sufficient supply of 2-day perishable and 7 days non-perishable food. Fresh produce, proteins, and dry goods were stocked. Knives and were observed in a locked kitchen drawer. Health-Related Services & Records Five (5) residents files were reviewed and contained current required documents Admissions Agreements, Pre-Placement Appraisals, Consents, Needs/Service Plans, Physician’s Reports, ambulatory status and Rights acknowledgments. R1 and R2 were missing TB screenings. Five (5) residents’ medications were reviewed; medications were observed to be centrally stored in a locked cabinet in laundry room. It was observed that R1 and R3 require assistance from staff with administration of injectable medications. Additionally, R1 did not have Albuterol medication available. Disaster Preparedness Last fire/earthquake drill was conducted on January 27, 2026, with logs available. LIC 610D Emergency Disaster Plan was posted on front entry bulletin board. Emergency supplies (water, food, flashlights, batteries, first aid) were observed in the garage. Infection Control Plan was updated. Personnel Records & Training Four (4) staff files were reviewed and included criminal record clearances in all staff files. Current CPR/First Aid certificates were observed for S1-S3; however S4 certificate was expired, TB screenings documentation was present for S1-S3 however, no TB screening for S2 was observed. Required training was observed to be in files. Insurance Liability insurance was in compliance with an expiration date of April 4, 2026. An exit interview was conducted with Ana Aparicio, Caregiver. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jan 28, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by Caregiver Claudia Orozco. Administrators Toby Miclat and Lea Loaiza arrived shortly after. LPA Ramirez explained the purpose of the visit. The facility is located on a main street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. Carbon monoxide detectors and smoke alarms in hallways were tested and operational. LPA Ramirez inspected five (5) resident rooms. All resident bedrooms contained required furniture, linens, and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Bathroom#2 has a wheelchair accessible shower. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 01/02/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in pantry. See 809-C Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: Medications are centrally stored in locked kitchen cabinet and in bubble packs and/or original containers. The facility uses electronic charting to document medications administered and other charting notes on residents. The facility provides incidental medical services. Staffing: Administrator Certificate for Toby Miclat expires 10/12/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for three (3) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed. Infection Control: Staff is using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. LPA Ramirez observed staff wearing gloves while handling food. LPA Ramirez observed staff wearing gloves while proving care to a resident. Operational Requirements: The fire clearance is approved for six (6) non-ambulatory. This facility may retain no more than two (2) hospice residents. There were 0 (zero) residents under hospice care during inspection. Resident Records/Incident Reports: LPA reviewed Resident files for six (6) residents in care. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were observed during this visit. Exit interview conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Feb 20, 2025

Allegation investigated: Staff did not prevent resident from sustaining severe fractures while in care Staff did not prevent resident from sustaining pressure injuries

