Fruitful Humble Abode II

Type of visit: Required - 1 Year

Unannounced Annual visit made out to this facility on 01/30/2026 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff persons, Dominic Gonzales and Ria Estopacia, who were briefly interviewed at this time. This LPA requested that they go ahead and contact the facility designated Administrator, Pedro Pancho, to inform him that CCL was present at this time. The facility designated Administrator, Pedro Pancho, arrived later to this facility while this LPA was conducting this annual visit. Current census was 6 residents. It was learned that there was (1) resident under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (6) residents under the care of hospice at any given time. It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there were (2) residents diagnosed with dementia at this time. It was learned that there was (1) resident receiving services through home health at this time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in facility hallway closet, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured. Additional food storage units located in the garage area were observed to be present and functional at this time. Laundry room, located prior to the entrance for the garage, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Administrator certificate, # 7026619740, for Pedro Pancho was observed to have an expiration date of 10/26/2027 and in compliance at this time. Forms and documents have been completed in order to renew this Administrator certificate at this time. Medication cabinet, located in the facility kitchen cabinets , was observed to be locked and made inaccessible to the residents at this time. First aid kit, located in the medication cabinet, was reviewed. This LPA observed that it did contain all of the required components at this time. Fire extinguisher, located hanging on the kitchen wall, was observed to have been annually inspected on 09/11/2025 by the local fire extinguisher company, Touch Down Fire, and in compliance at this time. Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted. A review of (5) facility personnel records was conducted and noted on the following LIC 859. A review of (6) facility resident records was conducted and noted on the following LIC 858. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal Rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jan 30, 2026

Type of visit: Post Licensing

Unannounced Post Licensing visit made out to this facility on 09/03/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Joyce Mabunga, to inform her that CCL was present at this time for the post licensing visit. Current census was 4 residents. It was learned that there were (2) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (6) residents under the care of hospice at any given time. It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there were (2) residents diagnosed with dementia at this time. It was learned that there weren't any residents receiving services through home health at this time. This facility does have a bedridden fire clearance to be able to accept and retain up to (1) bedridden resident at any given time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in facility hallway, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured. Laundry room was toured at this time. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Administrator certificate, # 7026619740, for Pedro Pancho was observed to have an expiration date of 10/26/2025 and in compliance at this time. Forms and documents were being updated in order to renew this Administrator certificate at this time. Medication cabinet, located in the facility hallway cabinets, was observed to be locked and made inaccessible to the residents at this time. First aid kit, located in the kitchen area, was reviewed. This LPA observed that it did contain all of the required components at this time. Fire extinguishers (2) were located throughout this facility and observed to have been annually inspected by the local fire extinguisher company, Touch Down Fire Company, on 09/10/2024 and found to be in compliance at this time. Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted. A review of (4) facility personnel records was conducted and noted on the following LIC 859. A review of (4) facility resident records was conducted and noted on the following LIC 858. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal Rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Sep 3, 2025

Type of visit: Prelicensing

Announced Prelicensing visit made out to this facility on 01/06/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Pedro Pancho and Joyce Mabunga, who were briefly interviewed at this time. Current census was 0 residents. It was learned that this facility will be looking to accept and retain residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (6) residents under the care of hospice at any given time. It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that this facility has a program to be able to accept and retain (1) bedridden resident at any given time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in facility hallway closet, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured. Laundry area, located in the room across from the garage, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. The door leading into the laundry room was observed to also have a lock that would make it inaccessible to the residents at this time. Administrator certificate, # 7026619740, for Pedro Pancho was observed to have an expiration date of 10/26/2025 and in compliance at this time. Medication cabinets, located in the facility kitchen cabinets, was observed to be locked and made inaccessible to the residents at this time. First aid kit, located in the medication closet, was reviewed. This LPA observed that it did contain all of the required components at this time. Fire extinguisher was located in the facility kitchen area and observed to have been inspected on 09/10/2024 by the local fire extinguisher company, Touch Down Fire Inc., and observed to be in compliance at this time. Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted. Facility resident files were observed to be present and set up at this time. Facility personnel files were observed to be present and set up at this time. Component III was waived and not conducted since this Applicant has been licensed for (2) other facilities at this time. This facility was found to be in compliance at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jan 6, 2025