Lovely Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Eliza Daquioag. During the visit, LPA observed 5 residents and 3 staff. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 5 restrooms and 5 residents bedrooms. There was no obstruction to block the walkways. The staff area of the facility was also inspected. The front yard and backyard were inspected. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 117 degrees F in resident bathrooms. ADM stated she has scheduled to have the fire extinguishers at the facility inspected this Friday. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on December 12, 2025. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. No deficiencies cited during today's visit. This report was reviewed with Administrator Eliza Daquioag and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Jan 14, 2026

Allegation investigated: Facility is not meeting the hygiene needs of residents in care

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Eliza Daquioag. Facility is not meeting the hygiene needs of residents in care On July 10, 2025, the Department received a complaint alleging Facility is not meeting the hygiene needs of residents in care. It has been alleged that resident R1 was observed with multiple diapers. On July 11, 2025, LPA interviewed Witness W1 and W2. Both witnesses interviewed stated they have observed resident R1 wearing multiple diapers at the same time, on at least 5 different occasions. W1 and W2 stated they were told by the ADM to use multiple diapers on resident R1. Unfounded On July 15, 2025, LPA Monter interviewed residents R1-R3. All residents interviewed were unable to respond to questions about complaint allegations due to their neurocognitive disorders. On July 15 & 24 and August 13, 2025, LPA Monter interviewed Staff S1 and S2. Both admitted they were using multiple diapers on R1, due to R1’s urination, which soils his/her bed and the resident him/herself. S1 stated if residents R1 or R2 get wet at night, they will use 3-4 diapers. S2 stated only R1 has multiple diapers at night. Both staff interviewed acknowledged there wasn’t a difference between R1 soiling him/herself at night or during waking hours. On July 15 & 24 and August 13, 2025 LPA interviewed ADM. ADM admitted staff place double diapers on R1 at night. ADM stated Only R1 has 2 diapers, because he/she has heavy urination. LPA asked ADM if there is a discrepancy with R1 when he/she soils him/herself in the morning, evening or night. ADM acknowledged that there wasn’t a difference. ADM stated R1 has two diapers at night because at night is easier to take it off and change him/her when he/she has 2 diapers. ADM stated she did instruct her staff to put 2 diapers on R1 at night. Based on a review of R1's Appraisal / Needs and Services Plan (ANS), dated May 28, 2025, R1 has episodes of yelling, screaming and hitting staff. Furthermore, the ANS states R1 needs 2 people during care. The ANS does not outline a specific bowel and bladder management plan for resident R1. The Department has completed the investigation of the above allegation. Based on interviews conducted and records review, the department has found that the above allegation were UNFOUNDED, meaning that the allegation was false, could not have happened and/or are without a reasonable basis.the state’s words, verbatim · CDSS document, Dec 8, 2025 · control 26-AS-20250710151220

Type of visit: Office

An informal meeting was conducted today at the San Jose Adult and Senior Care Regional office. Present in the meeting was Licensing Program Manager (LPM) Romeo Manzano, LPM Christine Kabariti, Licensing Program Analyst (LPA) Manuel Monter, Administrator / Licensee Eliza Daquioag During the meeting, LPM discussed the informal meeting process as a course of action for the facility to achieve compliance with Title 22 Regulations. The administrative action process was discussed by LPM. This informal meeting was initiated due to a recent serious violation issued to the facility at the conclusion of a complaint investigation (26-AS-20250710151220), regarding the allegation facility staff restrained resident. During office visit, deficiencies were discussed. LPA and LPM requested the facility ADM provide an action plan to discuss the following, Due 12/22/2025: Ensure resident's personal rights are not violated and residents are not restricted in their movement. How the facility staff will be trained in dealing with the many types of behaviors related to residents with neurocognitive disorder associated with behaviors such combativeness, confusion in the facility. How the facility will ensure residents appraisals are updated in writing as frequently as necessary to note significant changes in condition and to keep the appraisal accurate. How the facility shall be trained regarding personal rights and reporting requirements. During this office visit, LPM's and LPA's informed Licensee, the complaint dated July 10, 2025, 26-AS-20250710151220, to amend findings for the allegation: Facility is not meeting the hygiene needs of residents in care, from Substantiated to Unfounded, due to additional information The Department inadvertently did not issue Title 22 code of regulation, 87468.1 Personal Rights of Residents in All Facilities(a)(1), on August 22, 2025. RO provided PIN 22-24-ASC Collaborating With Home Health Agencies and Hospice Agencies To Provide Care To Residents RO provided the Licensees information regarding the Department’s technical support program (TSP) and provided a TSP brochure, Community Care Licensing Division (CCLD) website www.cdss.ca.gov The Licensee was advised a the end of the office meeting that non-adherence to the plan will result in a non-compliance conference. Deficiencies are being cited during this meeting, see LIC809-D. This report was reviewed and explained to Administrator / Licensee Eliza Daquioag. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Dec 8, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Dec 9, 2025