.Licensing Program Analyst (LPA) Alberto Lopez made subsequent visit today to deliver findings for complaint received on 12/02/2022. LPA met with Administrator Toby Miclat and discussed the purpose of the visit. During today’s visit, LPA took a tour of the facility, including random resident rooms, and common areas of the facility. On 12/05/2022, Licensing Program Analyst (LPA) Alberto Lopez made initial 10-day visit. During this visit LPA met with Acting Administrator Lea Loaiza and explained the purpose of today's visit. LPA conducted a tour of this facility. LPA did not observe any signs of neglect, or abuse, but did observe health and safety risks. LPA cited facility on Case Management report and 809D. LPA also reviewed files for three residents and obtained relevant documentation. (CONTINUED ON 9099C) Substantiated LPA obtained resident roster and names of staff. LPA asked facility for LIC500, and facility staff stated they would email it later today. LPA interviewed four staff (S#1- S#4), six residents (R#1-R#6) and two witnesses (W#1-W#2). Allegation: Staff did not prevent resident from sustaining severe fractures while in care. It is alleged that resident sustained fractures while in care due to facility Neglect/Lack of Care and Supervision. The investigation revealed: LPA Interviewed four (4) staff S1-S4 and four (4) of four (4) staff denied the allegations. LPA interviewed six (6) residents R1-R6 and six (6) of six (6) residents could not collaborate the allegation. Administrator denied that facility caused fractures, and three (3) of three (3) staff stated they were unaware that resident had facial fractures. According to Department interviews, and records reviewed, resident was admitted to facility on 05/01/2022. On 11/26/2022, resident was found to be lethargic and unresponsive. Facility called 911 and the resident was transported to Pomona Valley Hospital. At the hospital, evidence of facial fractures (Right orbital lateral wall fracture, right zygomatic arch fracture) was documented on hospital records for admission date of 11/26/2022. Based on supporting evidence, facility failed to provide proper medical attention, and the facility provided inadequate care and supervision that caused unexplained injuries while under care and supervision of the facility. There is sufficient evidence to substantiate this allegation. Allegation: Staff did not prevent resident from sustaining pressure injuries. It is alleged that staff did not prevent resident from sustaining pressure injuries while in care. The investigation revealed the following, LPA Interviewed four (4) staff S1-S4 and four (4) of four (4) staff denied the allegation. LPA interviewed six (6) residents R1-R6 and six (6) of six (6) residents could not collaborate the allegation. Administrator denied that resident developed pressure injury while at the facility. Administrator stated that resident arrived at facility with pressure injuries. (CONTINUED) According to Department interviews, and records reviewed, resident was admitted to facility from nursing home on 05/01/2022. Discharge paperwork from the nursing home documents a stage 1 pressure injury on each heel and sacrococcyx blanchable redness. Administrator agreed that resident arrived to the facility as described by the nursing home discharge paperwork. Resident was found to be lethargic and unresponsive on 11/26/2022. Facility called 911, and the resident was transported to Pomona Valley Hospital. While at the hospital, RN documented wound on resident’s buttock midline coccyx: 6cm x 6cm x 0cm (wound had no documented staging, photograph showed area to be redden, not open). RN also documented right foot wound with no documented staging. There was no mention of the left foot in the hospital records. Additional RN staff documented that resident had a “closed stage 3 pressure injury on coccyx and evidence of scar tissue”. Due to facility failing to provide proper care and supervision, resident’s pressure injury on coccyx progressed from blanchable redness to stage 3 during her stay at facility. There is sufficient evidence to substantiate this allegation. 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 cited on the attached LIC 9099D. An immediate $500 civil penalty is being issued during today's visit due to the neglect/lack of care and supervision resulting in resident sustaining fractures to face. An exit interview was conducted with the Administrator Toby Miclat and a hard copy of licensing report was provided along with appeal rights. . LPA obtained resident roster and names of staff. LPA asked facility for LIC500, and facility staff stated they would email it later today. On 08/08/2023 LPA Alberto Lopez made a subsequent visit to facility and met with Administrator Toby Miclat and discussed the purpose of the visit. LPA took a tour of the living room, dining areas, kitchen, common areas, and random resident rooms. LPA did not observe any signs of neglect, abuse or other immediate health and safety risks. LPA requested copies of staff and resident roster, and interviewed four(4) Staff (S#1-S#4) and six (6)residents (R#1-R#6). LPA interviewed four staff (S#1- S#4), six residents (R#1-R#6) and two witnesses (W#1-W#2). Allegation: Staff did not meet residents hygiene needs. It is alleged that facility failed to provide resident with adequate hygiene needs The investigation revealed, LPA interviewed four (4) staff S1-S4 and four (4) of four (4) staff denied the allegation. W1 and W2, who are family members, stated resident had a bad body odor. LPA interviewed six (6) residents R1-R6 and six (6) of six (6) residents could not collaborate the allegation. Administrator denied that facility did not meet resident hygiene needs, and three (3) of three (3) staff stated they provide all residents with proper hygiene needs daily. LPA toured all rooms, all residents were clean, bed linens were clean, and the rooms were free of odors. There is not enough evidence to support this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and copy of report provided to Administrator Toby Miclatthe state’s words, verbatim · CDSS document, Apr 30, 2024 · control 28-AS-20221202102319

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1)(c) · Plan of correction due date: May 1, 2024

87464(f)(1)(c) Basic Services: Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). H&S Code 1569.2(c) “Care and supervision ” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not being met as evidenced by: Based on interviews and record review, resident suffered 2 facial fractures while in care at the facility and facility failed to provide medical attention to resident. Lack of care and supervision by facility resulted in staff not knowing resident had facial fractures. The fractures were discovered when resident made visit to emergency room for unrelated health issues.the state’s words, verbatim · CDSS document, Apr 30, 2024

Plan of correction: Licensee to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to train staff on providing care and supervision and send roster with signatures of participants of training to LPA. Licensee to submit a faxed copy of POC by due date of 05/01/2024 Immediate $500 dollar penalty assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: May 1, 2024

87465(a)(1) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and record review, facility did not contact PCP or arrange to have wound care specialist provide wound care to resident who was admitted to facility with two stage 1 pressure injuries on both heals and developed stage 3 pressure injury on coccyx while in care.the state’s words, verbatim · CDSS document, Apr 30, 2024

Plan of correction: The administrator shall develop a written plan to ensure that residents receive medical attention while in care. The plan shall also include the steps the facility will take when a resident's health condition declines or refuses. This POC is due to LPA by 05/01/2024

Type of visit: Case Management - Deficiencies

On 12/05/2022, Licensing Program Analyst (LPA) Alberto Lopez made initial 10-day visit. During this visit LPA met with Acting Administrator Lea Loaiza and explained the purpose of today's visit. LPA conducted a tour of this facility. LPA did not observe any signs of neglect, or abuse, but did observe health and safety risk. LPA cited facility on Case Management report and 809D. LPA also reviewed files for three residents and obtained relevant documentation. LPA obtained resident roster and names of staff. LPA asked facility for LIC500, and facility staff stated they would email it later today. On 08/08/2023 LPA Alberto Lopez made a subsequent visit to facility and met with Administrator Toby Miclat and discussed the purpose of the visit. LPA took a tour of the living room, dining areas, kitchen, common areas, and random resident rooms. LPA did not observe any signs of neglect, abuse or other immediate health and safety risks. LPA requested copies of staff and resident roster, and interviewed four(4) Staff (S#1-S#4) and six (6)residents (R#1-R#6). LPA interviewed four staff (S#1- S#4), six residents (R#1-R#6) and two witnesses (W#1-W#2). 04/30/24 - During today’s visit, LPA took a tour of the facility, including random resident rooms, and common areas of the facility. According to Department interviews, and records reviewed, and observation, The facility was using half rails for resident #1 (1) and #6 (6) without a doctor’s orders which poses an immediate health, safety, or personal rights risk to persons in care. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6 and Chapter 8 Exit interview, a copy of this report and Appeals Rights were provided to the Facility Administrator Toby Miclatthe state’s words, verbatim · CDSS document, Apr 30, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: May 2, 2024

