Traditions at Lucero Way

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a Plan of Correction visit, during the visit LPA observed the following: During a walk of the facility LPA Mendivil observed staff bedroom was open with medications unsecured on the night stand. Based on the following a deficiency is being cited per Title 22 California Code of Regulations. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 18, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87456(h)(2) · Plan of correction due date: Sep 19, 2026

(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 than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidence by staff room's door was open and room contained unsecured medications. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 18, 2026

Plan of correction: Corrected during visit

Type of visit: POC

On this day, Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 09/08/2026. LPA was greeted and granted entry into the facility and explained the reason for the visit. LPA Mendivil observed the following: Deficiency cited under Title 22 87057 ( c) pertaining to admission agreements are signed by facility. Administrator corrected during visit. Licensee has complied with POC Deficiency cited under Title 22 87412 (a) (11) pertaining to health screenings for staff. Licensee has complied with the POC. Licensee emailed copies of health assessments for staff on September 15, 2026. Licensee has complied with POC. Deficiency cited under Title 22 87203 pertaining to conformity to fire regulations. Licensee has complied with POC. Deficiency cited under Title 22 87608 (a) (3) pertaining to physician orders for postural supports. Licensee has not complied with POC as there are still bed rails on Resident 5's bed without physician orders. CIVIL PENALTY ASSESSED Deficiency cited under Title 22 87465 (e) pertaining to physician's orders. Licensee has complied with the POC. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 18, 2026

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual. LPA was greeted and granted entry by staff and explained the reason for the visit. The facility is a seven bedroom, three and a half bathroom single story home with an attached garage. The facility is licensed for five non-ambulatory residents and one bedridden resident in room #6 only. The facility has a hospice waiver for four residents and currently zero residents are on hospice. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and water temperatures. The water temperatures tested at 116.2 to 116.9 degrees. All smoke detectors were operational. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. Facility conducted a fire drill on June 3, 2026. LPA reviewed six out of six resident files. LPA observed two out of six residents did not have a signed admission agreement. LPA reviewed four staff records, two out of five staff members do not have an updated health screening. LPA observed two out of three residents with bed rails did not have physician's orders. LPA observed one exit gate was obstructed by trees and the other exit gate was locked blocking access to outside. LPA observed Resident 2's medication to have a note indicating medications were discontinued per family and facility did not retain physician's orders to discontinue medications. LPA Mendivil consulted with Administrator Lordele regarding reporting requirements, the importance of documentation and time administrator spends at the facility. Based on observations made during today's visit deficiencies are being cited per Title 22. A copy of this report, appeal rights, LIC 858 and LIC 859, LIC 421 provided to the facility representative.the state’s words, verbatim · CDSS document, Sep 8, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Sep 14, 2026

c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission... This requirement was not met as evidence by two out of six residents' admission agreement did not have facility signature. This poses a potential personal rights risk to persons in care. Repeat violation. Immediate civil penalty assesedthe state’s words, verbatim · CDSS document, Sep 8, 2026

Plan of correction: Corrected during visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(f) · Plan of correction due date: Sep 15, 2026

(f) All personnel,, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure... This requirement was not met as evidence by two of out five staff reviewed did not have an updated health screening. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 8, 2026

Plan of correction: Licensee to obtain updated health screenings and provide proof to LPA by POC due date

From the deficiency page — Deficiency type: Type A · Section cited: CCR87203 · Plan of correction due date: Sep 9, 2026

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidence by two emergency exits were inaccessible. The exit gate to the right of the facility was locked (picture taken) and the exit gate to the left of house had trees blocking the emergency exit. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 8, 2026

Plan of correction: Administrator unlocked side gate, Administrator to clear tree leaves and clear pathway to all exits. Immediate Civil Penatly assessed

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Sep 9, 2026

(a) (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. This requirement was not met as evidence by two out of three resident's with half bedrails did not have physician's orders Residents 5 and Resident 6 did not have phsycians orders. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 8, 2026

Plan of correction: Administrator to obtain physciain's orders and provide proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(e) · Plan of correction due date: Sep 9, 2026

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication This requirement was not met as evidence by Resident 2 had medication discontined without orders to discontinue medication. This poses an immediate health and saftey risk to persons in care.the state’s words, verbatim · CDSS document, Sep 8, 2026

Plan of correction: Administrator to obtain physician's order to discontinue medications and provide proof to LPA by POC due date.

