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Type of visit: POC

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Proof of Correction (POC) visit to ensure that the deficiency cited on the 1 year/Annual visit conducted on 9/3/26 has been corrected. LPA met with Administrator/Licensee Margie Isidro and explained the purpose for todays visit. The following sections are now in compliance: 87465(a)(4) Incidental Medical and Dental Care: - cited during annual inspection for missing medication that was listed on the medication list available at facility during the time of visit. - during todays visit LPA compared residents medication to the updated medication list that was provided, all medications were accounted for and there were no discrepancies observed during medication review. Deficiencies cited on 9/3/26 were corrected as required.Therefore, no civil penalties were assessed. LPA has cleared the citation and provided a copy of the POC Clearance Letter. Exit interview held and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 14, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Margie Isidro and explained the purpose for today’s visit. The facility is licensed to serve 6 Ambulatory Adults Age 60 and over, (2 of which may be non-ambulatory in Room #1, 1 non-ambulatory in room #2, 2 non-ambulatory in room #3, and 1 ambulatory). There is a Hospice waiver for 2 residents. The facility is a single-story home located in Bellflower, Ca. A tour of the facility includes: 4 bedrooms (2 of which are vacant), 2 full bath (1 full bath is inside room #1), 1 1/2 bath, living room, dining area, kitchen, attached garage with laundry, front yard and back yard. There is an ADU in the back yard that Administrator resides in, there are no residents living in ADU. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit observed the following: Infection Control: Facility maintains the required Infection Control Plan. Operational Requirements: There's an approved fire clearance. Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Residents with Special Health Needs: There currently are no residents on hospice at the facility. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/earthquake drill was conducted on 8/18/26. (Continued on LIC809-C) Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Staffing: There are currently 2 staff for facility, Administrator stated since there are only 3 residents with little care needs there is no need for additional staff, LPA advised Administrator that additional staff may need to be hired if more residents are admitted to meet their needs. Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 2 staff files with no issues observed. Administrator Margie Isidro has a valid certificate that was verified through the CCL website with an expiration date of 2/1/28. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 3 resident files and reminded Administrator to use the proper forms for the required yearly appraisal needs and service planIncidental Medical & Dental: Medication is centrally stored in a locked cabinet. LPA reviewed 3 residents’ medications and observed the following. LPA observed Resident #1 was missing 3 medications that are listed on the Medication list and there were other medications stored in basket that are not listed on medication list, for Resident #2 LPA observed 2 medications that are being administered but not on medication list provided for review. There were 2 medications in R1's private bath that were unlocked, per physician report cannot administer own medications. (citations will be issued and detailed on LIC809-D). Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during todays visit will be documented on LIC809-D. Exit interview held and a copy of the report and appeal rights were provided to Margie Isidro.the state’s words, verbatim · CDSS document, Sep 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Sep 4, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidence by: During facility tour LPA observed 2 bottles of liquid medication in R1's private bath within their room, per physician report they are not able to administer their own medications. (administrator removed medication from room and stored in the medication cabinet during visit)the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Administrator/Licensee was reminded of this requirement and it was explained that moving forward all medication for residents that cannot administer their own medications must be centrally stored in a locked area. POC was cleared during visit

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(4) · Plan of correction due date: Sep 4, 2026