87468.1 Personal Rights of Residents in All Facilities(a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews conducted, facility staff S1-S3 and ADM admitted to putting multiple diapers on resident R1 and R2. S1, S2 and ADM admitted that R1 feet were tied. This poses an immediate threat to residents health, safety and personal rights.the state’s words, verbatim · CDSS document, Dec 8, 2025

Plan of correction: ADM stated the facility will not use multiple diapers on the resident. ADM stated if a resident is being combative, staff will give resident time to calm down and redirect his/her behaviors. ADM stated she shall provide training to staff training regarding personal rights. ADM stated will consult medical doctor to address behavior. ADM stated she will submit the written plan of correction to LPA by POC due date, December 9, 2025.

Type of visit: POC

Licensing Program Analyst Manuel Monter conducted a POC case management visit to clear deficiencies cited on Administrator Eliza Daquioag, during the conclusion of a complaint investigation. LPA explained the purpose of the visit. The facility was cited the following Type A deficiencies on August 22, 2025 1569.50 Denial, suspension or revocation of license, POC due date August 23, 2025 87405 Administrator - Qualifications and Duties (d)(2), POC due date August 23, 2025 The Facility was cited the following Type B deficiencies on August 22, 2025. 87463 Reappraisals (a), POC due date August 29, 2025 87211 Reporting Requirements (a)(1)(D), POC due date August 29, 2025 LPA received plan of corrections by POC date. Deficiencies cleared during todays visit. POC cleared letter provided to ADM. No deficiency was cited during todays visit. This report was reviewed with Administrator Eliza Daquioag.the state’s words, verbatim · CDSS document, Sep 3, 2025

Allegation investigated: Staff restrained resident Facility is not meeting the hygiene needs of residents in care