Type of visit: POC

On this day, Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 09/23/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. LPA Mendivil observed the following: Deficiency cited under Title 22 Regulation Health & Safety Code 1569.605 pertaining to the facility retaining liability insurance. Licensee emailed LPA a copy on 10/3/2025 at 8:25am. Deficiency cited under Title 22 87458 (c ) (1) (A) pertaining to medical assessment including an examination of TB. Licensee has complied with POC as Licensee emailed document to LPA at 9:20am on 10/3/2025. Deficiency cited under Title 22 87463 (a) pertaining to appraisals. Licensee has NOT complied with POC as Licensee emailed 2 out of 5 appraisals to LPA on 10/3/2025. . CIVIL PENALTY ASSESSED. Deficiency cited under Title 22 87463 (h) (1) pertaining to documentation of an annual routine visit. Licensee has complied with POC as physician reports were emailed to LPA at 8:30am on 10/3/2025. Deficiency cited under Title 22 87412 (a) (11) pertaining to health screenings for staff. Licensee has complied with the POC. Licensee emailed copies of health assessments for staff at 8:33am on 10/3/2025. Deficiency cited under Title 22 87468 (c ) (2) (A) pertaining to PUB 475. Licensee has NOT complied with POC. CIVIL PENALTY ASSESSED. Deficiency cited under Title 22 87057 ( c) pertaining to admission agreements are signed by facility and resident/ resident representatives. Licensee has NOT complied with the POC. CIVIL PENALTY ASSESSED. LPA Mendivil spoke with Licensee Lordele De Los Reyes via telephone. LPA advised Lordele of POCs that were not cleared. LPA Mendivil advised Licensee that per conversations on 09/23/2025 and the subsequent email sent on 09/24/2025 LPA advised Licensee to adhere to the POC due dates. Licensee did not communicate to LPA that more time was needed. An exit interview was conducted and a copy of this report was provided with LIC 421FC and appeal rights.the state’s words, verbatim · CDSS document, Oct 3, 2025

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual. LPA was greeted and granted entry by staff and explained the reason for the visit. Licensee/Administrator Lordele De Los Reyes arrived at 8:45am. The facility is a 7 bedroom, 3.5 bathroom single story home with an attached garage. The facility is licensed for 5 non-ambulatory residents and 1 bedridden resident in room #6 only. The facility has a hospice waiver for 4 residents and currently has 2 residents on hospice. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and water temperatures. The water temperatures tested at 105 to 105.8 degrees. All smoke detectors were operational. The facility’s last fire drill was conducted on June 1, 2025. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed 5 different food items that were expired dates ranging from September 2022 to April 2025 found in kitchen cabinets. LPA did not observe a PUB 475 in regulation size or facility license posted in the facility. LPA reviewed 5 out of 5 resident files. LPA observed 5 out of 5 residents did not have a signed admission agreement. LPA observed 5 out of 5 residents did not have an appraisal conducted at admission or an updated appraisal. LPA observed 3 out of 5 residents did not have an updated medical assessment. LPA Mendivil requested a copy of facility liability insurance and Administrator was not able to produce a copy. LPA reviewed 3 out of 3 staff members files, 2 out of 3 staff did not have a health screening on record. LPA Mendivil observed 1 out of 3 staff member's criminal clearance not associated to the facility. LPA Mendivil confirmed Administrator certificate expires on October 6th 2025. LPA Mendivil consulted with Administrator Lordele regarding reporting requirements, the importance of documentation and time administrator spends at the facility. Based on observations made during today's visit deficiencies are being cited per Title 22. A copy of this report, appeal rights, LIC 858 and LIC 859, LIC 421 BG provided to the facility representative.the state’s words, verbatim · CDSS document, Sep 23, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1. During today’s visit, LPA met with Lordele De Los Reyes, Administrator. The facility is a seven bedroom, single story building with an approved fire clearance of five non-ambulatory residents of which one may be bedridden in bedroom six and four are approved for hospice. The facility currently has a census of five residents in care. During today’s visit, LPA arrived at 8:00am and observed three residents eating breakfast. LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in four of four resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 106.3 and 112.2 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on August 7, 2023. The facility’s last fire drill was conducted on July 7, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed and the First Aid kit is complete. PUB 475 sign is not 20" X 26" regulation size. Chlorox was immediately secured underneath kitchen sink. LPA reviewed three of three staffing and fingerprint records and a complete review of resident records. 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 October 6, 2025. (Continued on LIC 809-C) (Continued from LIC 809) Upon records review, two of five residents had Admissions Agreements on file. Five of five residents require updated physicians' reports due to clinical diagnosis on file. Two of five residents did not have postural supports orders. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Lordele De Los Reyes, Administrator and a copy of this report was given to the facility along with a copy of the LIC 9102-TV,LIC 858, LIC 859; LIC 809-D and Appeal Rights.the state’s words, verbatim · CDSS document, Aug 30, 2024

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.