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, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: During medication review LPA observed the following medication missing for R1 (that is listed on medication list) Cefdinir (capsule) {Brang-Omnicef) 300mg, Diclofenac Sodium (gel) {Brand-Voltaren) 1%, Neomycin Polymyxin-HC (solution) 1% and the following medication missing for R2 that is being administered but not on med list Senna 8.6mg tablet, Olmesartan Medoxomil 40 mg tablet which poses an immediate threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Administrator/Licensee to obtain most up to date medication list for both residents and ensure that the facility has all medications on hand for proper medication administration. A copy of the updated medication list and proof of all medications being ordered or at facility shall be sent to LPA via email by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Margie Isidro and explained the purpose for today’s visit. The facility is licensed to serve 6 Ambulatory Adults Age 60 and over, (2 of which may be non-ambulatory in Room #1, 1 non-ambulatory in room #2, 2 non-ambulatory in room #3, and 1 ambulatory). There is a Hospice waiver for 2 residents. The facility is a single-story home located in Bellflower, Ca. A tour of the facility includes: 4 bedrooms (2 of which are vacant), 2 full bath (1 full bath is inside room #1), 1 1/2 bath, living room, dining area, kitchen, attached garage with laundry, front yard and back yard. There is an ADU in the back yard that Administrator resides in, there are no residents living in ADU. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit observed the following: Infection Control: Facility maintains the required Infection Control Plan. Operational Requirements: There's an approved fire clearance and maintain the required liability insurance. Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Residents with Special Health Needs: There currently are no residents on hospice at the facility. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/earthquake drill was conducted on 9/18/25. (Continued on LIC809-C) Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured outside the required range of 105-120 degrees F, restrooms water temperatures ranged from 90.8-100.8 degrees F (citation issued and details will be documented on LIC809-D page). All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Staffing: There are currently 2 staff for facility, Administrator stated since there are only 3 residents with little care needs there is no need for additional staff, LPA advised Administrator that additional staff may need to be hired if more residents are admitted to meet their needs. Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 2 staff files with no issues observed. Administrator Margie Isidro has a valid certificate that was verified through the CCL website with an expiration date of 2/2/26. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. Although residents have their initial appraisal and physician reports, Resident # 1's last Appraisal is dated 2/29/24, Resident # 2's last complete physician report is dated 8/15/24.(citation will be issued and documented on the LIC809-D page) Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a locked cabinet. LPA reviewed 2 residents’ medications and observed the following. LPA observed Resident #2 was missing 2 medications that are listed on the Medication list and there were other medications stored in basket that are not listed on medication list, for Resident #3 there were 4 mediations listed on the doctors medication list that were not at the facility, also LPA noticed facility is using medication pill box Sun-Sat with pills inside the Wed/Thurs slots. (812 with details of medication and residents names provided, citations will be issued and detailed on LIC809-D page). Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during todays visit will be documented on LIC809-D. Exit interview held and a copy of the report and appeal rights were provided to Margie Isidro.the state’s words, verbatim · CDSS document, Oct 27, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tena Herrera made an announced visit to the facility regarding updated fire clearance and change of ambulatory status. LPA met with Administrator Margie Isidro and explained the purpose for the visit. Applicant completed the change of AMB/NON-AMB status and clearance from the fire department was granted on 5/7/25; granted clearance is for (2) non-ambulatory residents in bedroom #1, (1) non-ambulatory resident in bedroom #2, (2) non-ambulatory residents bedroom #3, and (1) ambulatory resident in room #4. LPA toured the facility and observed the following: Ramps: Exits from bedrooms #2 & #3 have a shared detachable ramp. LPA advised that once non-ambulatory residents are admitted to those rooms it would be a good idea to have additional ramps, so rooms don't share the one removable ramp, this will be helpful in the case of an emergency. Additionally, LPA advised that ramps should be stored in the bedrooms rather than storage garage for easier and quicker accessibility. Grab-Bars: Both restrooms are equipped with grab-bars within the shower and around the toilet. Doors: Door widths, within rooms #1-3 appear wide, to ensure accessibility for wheelchair and/or walker and each room has their own exit doors. All entrance/exits, doorways and ramps were unobstructed and had clear walkways. No deficiencies observed during today's visit, exit interview held and a copy of this report was emailed to margieisidro@yahoo.comthe state’s words, verbatim · CDSS document, Jul 17, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Plan of Correction (POC) visit to follow up on a citation that was issued on 10/26/24 during the facility's Annual Inspection. LPA met with Administrator Margie Isidro who assisted with the visit. On 10/26/24 the facility was cited for the following: 87204(a) - Limitations - Capacity and Ambulatory Status - (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. On 11/17/24 LPA received photos of R1 to be in what appeared to be Room #1 which is the only room in facility that is Fire Clearance Cleared for non-ambulatory residents and meets the non-ambulatory status that R1 has. During todays visit 11/22/24 LPA toured Room #1 and observed R1's belongings in room and R1 also in room. R1 confirmed they have moved into Room #1. Room #3 was also toured and there were no longer any of R1's belongings observed in room. The POC was reviewed at the time of visit and was deemed sufficient to clear. Exit interview held. A copy of the report and copy of Cleared Deficiency Letter was provided.the state’s words, verbatim · CDSS document, Nov 22, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Plan of Correction (POC) visit to follow up on a citation that was issued on 10/26/24 during the facility's Annual Inspection. LPA met with Alodia Penas who assisted with the visit. On 10/26/24 the facility was cited for the following: 87204(a) - Limitations - Capacity and Ambulatory Status - (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. During todays visit LPA observed Resident #1 to be residing in Room #3 which is not a designated room for their non-ambulatory status. Only Room #1 is designated for non-ambulatory. Civil penalties will be assessed during todays visit on the above citation in the amount of $400 for dates 11/10/24-11/13/24. Administrator Margie Isidro to relocate Resident #1 to room #3 and send a proof of correction by 11/17/2024. 87412(a)(11) - Personnel Records - (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. On 11/5/24 LPA received via email, a copy of Staff #2's Health Screening with negative TB result that was dated 2/29/2024. Proof of Correction (POC) is now cleared for the above citation. Exit interview conducted and a copy of this report was provided to Alodia Penas.the state’s words, verbatim · CDSS document, Nov 14, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Margie Isidro and explained the purpose for today’s visit. The facility is licensed to serve 6 Ambulatory Adults Age 60 and over, (2 of which may be non-ambulatory in Room #1). There is a Hospice waiver for 2 residents. The facility is a single-story home located in Bellflower, Ca. A tour of the facility includes: 4 bedrooms (2 of which are used for Administrator and Daughter who live in the facility), 2 full bath (1 full bath is inside room occupied by administrator), 1 1/2 bath, living room, dining area, kitchen, attached garage with laundry, front yard and back yard. There is an empty ADU in the back yard that administrator stated will be used by staff and/or storage, Administrator stated the permits for the ADU were sent to LPA Pena, this will be verified during upcoming work week. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Infection Control: Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan and facility maintains the required liability insurance. Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Residents with Special Health Needs: There currently are no residents on hospice at the facility. (Continued on LIC809-C) Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. After file review it was observed that Resident #2 is Non-Ambulatoy and is residing in Room #3, per license and fire clearance non-ambulatory residents are approved for room #1 only, citation will be issued and detailed on LIC809-D. Staffing: There are currently 2 staff for facility, Administrator stated since there are only 2 residents with little care needs there is no need for additional staff, LPA advised Administrator that additional staff may need to be hired if more residents are admitted to meet their needs. Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 2 staff files, and observed that Staff #2 was missing their Health Screening and TB results from file, citation will be issued and detailed in LIC809-D. Administrator Margie Isidro has a valid certificate that was verified through the CCL website with an expiration date of 2/2/26. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a cabinet and are in their original containers. LPA reviewed 1 residents’ medications and there were no issues observed. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/earthquake drill was conducted on 9/1/24. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during todays visit will be documented on LIC809-D. Exit interview held and a copy of the report will be emailed to Margie Isidro.the state’s words, verbatim · CDSS document, Oct 26, 2024