Princeville-Bolsa Chica

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 (S1) at 8am. LPA met with Administrator (AD) Karl Padua and explained the purpose of the visit. The facility is a six- bedroom, two-and-a-half bathroom, single story home with a fire clearance for six non-ambulatory residents and hospice waiver approved for six residents. The facility currently has a census of six residents in care and four residents on hospice. During today's visit, LPA toured the facility and tested carbon monoxide and smoke detectors and both were operational. LPA observed a video camera in the common area that does not have audio. LPA observed the fire extinguisher was charged and inspected on November 3, 2024. The facility conducted their last fire drill on December 12, 2025. The facility was clean and there were no odors detected. LPA inspected the kitchen and all of the stove burners are in working order. Cleaning chemicals and disinfectants were secured beneath the sink and knives/sharps were secured in a drawer. The refrigerator had the required two day perishable items and the pantry had seven days of non-perishables on-hand. Fruits were observed on the counter and, at time of the entry, residents were eating breakfast. Emergency water was in the garage. While touring the interior LPA observed the PUB 475 posted, as well as Personal Rights, Resident Council information and Visiting Hours. LPA tested two of two resident bathroom water temperatures. The hot water temperatures ranged between 105.3 to 108.1 degrees Fahrenheit. Showers had grab bars and non-skid (Continued on LIC 809-C) (Continued from LIC 809) mats and all disinfectants were secured. LPA toured resident rooms and noted they had the required furnishings of tables, chairs and beds. Bed rail orders were observed on file and all linens were clean and there was an ample supply of linens in hallway closet. LPA toured the exterior of the property and observed the exterior gates were unlocked. There was ample space for residents to walk outside and the bird bath and water fountains were empty for the winter months. LPA observed a shaded seating area and there were no hazards obstructing pathways. After breakfast, LPA observed three residents doing chair exercise and listening to music. LPA reviewed three of three staff training and fingerprint records.and conducted a complete review of resident records. LPA observed medication storage and reviewed the centrally stored medications. Per review of Medication Administration Records, medications are being given as prescribed. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on November 16, 2026. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Karl Padua, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Dec 18, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Michael Tea and Fred Arias conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 1:13 PM, LPAs Tea and Arias was greeted and granted entry into the facility by caregiver, Honey Cel Nguyen and explained the reason for the visit. The Administrator (AD) Karl Padua arrived shortly after to assist during the visit. The facility is licensed for 6 non-ambulatory residents, with a hospice waiver for four. Currently there are six residents, of which four are on hospice during today's visit. Around 1:30 PM, LPAs reviewed six resident files and two staff files. Resident files and staff files contained all required documentation. Upon review of records, the facility is up to date with required quarterly fire drill, which was last conducted in December 10, 2024. AD Padua’s current certificate has expired on November 16, 2024 and completed the renewal process and due to the department’s back log is currently pending. LPAs along with the AD Padua toured the facility around 2:10 PM. LPAs toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 5 resident bedrooms, one staff room, 2 full bathrooms and 1 half bathroom, living room, dining room, kitchen and attached garage. LPAs observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. 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, and shower was free of mold/mildew. Water temperature measured between 109.5 F degrees and 111.2 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Continuation of Annual Inspection report on LIC809C LPAs observed sharps locked in a kitchen drawer. LPAs also observed toxin substances to be locked and inaccessible to clients in care underneath the kitchen sink. Fire extinguisher was fully charged in the kitchen. Kitchen appliances are mostly operational during today's visit except a few of the stove burners were out of order. LPAs toured the outside grounds and there is ample seating underneath a shaded patio area in the backyard. There is a water fountain and flowers and lemon trees surrounding the seating area. There are two exit gates that are self-latching and operational on both sides of the house. LPAs observed emergency water supply and other supplies in the garage. There is emergency food stored in the pantry in the kitchen. Facility provides activities based on their personal choice, residents work on puzzles, color, and play games. They do exercises and go out for walks if the weather permits. Sometimes the administrator brings his dog for the resident’s entertainment. Residents read to past the time. At the time of the visit, LPAs observed residents watching TV leisurely and eating dinner together. LPAs reviewed medication storage and administration. Medications are stored in locked drawers in the kitchen area. Medications are being administered per physician order but there were discrepancies in documentation and management of medications. LPAs explained the importance of documentation and management of medications. LPAs interviewed residents regarding their quality of care and spoke to staff present regarding care provided. Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Administrator Karl Padua and a copy of this report LIC809, along with the 809-C, LIC858, LIC859 and LIC9102 were read and provided to the facility.the state’s words, verbatim · CDSS document, Dec 13, 2024

The state marks this report as 6 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.