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Eliza Daquioag. Facility is not meeting the hygiene needs of residents in care On July 10, 2025, the Department received a complaint alleging Facility is not meeting the hygiene needs of residents in care. It has been alleged that resident R1 was observed with multiple diapers. On July 11, 2025, LPA interviewed Witness W1 and W2. Both witnesses interviewed stated they have observed resident R1 wearing multiple diapers at the same time, on at least 5 different occasions. W1 and W2 stated they were told by the ADM to use multiple diapers on resident R1. Page 1 Out of 4. Substantiated On July 15, 2025, LPA Monter interviewed residents R1-R3. All residents interviewed were unable to respond to questions about complaint allegations due to their neurocognitive disorders. On July 15 & 24 and August 13, 2025, LPA Monter interviewed Staff S1 and S2. Both admitted they were using multiple diapers on R1, due to R1’s urination, which soils his/her bed and the resident him/herself. S1 stated if residents R1 or R2 get wet at night, they will use 3-4 diapers. S2 stated only R1 has multiple diapers at night. Both staff interviewed acknowledged there wasn’t a difference between R1 soiling him/herself at night or during waking hours. On July 15 & 24 and August 13, 2025 LPA interviewed ADM. ADM admitted staff place double diapers on R1 at night. ADM stated Only R1 has 2 diapers, because he/she has heavy urination. LPA asked ADM if there is a discrepancy with R1 when he/she soils him/herself in the morning, evening or night. ADM acknowledged that there wasn’t a difference. ADM stated R1 has two diapers at night because at night is easier to take it off and change him/her when he/she has 2 diapers. ADM stated she did instruct her staff to put 2 diapers on R1 at night. Based on a review of R1's Appraisal / Needs and Services Plan (ANS), dated May 28, 2025, R1 has episodes of yelling, screaming and hitting staff. Furthermore, the ANS states R1 needs 2 people during care. The ANS does not outline a specific bowel and bladder management plan for resident R1. Based on interviews and documents review the preponderance of evidence has been met therefore the above allegations is found to be SUBSTANTIATED. Staff restrained resident On July 10, 2025, the Department received a complaint alleging Staff restrained resident. It has been alleged that R1 was observed lying in bed with both of his/her legs tied together with a bed sheet. Page 2 Out of 4. On July 11, 2025, LPA interviewed Witness W1 and W2. Both witness interviewed stated on July 7, 2025, around 9am both W1 and W2 entered the facility and met with the facility administrator. W1 and W2 headed towards R1’s bedroom and observed resident R1 had his/her feet tied together with a bedsheet. W1 stated he/she asked ADM why R1 feet were tied. Both witnesses stated the ADM had told them, R1 was tied because R1 was being combative when he/she was being changed. On July 15, 2025, LPA Monter interviewed residents R1-R3. All residents interviewed were unable communicate or respond to interview questions due to their neurocognitive disorder. On July 15 & 24 and August 13, 2025, LPA Monter interviewed Staff S1. S1 stated on July 7, 2025, the ADM and S2 called him/her for assistance. S1 stated he/she went to R1’s room and helped by holding R1’s hands and holding them close to R1’s chest, while ADM cleaned R1. S1 stated R1 was tied in a manner that was not tight, but closed off enough to keep R1 from kicking his/her feet. S1 stated ADM initiated tying R1’s feet. S1 stated after R1 was tied, two hospice care givers arrived at the care home. S1 stated the hospice care givers arrived either a few minutes or half an hour after R1’s diaper was changed. On July 15 & 24 and August 13, 2025, LPA Monter interviewed staff S2. S2 stated that morning, R1 was yelling and found R1 had a large bowel movement (BM). S2 stated staff attempted to change R1 but he/she was combative. S2 stated that R1 was mostly kicking and moving his/her arms. S2 stated he/she and the ADM were the ones who did the tying. S2 stated R1 was tied with the bedsheet around R1’s ankles area. S2 stated after R1 was changed, 5-10 minutes later, two staff from redwood hospice came and saw that R1 was tied. S2 stated they forgot to remove the tied bed sheet. On July 15 & 24 and August 13, 2025, LPA Monter interviewed ADM. ADM stated on July 7, 2025 , around 7:30-8:30am R1 woke up, yelling. ADM stated she saw R1’s had a defecated so much that it leaked out of the diaper. ADM asked S2 for assistance, but R1 was kicking and swinging his/her arms. ADM stated because R1 was being combative, and she decided to tie R1, to get R1 clean and to minimize R1’s from hitting and swinging his arms or hurting himself or the staff. ADM stated R1 was tied slightly above the ankle area. ADM described the tying as not tight, but closed off enough to keep R1 from kicking while he/she is being changed. ADM stated R1 was tied around 8-9am. ADM stated after they assisted R1, the care givers from redwood hospice arrived 15-20 minutes after, and that’s when they saw R1 tied. Page 3 Out of 4. Staff S1, S2 and ADM stated that was the only time resident R1 was tied. S1, S2 and ADM acknowledged that R1 has had this combative behavior since move in. S1, S2 and ADM acknowledged that there wasn’t a discrepancy when R1 soiled him/herself in the morning, evening or night. Based on a review of R1's Appraisal / Needs and Services Plan (ANS), dated May 28, 2025 , R1 has episodes of yelling, screaming and hitting staff. Furthermore, the ANS states R1 needs 2 people during care. The ANS does not detail how the facility will change resident R1 when he/she is being combative. Based on interviews conducted, Witness observed resident R1’s feet were tied on July 7, 2025. Interviews conducted with facility staff confirmed that on July 7, 2025, R1’s feet were tied, and his/her personal rights were violated. Staff interviewed, stated they tied R1 because of his/her combative behavior when he/she is being changed. Facility staff confirmed R1 has had this combative behavior since move in and R1’s ANS does not detail how the facility will change R1 when he/she is being combative. Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Administrator Eliza Daquioag. A copy of the report was provided. Appeal rights were provided. Page 4 Out of 4. END OF REPORT.the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 26-AS-20250710151220

