Pacific Care Home III

Type of visit: Required - 1 Year

On March 3, 2026, Licensing Program Analyst(LPA) Murial Han and IB investigator Gina Dutta conducted an unannounced annual inspection. LPA and IB investigator were greeted by caregiver, Emily Soriano. LPA explained the purpose of the visit. Facility supervisor, Moddie Andaya and licensee, Wilhelm Ick arrived shortly thereafter and assisted with the inspection. LPA toured facility and grounds. No accessible bodies of water. LPA toured inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed 5 resident rooms. Rooms were spacious and included all required furnishings. Bathrooms were observed to be clean; equipped with paper towels, soap, grab bars, and non-skid mats. Hot water temperature in the kitchen, and bathroom was measured at 108- 113 degrees F. 2 days for perishables and & 7 days non-perishable were observed to be present. The facility is approved for 3 hospice and 1 bedridden; during today's visit, there are 5 resident and 2 of which are on hospice care. Medications, toxins, chemicals were observed to be locked and inaccessible to residents in care. Emergency drills were reviewed. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last inspected on 10/9/2025. A review of (5) resident files was conducted and noted on the LIC 858. A review of (2) staff files was conducted and noted on the LIC 859. During the tour of the facility, LPA and IB investigator observed the garage consisted of a metal/wooden frame with a folded cushion on top (similar to a Fulton bed), Rosary, clothes with staff clothing, staff medication, shoes, comb, etc. In addition, during the medication review, LPA observed medication was removed from its original containers, and poured into a pill organizer container for the next day. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with administrator and supervisor. A copy is provided and the appeal rights.the state’s words, verbatim · CDSS document, Mar 3, 2026

Type of visit: Required - 1 Year

On April 2, 2025, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregiver, Emily Soriano. LPA explained the purpose of the visit. Facility supervisor, Moddie Andaya and licensee, Wilhelm Ick arrived shortly thereafter and assisted with the inspection. LPA toured facility and grounds. No accessible bodies of water. LPA toured inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed 5 resident rooms. Rooms were spacious and included all required furnishings. Bathrooms were observed to be clean; equipped with paper towels, soap, grab bars, and non-skid mats. Hot water temperature in the kitchen, and bathroom was measured at 105- 107 degrees F. 2 days for perishables and & 7 days non-perishable were observed to be present. The facility is approved for 2 hospice and 1 bedridden; during today's visit, there are 5 resident and 3 of which are on hospice care. Medications, toxins, chemicals were observed to be locked and inaccessible to residents in care. Emergency drills were reviewed. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last inspected on 10/21/2024. A review of (5) resident files was conducted and noted on the LIC 858. A review of (3) staff files was conducted and noted on the LIC 859. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with administrator and supervisor. A copy is provided and the appeal rights.the state’s words, verbatim · CDSS document, Apr 2, 2025

Type of visit: Required - 1 Year

On April 23, 2024 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregiver, Emily Soriano. LPA explained the purpose of the visit. Facility supervisor, Moddie Andaya arrived toward the end of the inspection and assisted with the rest of the inspection. LPA toured facility and grounds. No accessible bodies of water. LPA toured inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed 5 resident rooms. Rooms were spacious and included all required furnishings. Bathrooms were observed to be clean; equipped with paper towels, soap, grab bars, and non-skid mats. Hot water temperature in the kitchen, and bathroom was measured at 107- 110 degrees F. 2 days for perishables and & 7 days non-perishable were observed to be present. During the tour of the garage, LPA observed chemicals were unlocked and accessible to residents. LPA also observed the garage was sectioned off in the middle; one side is for laundry, toxins and chemical storage, etc. and the other side consisted of: futon beds, clothing, plastic shoe storage unit, closet, toiletries, and a blue luggage. Medication cabinet, located in the kitchen area, was reviewed. Chemical was observed to be unlocked underneath the kitchen sink. Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time. Facility was not able to provide documentation that emergency drills were conducted. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last inspected on 10/19/2023. A review of (4) facility resident records was conducted; A review of (2) facility staff records was conducted and 1 file was not available for review and according to the supervisor this staff just starting working at this facility yesterday and the file is still at one of the sister facilities. During today's inspection, there were 4 residents and 2 staff present. LPA requested these documents to be submitted by 4/24/2024: a copy of the administrator certification. Civil penalty is being assess today for repeat violation during the annual inspection on 10/14/2023. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with administrator and supervisor. A copy is provided and the appeal rightsthe state’s words, verbatim · CDSS document, Apr 23, 2024