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Type of visit: POC

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced Case Management Plan of Correction (POC) follow-up visit to the facility. LPA Haddadin was greeted and granted entry into the facility by staff, Alice Dabu, and explained the purpose of the visit. The purpose of today’s visit was to follow up on Plans of Correction (POC) issued on September 13, 2026, in connection with complaint control number 22-AS-20260512142639 and a separate Case Management visit conducted on the same date.The facility was cited under Title 22, Section 87464(f)(1), Basic Services, Care and Supervision. The facility was required to submit proof of the completed review and staff training, including the training date, topics covered, and staff signatures. During today’s visit, LPA reviewed documentation provided by the facility demonstrating completion of the required resident review and staff training. Based on the documentation reviewed during today’s visit, the POC has been completed and is cleared as of today’s date.The facility was also cited under Title 22, Section 87465(g), Incidental Medical and Dental Care Services. During today’s visit, LPA reviewed the staff training documentation provided by the facility. Based on the documentation reviewed during today’s visit, the POC has been completed and is cleared as of today’s date.Both Plans of Correction issued on September 13, 2026, have been cleared.An exit interview was conducted with the facility representative, and a copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Sep 23, 2026

Allegation investigated: Neglect/Lack of Care and Supervision resulted in resident sustaining serious injury.

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility for the purpose of delivering findings regarding the complaint investigation. LPA Haddadin was greeted by staff, Alice Dabu, who granted access to the facility, at which time the purpose of the visit was explained. On May 12, 2026, the Regional Office received a complaint alleging, “Neglect/Lack of Care and Supervision resulted in resident sustaining serious injury.” The investigation determined as follows: Per medical assessment record dated August 8, 2025, Resident 1 (R1) had a prior right femur fracture. R1’s resident appraisal dated July 7, 2025, identified R1 as non-ambulatory, requiring assistance with moving around the facility and supervision and at high risk for fall. R1 required the use of a walker due to paralysis. On May 8, 2026, R1 sustained a fall in the living room area of the facility. {****CONTINUE9099C***} Substantiated Interviews established that one staff member was near the living room when the fall occurred but did not directly observe the fall, while another staff member heard R1 fall from the nearby garage area and subsequently observed R1 on the floor. Staff assisted R1 from the floor and placed them in a seated position. Although staff reported that they did not initially observe bleeding or other visible injuries, R1 reported that their head hurt. Staff asked R1 if they wanted them to call 911; however, R1 requested that their family be contacted instead. Staff did not contact 911 and instead contacted the Facility Administrator (AD), who was not present at the facility. The Facility AD subsequently notified R1’s family member by text message regarding the fall. At approximately 9:54 A.M., R1 spoke with their family by telephone. During the conversation, the family member observed that R1 did not appear to recall what had occurred and was not communicating as they normally did. Due to the change in R1’s cognitive condition, R1’s family member went to the facility to assess R1 in person and contacted R1’s nurse practitioner. Upon arrival, R1’s family member observed a bruise or bump on the back of R1’s head. R1 also demonstrated confusion and difficulty recalling information. R1’s nurse practitioner arrived at the facility and assessed R1. The nurse practitioner confirmed that R1 was taking blood thinner medication and that facility staff were aware of this medication. Due to R1’s change in mental status following the fall, the nurse practitioner advised that R1 needed to be transported to the hospital. R1’s family member subsequently transported R1 to the hospital. During the interview with the nurse practitioner, she stated that, based on R1’s condition and diagnosis, R1 should have been transported to the hospital sooner. Hospital records show that R1 was admitted on May 8, 2026, following the fall with head impact. A CT scan revealed a large subarachnoid hemorrhage, subdural hematoma, and left frontal intracerebral hemorrhage. On May 14, 2026, R1 was enrolled in hospice care following the discharge from the hospital and passed away on May 15, 2026. R1’s death certificate identified the immediate cause of death as Traumatic Intracerebral Hemorrhage. {CONTINUE 9099C2***} Based on the preponderance of evidence, the allegation, “Neglect/Lack of Care and Supervision resulted in resident sustaining serious injury,” is Substantiated. The facility is being cited for violating Title 22, Division 6 of the California Code of Regulations. An immediate civil penalty was assessed per LIC421IM. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49. An exit interview was conducted and a copy of this report along with LIC809-D, Appeal Rights, Civil Penalty Assessment -LIC 421 IM and the LIC 811, identifying confidential names were providedthe state’s words, verbatim · CDSS document, Sep 13, 2026 · control 22-AS-20260512142639

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 14, 2026

87464(f)(1)“Basic services shall at a minimum include: (1) Care and supervision…” This requirement was not met as evidenced by record review. Facility staff failed to provide adequate care and supervision to R1, resulting in a fall with a subarachnoid hemorrhage, subdural hematoma, and left frontal intracerebral hemorrhage. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 13, 2026