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.50(a)(3) · Plan of correction due date: Aug 23, 2025

1569.50 Denial, suspension or revocation of license; ...exclusion from licensee without right to petition for reinstatement (a)(3) Conduct that is inimical to the health, morals, welfare, or safety ... from the facility or the people of the State of California. This requirement was not met as evidenced by; Based on interviews conducted, and evidenced reviewed, staff S1, S2 and ADM admitted that resident R1 feet were tied because he/she was being combative when he/she was being changed. This poses an immediate threat to residents health, safety and personal rights.the state’s words, verbatim · CDSS document, Aug 22, 2025

Plan of correction: ADM stated she will conduct a personal rights training with her staff. ADM stated she will send documentation of the training with the following information: who participated, who conducted the training, duration of the training, what materials were used. ADM stated she will send the plan of corrections to LPA by POC date, August 23, 2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(2) · Plan of correction due date: Aug 23, 2025

87405 Administrator - Qualifications and Duties (d) (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by; Based on interviews conducted, ADM admitted to tying R1’s feet, due to R1 being combative when he/she is being changed and the deficiencies cited during this complaint investigation. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2025

Plan of correction: ADM stated she will also send a letter of understanding regarding the regulation and her duties and responsibilities as administrator, which includes respecting residents personal rights not be tied or restrained. ADM stated she will send the plan of corrections to LPA by POC date, August 23, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Aug 29, 2025

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, … shall be updated in writing as frequently as necessary … keep the appraisal accurate… This requirement was not met as evidenced by; Based on records reviewed, resident R1’s ANS does not address R1’s combative behavior when he/she is being changed. The ANS also does not detail R1’s incontinence plan. This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2025

Plan of correction: ADM stated she will develop an updated care plan, to address R1's combative behavior when he/she is being changed, without restraining or tying. ADM stated the updated care plan will also detail R1's updated incontinence plan. ADM stated she will send the updated care plan to LPA by POC date, August 29, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 29, 2025

87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by: Based on interviews conducted, facility staff admitted that R1 was tied and they should have reported it. Based on records reviewed, the facility did not submit an incident report for the incident where R1 was tied. This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2025

Plan of correction: ADM stated she will conduct a training regarding reporting requirement. ADM stated she will submit documentation this training took place by POC date, August 29, 2025. ADM stated she will send a letter of understanding regarding the regulation, and the importance of reporting any incident which threatens the welfare, safety or health of any resident. ADM stated she will send the plan of correction by POC date, August 29, 2025.

