Pacific Care Home II

Type of visit: Required - 1 Year

On 12/29/2025, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator Moddie Andaya and explained the purpose of today’s visit. Currently there are 6 residents and 3 staff present including the administrator. This is a single two level facility with 6 bedrooms for residents. All residents reside on the ground floor only. The upper floor is for staff. The facility is licensed for age 60 and over; All may be Non-Ambulatory residents and 1 may be bedridden. Hospice waiver granted for 3 residents. Currently there are 3 residents on hospice. LPA Vado toured the facility both inside and outside with Moddie. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. There is a freezer located in the garage and a full refrigerator and freezer in the kitchen. Canned food supplies are primarily observed as stored in a pantry located in the formal dining area. Knives are locked in the kitchen in a drawer next to the stove. Toxic chemicals are stored in the garage. Cleaning supplies and laundry soaps are also locked in the garage. Laundry area is in the garage and both the washer and dryer are operational. Continued on next page... Page 2 Additionally the facility fire panel is located in the garage above the PPE and incontinence supplies are observed to be in place stored in the garage in boxes. Medications are locked in the kitchen in a large cabinet. Each resident room is observed to contain the required furniture as outlined in regulations. Facility has functioning smoke detectors and carbon monoxide detectors through out the facility. LPA Observed a fire pull station located at the front of the facility. The facility is equipped with private half baths in each resident room and a common full bathroom for bathing. All are observed in good working order for resident use. Water temperature is tested at 112F in the kitchen and 105F in the resident rooms. There are two fire extinguishers in the facility that is observed with inspection tags of 11/07/2025. LPA observed resident linen supplies and incidentals also store in a hallway closet. There is one common shower room located in the rear of the facility. Shower room floor is equipped with a non-skid mats when in use. Based on review of all resident files, and medications all items are current and logged accurately. Last fire/disaster drill was conducted on 12/05/2025 per records reviewed. Administrator certificates are observed to be current an posted in the facility. Required signs are posted in the facility. Administrator certificate is current expiring on 11/15/2027. The following updated forms were received in person on this day: • Copy of updated administrator certificate • LIC308 Designation of responsible staff person • LIC500 Staff Schedule There are no citations issued during today's inspection visit. Report is reviewed with Moddie and a copy is provided.the state’s words, verbatim · CDSS document, Dec 29, 2025

Type of visit: Required - 1 Year

On 01/14/2024, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator Moddie Andaya and explained the purpose of today’s visit. Currently there are 6 residents and 3 staff present including the administrator. This is a single two level facility with 6 bedrooms for residents. All residents reside on the ground floor only. The upper floor is for staff. The facility is licensed for age 60 and over; All may be Non-Ambulatory residents and 1 may be bedridden. Hospice waiver granted for 3 residents. Currently there are 3 residents on hospice. LPA Vado toured the facility both inside and outside with Moddie. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. There is a freezer located in the garage and a full refrigerator and freezer in the kitchen. Canned food supplies are primarily observed as stored in the garage. Knives are locked in the kitchen in a drawer next to the stove. Toxic chemicals are stored in the garage primarily. Cleaning supplies and laundry soaps are also locked in the garage. Laundry area is in the garage and both the washer and dryer are operational. Additionally the facility fire panel is located in the garage above the PPE and incontinence supplies are observed to be in place stored in the garage in boxes. Medications are locked in the kitchen in a large cabinet. Each resident room is observed to contain the required furniture as outlined in regulations. Facility has functioning smoke detectors and carbon monoxide detectors through out the facility. LPA Observed a fire pull station located at the front of the facility. The facility is equipped with private half baths in each resident room and a common full bathroom for bathing. All are observed in good working order for resident use. Water temperature is tested at 120F in the kitchen and 105F in a rear bedroom half bathroom. There are two fire extinguishers in the facility that is observed with inspection tags of 11/18/2024. Continued on next page... Page 2 LPA observed resident linen supplies and incidentals also store in a hallway closet. All resident bedrooms contain a half bath for resident use. There is one common shower room with toilet as well. Shower room floor is equipped with a non-skid mats when in use. Based on review of all resident files, and medications all items are current and logged accurately. Last fire/disaster drill was conducted on 01/09/2025 per records reviewed. Administrator certificates are observed to be current an posted in the facility. Required signs are posted in the facility. The following updated forms were received in person on this day: • Copy of updated administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease There are no citations issued during today's inspection visit. Report is reviewed with Moddie and a copy is provided.the state’s words, verbatim · CDSS document, Jan 14, 2025

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds. Six residents are accommodated in private rooms--5 have private half bathrooms--all of which have direct exits to outside. There is a staff room with 5 beds, as well as upstairs staff residence that includes one bedroom. Fenced backyard is level, landscaped, and partially paved; it is shared with Pacific Care Home (3647 Pacific Blvd.)--also operated by J & I LLC. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is complete and maintained. Client files are reviewed, and medications are recorded on Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records. Wilhelm Ick (x 3/24) and Moddie Andaya are certified RCFE administrators that oversee facility operations, with assistance from Rafael Jison (RCFE x 3/24). As per legislation, effective 1/1/2015, the following information is posted: 1) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C), per AB2171; 2) CCLD Hotline information, per SB895. Signature page of Emergency Disaster Plan(LIC610-E) & proof of current liability insurance are given to LPA. The following licensing forms are requested to be updated and submitted to CCLD by 3/5/24: - Personnel Report (LIC500) - Administrative Organization (LIC309) - Designation of Facility Responsibility (LIC308) Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages.the state’s words, verbatim · CDSS document, Feb 20, 2024