Plan of correction: The Administrator will review all current residents for changes in condition and ensure care plans are updated when additional assistance or supervision is needed. Staff will be trained on Section 87464(f)(1). Proof of the completed resident reviews and staff training will be submitted to LPA by the POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Samer Haddadin conducted an announced case management visit to the facility. LPA Haddadin was greeted and granted entry by Alice Dabu. The purpose of the visit was to address deficiencies identified during the investigation of complaint # 22-AS-20260512142639- The following deficiencies were observed: On May 8, 2026, Resident 1 (R1) sustained an unwitnessed fall in the living room area of the facility. Interviews established that one staff member was near the living room at the time of the incident but did not directly observe the fall. A second staff member, who was in the nearby garage area, heard R1 fall and subsequently observed R1 on the floor. Staff assisted R1 from the floor and placed R1 in a seated position. Staff reported that they did not initially observe any bleeding or other visible injuries; however, R1 complained of head pain. Staff asked R1 whether they wanted 911 to be contacted, but R1 requested that their family be notified instead. Staff did not call 911. Instead, staff contacted the Facility Administrator (AD), who was not present at the facility. The AD then notified R1’s family member by text message regarding the fall. R1’s family member arrived and reported R1 also demonstrated confusion and difficulty recalling information.R1 was later observed by a nurse practitioner at the facility who stated that, based on R1’s condition and diagnosis, R1 should have been transported to the hospital sooner.R1 passed away on May 15, 2026. R1’s death certificate identified the immediate cause of death as Traumatic Intracerebral Hemorrhage. Based on record review, the following are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, confidential names list and appeal rights were provided at the time of exit.the state’s words, verbatim · CDSS document, Sep 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Sep 14, 2026

87465(g) “The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident's health...” This requirement was not met as evidenced by interviews and record review. R1 sustained an unwitnessed fall. Staff failed to immediately call 911, resulting in hospitalization with intracerebral hemorrhage. This poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Sep 13, 2026

Plan of correction: The Administrator will provide staff training on Section 87465(g), including when staff are required to immediately call 911 following an injury or circumstance that presents an imminent threat to a resident’s health. Proof of completed staff training, including the training date, topics covered, and staff signatures, will be submitted to LPA by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility for the purpose of completing the required annual inspection. Upon arrival, LPA met with Licensee Fernan David and Administrator (AD) Maria Quiogue. LPA explained the purpose of the visit. The facility is a single-story residence licensed to serve six non-ambulatory residents. The facility consists of five bedrooms and two bathrooms. At the time of the visit, there were four residents in care. During the inspection, LPA toured the interior and exterior areas of the facility. The bathrooms were observed to be clean, sanitary, and operational. Hot water temperatures were tested and measured between 115.9 degrees Fahrenheit and 118.2 degrees Fahrenheit. The kitchen was observed to be clean and organized. The facility had an adequate food supply, including at least a two-day supply of perishable food and a seven-day supply of non-perishable food. Knives and cleaning supplies were secured in locked areas, including a kitchen drawer and under the kitchen sink, and were inaccessible to residents. All kitchen appliances were observed to be operational and in good working condition. Fire extinguishers were observed to be fully charged, with a last purchase date of August 10, 2025. Smoke detectors and carbon monoxide detectors were tested and found to be operational. The first aid kit contained the required supplies. Medications were secured in a locked cabinet and were inaccessible to residents. {CONTINUE 809C} Resident bedrooms were inspected and contained the required furnishings. LPA observed the garage, which is used for storage and laundry purposes. The backyard had a covered patio with a designated seating area for residents. LPA did not observe any bodies of water, hazards, or obstructions on the premises. The exit gate was observed to be operational. LPA reviewed resident and staff files. Resident files were reviewed and no discrepancies were observed. Staff files were reviewed and contained the required documentation. The most recent emergency disaster drill was conducted on June 15, 2026. Based on today’s inspection, no deficiencies were cited pursuant to Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to Administrator Maria Quiogue at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 7, 2026

Type of visit: Prelicensing

Facility Overview LPA Haddadin was greeted and granted entry by Administrator Maria Quiogue. The facility is a single-story residence featuring five bedrooms and two restrooms. It is approved to accommodate a maximum of six non-ambulatory residents. Physical Plant Inspection During the visit, LPA Haddadin conducted a comprehensive tour and inspection of the facility's physical plant. This inspection included, but was not limited to, testing all smoke detectors, which were found to be operational. Hot water temperatures were verified in both restrooms, ranging from 110.8∘F to 111.9∘F. Audio devices at all exits were also tested. Both fire extinguishers were found to be fully charged and had a purchase date of June 19, 2025. Exterior Inspection The exterior of the facility was inspected, and no bodies of water were observed. The outdoor space is sufficient for resident activities. All emergency exits were checked and confirmed to be clear and free of obstructions. Food Supply and Storage An inspection of the facility's food supply revealed that a seven-day supply of non-perishable food was not on hand. This was attributed to the absence of active residents in the facility at the time of the visit. The administrator stated that a two-day supply of perishable items would be maintained once residents are in care. Knives and cleaning supplies were observed to be securely stored in a kitchen drawer. Administrative and Compliance Review The PUB 475 notice was posted in the required 20" x 26" size, and visiting hours were clearly posted. Confirmation was obtained that the administrator possesses a current certificate, which expires on November 8, 2025. Component III of the licensing process was successfully completed with the Administrator. Medication and Safety Equipment The First Aid Kit was inspected and found to contain all required components. Medication will be stored in a locked cabinet in the garage, ensuring it is inaccessible to residents. All required department postings were observed and displayed near the entrance. The administrator's certificate is also posted and expires on November 13, 2027. Conclusion The Administrator was informed that the final application approval would be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted, and a copy of this report was provided to the Licenseethe state’s words, verbatim · CDSS document, Jun 19, 2025