Allegation investigated: Staff restrained resident

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Eliza Daquioag. (The complaint allegation "Facility is not meeing the hygine needs of residents in care," is amended to from SUBSTANTIATED to UNFOUNDED due to new information.) Page 1 Out of 4. Substantiated (The complaint allegation "Facility is not meeting the hygiene needs of residents in care," is amended to from SUBSTANTIATED to UNFOUNDED due to new information.) Staff restrained resident On July 10, 2025, the Department received a complaint alleging Staff restrained resident. It has been alleged that R1 was observed lying in bed with both of his/her legs tied together with a bed sheet. Page 2 Out of 4. On July 11, 2025, LPA interviewed Witness W1 and W2. Both witness interviewed stated on July 7, 2025, around 9am both W1 and W2 entered the facility and met with the facility administrator. W1 and W2 headed towards R1’s bedroom and observed resident R1 had his/her feet tied together with a bedsheet. W1 stated he/she asked ADM why R1 feet were tied. Both witnesses stated the ADM had told them, R1 was tied because R1 was being combative when he/she was being changed. On July 15, 2025, LPA Monter interviewed residents R1-R3. All residents interviewed were unable communicate or respond to interview questions due to their neurocognitive disorder. On July 15 & 24 and August 13, 2025, LPA Monter interviewed Staff S1. S1 stated on July 7, 2025, the ADM and S2 called him/her for assistance. S1 stated he/she went to R1’s room and helped by holding R1’s hands and holding them close to R1’s chest, while ADM cleaned R1. S1 stated R1 was tied in a manner that was not tight, but closed off enough to keep R1 from kicking his/her feet. S1 stated ADM initiated tying R1’s feet. S1 stated after R1 was tied, two hospice care givers arrived at the care home. S1 stated the hospice care givers arrived either a few minutes or half an hour after R1’s diaper was changed. On July 15 & 24 and August 13, 2025, LPA Monter interviewed staff S2. S2 stated that morning, R1 was yelling and found R1 had a large bowel movement (BM). S2 stated staff attempted to change R1 but he/she was combative. S2 stated that R1 was mostly kicking and moving his/her arms. S2 stated he/she and the ADM were the ones who did the tying. S2 stated R1 was tied with the bedsheet around R1’s ankles area. S2 stated after R1 was changed, 5-10 minutes later, two staff from redwood hospice came and saw that R1 was tied. S2 stated they forgot to remove the tied bed sheet. On July 15 & 24 and August 13, 2025, LPA Monter interviewed ADM. ADM stated on July 7, 2025 , around 7:30-8:30am R1 woke up, yelling. ADM stated she saw R1’s had a defecated so much that it leaked out of the diaper. ADM asked S2 for assistance, but R1 was kicking and swinging his/her arms. ADM stated because R1 was being combative, and she decided to tie R1, to get R1 clean and to minimize R1’s from hitting and swinging his arms or hurting himself or the staff. ADM stated R1 was tied slightly above the ankle area. ADM described the tying as not tight, but closed off enough to keep R1 from kicking while he/she is being changed. ADM stated R1 was tied around 8-9am. ADM stated after they assisted R1, the care givers from redwood hospice arrived 15-20 minutes after, and that’s when they saw R1 tied. Page 3 Out of 4. Staff S1, S2 and ADM stated that was the only time resident R1 was tied. S1, S2 and ADM acknowledged that R1 has had this combative behavior since move in. S1, S2 and ADM acknowledged that there wasn’t a discrepancy when R1 soiled him/herself in the morning, evening or night. Based on a review of R1's Appraisal / Needs and Services Plan (ANS), dated May 28, 2025 , R1 has episodes of yelling, screaming and hitting staff. Furthermore, the ANS states R1 needs 2 people during care. The ANS does not detail how the facility will change resident R1 when he/she is being combative. Based on interviews conducted, Witness observed resident R1’s feet were tied on July 7, 2025. Interviews conducted with facility staff confirmed that on July 7, 2025, R1’s feet were tied, and his/her personal rights were violated. Staff interviewed, stated they tied R1 because of his/her combative behavior when he/she is being changed. Facility staff confirmed R1 has had this combative behavior since move in and R1’s ANS does not detail how the facility will change R1 when he/she is being combative. Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Administrator Eliza Daquioag. A copy of the report was provided. Appeal rights were provided. Page 4 Out of 4. END OF REPORT.the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 26-AS-20250710151220

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.50(a)(3) · Plan of correction due date: Aug 23, 2025

1569.50 Denial, suspension or revocation of license; ...exclusion from licensee without right to petition for reinstatement (a)(3) Conduct that is inimical to the health, morals, welfare, or safety ... from the facility or the people of the State of California. This requirement was not met as evidenced by; Based on interviews conducted, and evidenced reviewed, staff S1, S2 and ADM admitted that resident R1 feet were tied because he/she was being combative when he/she was being changed. This poses an immediate threat to residents health, safety and personal rights.the state’s words, verbatim · CDSS document, Aug 22, 2025

Plan of correction: ADM stated she will conduct a personal rights training with her staff. ADM stated she will send documentation of the training with the following information: who participated, who conducted the training, duration of the training, what materials were used. ADM stated she will send the plan of corrections to LPA by POC date, August 23, 2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(2) · Plan of correction due date: Aug 23, 2025