87608(a)(3) 87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidence by: LPA observed R1 with double half rails and Administrator stated that the facility did not have a doctor’s order for the half bed rails that were used for R1 and R6 bed which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2024

Plan of correction: Administrator will obtain doctor's orders for R1 and will read section 87608 and send a written letter to LPA indicting that Administrator understood the section and how it facility will prevent this from happening again by POC date.

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Plan of Correction (POC) visit to follow-up on the POC's due on 02/16/24. An annual required visit was conducted on 02/09/24 by LPA Ramirez. During the annual visit, the facility was issued three (3) deficiencies and one (1) Technical Violation. The facility did not clear two (2) out of the three (3) POC’s that had a due date of 2/16/24. The following POC’s are still outstanding: HSC 1569.605 ** LPA Ramirez originally requested proof of liability insurance.** On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. HSC 1569.695(c) **LPA Ramirez originally requested proof of staff re-training on this regulation.** (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. LPA Ramirez spoke with Administrator Toby Miclat and Co-administrator Lea Loaiza by telephone and agreed that LPA Ramirez will receive proof staff re-training on HSC 1569.605 by the end of business on 2/23/24. LPA Ramirez granted an extension to submit liability insurance no later than the end of business on 3/1/24. LPA Ramirez will issue civil penalties in the amount of $700 for each deficiency noted above, 7 days x $100 starting from 2/17/24 till 2/23/24. Exit interview conducted with Caregiver Judith Sabando. A copy of this report and (2) LIC 421FC was provided.the state’s words, verbatim · CDSS document, Feb 23, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 02/00/2024. LPA was met by Caregiver Baltazar Reyes and explained the purpose of the visit. The facility is licensed to serve six (6six (6) residents over the age of 60, of which six (6) may be non-ambulatory and has a hospice waiver approved for two (2). LPA OBSERVATIONS: The facility is a single-story dwelling located on a main street and consists of four (4) resident bedrooms, one (1) staff bedroom, two (2) shared bathrooms, kitchen, dining room, living room, attached garage, front yard, and backyard. LPA Ramirez observed auditory device on entry of door to be operational, sliding door and exits. Front Yard: Front yard is well maintained, and no hazards were observed. Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed centrally stored medications in kitchen cabinet to be locked during visit. LPA Ramirez observed sharps and knives near kitchen cabinet to be locked during visit. First aid kit was observed in kitchen cabinet. Emergency food supply was stored in kitchen pantry. Dining Room/Living room/: LPA Ramirez observed plenty of lighting and seating in this area. LPA Ramirez observed several recliners in living room area. One (1) large dining room table with six (6) chairs was observed. Laundry room: LPA Ramirez observed laundry detergent to be locked during visit. Linen Closet: Contained plenty linens, towels, and hygiene products. Resident Rooms 1-4: LPA Ramirez inspected four (4) resident rooms. LPA Ramirez observed all rooms to contain required lighting, furniture, and linen. LPA Ramirez observed auditory device on S6’s bedroom door. Bathrooms 1-2: bathroom# 1 water temperature measured at 106.2-degree F which is within the required 105F - 120F degrees. LPA Ramirez observed Resident bathroom #2 water temperature was measured at 105.6-degree F which is within the required 105F- 120F. LPA Ramirez observed signs promoting proper hand washing. LPA Ramirez observed grab bars near toilet and showers and no slip coating in showers. Backyard: No hazards were observed. Plenty of shade and seating was observed. Garage: LPA Ramirez observed emergency water in this area. Emergency Drills: Last documented fire drill wasdrills were conducted on 01/16/2024 and 02/13/2023. Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable. Personnel Records: Personnel records are maintained at the facility. LPA Ramirez reviewed three (3) personnel records. Documented proof of required annual initial training and annual training was observed. Administrator's Certificate for Lea Loaiza was observed with an expiration date of 9/19/2024. Resident Files: Six (6) resident files and Medications Administration Record (MAR) were reviewed. Liability Insurance & Infection Control Plan: Licensee could not provide liability insurance. LPA Ramirez observed infection control plan however, infection control plan was not observed to comply with Title 22. Deficiencies are being cited. Deficiencies and technical advisories are being cited. A copy of this report, 809-D, and appeals rights were provided to Lea Loaiza.the state’s words, verbatim · CDSS document, Feb 9, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.