87405 Administrator - Qualifications and Duties (d) (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by; Based on interviews conducted, ADM admitted to tying R1’s feet, due to R1 being combative when he/she is being changed and the deficiencies cited during this complaint investigation. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2025

Plan of correction: ADM stated she will also send a letter of understanding regarding the regulation and her duties and responsibilities as administrator, which includes respecting residents personal rights not be tied or restrained. ADM stated she will send the plan of corrections to LPA by POC date, August 23, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Aug 29, 2025

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, … shall be updated in writing as frequently as necessary … keep the appraisal accurate… This requirement was not met as evidenced by; Based on records reviewed, resident R1’s ANS does not address R1’s combative behavior when he/she is being changed. The ANS also does not detail R1’s incontinence plan. This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2025

Plan of correction: ADM stated she will develop an updated care plan, to address R1's combative behavior when he/she is being changed, without restraining or tying. ADM stated the updated care plan will also detail R1's updated incontinence plan. ADM stated she will send the updated care plan to LPA by POC date, August 29, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 29, 2025

87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by: Based on interviews conducted, facility staff admitted that R1 was tied and they should have reported it. Based on records reviewed, the facility did not submit an incident report for the incident where R1 was tied. This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2025

Plan of correction: ADM stated she will conduct a training regarding reporting requirement. ADM stated she will submit documentation this training took place by POC date, August 29, 2025. ADM stated she will send a letter of understanding regarding the regulation, and the importance of reporting any incident which threatens the welfare, safety or health of any resident. ADM stated she will send the plan of correction by POC date, August 29, 2025.

Type of visit: Case Management - Other

Licensing Program Analyst Manuel Monter and Simi Rai conducted an unannounced case management to amend a Complaint investigation, LIC9099, LIC9099-C and LIC9099-D issued on July 15, 2025. LPA met with Administrator Eliza Daquioag explained the purpose of the visit. The complaint investigation closed on July 15, 2025 is being amended and re-opened due to new information provided to the Department. No deficiencies cited during todays visit. This Report was reviewed with Administrator Eliza Daquioag. A signed copy was provided.the state’s words, verbatim · CDSS document, Jul 24, 2025

Type of visit: Required - 1 Year

On January 28, 2025, at 1:00 PM, Licensing Program Analysts (LPA), Kenneth Madrigal and Manuel Monter, conducted an unannounced annual inspection and met with Eliza Daquioag, Administrator (ADM) and discussed the purpose of the visit. LPAs observed two staff members, and four residents during the visit. LPAs toured the facility inside and out which included 5 resident rooms, four bathrooms, a living room, a kitchen, a dining area, and staff areas. LPAs toured the front and back of the facility. LPAs observed a shed in the backyard being used a storage area. There were no obstructions that blocked the emergency exit doors. In the kitchen, LPAs observed that all sharps are in a locked container and that the chemicals are locked in the cabinet. LPAs observed seven-day nonperishable and a two-day perishable food supply. LPAs observed the freezer and refrigerator temperatures recorded within the regulated range. The room temperature is 78 degrees Fahrenheit. The facility water temperature was recorded 109 degrees Fahrenheit.In the hallway, the fire extinguisher was last serviced in January 2025. LPAs observed the emergency fire and earthquake drill logs. The last drill was conducted on December 4, 2024. ADM tested the smoke detectors in the facility. LPAs reviewed three staff records, four resident records, and four resident centrally stored medication records. LPAs conducted two staff interviews (S2 & S3) and one resident interview (R1). LPAs provided ADM CDSS changes in regulations for RCFE/Dementia Flyer. No deficiencies were cited today per today’s visit. A signed copy of this Evaluation Report was provided to the administrator and was reviewed with the administrator.the state’s words, verbatim · CDSS document, Jan 28, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Eliza Daquioag. During the visit, LPA observed 5 residents and 2 staff. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 4 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 117 degrees F in resident bathrooms. Fire extinguisher was serviced in February 7, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on December 3, 2023. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff (S1 to S3) and 2 residents (R1-R2). 1 resident was attending day program during LPA's visit. No deficiencies cited during today's visit. This report was reviewed with Administrator Eliza Daquioag and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Feb 22, 2024