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Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced follow-up Case Management visit. LPA announced the purpose of the visit and met with Daniel Mabunay, Administrator. On 07/02/26 the department received an SOC341 for an incident that occurred on 06/16/26. On 06/16/26 the facility reported of a Staff, (S1) that was using intimidation tactics including forcefully banging on the table. On 07/08/26 LPA conducted an initial Case Management visit and interviewed staff and Adminsitrator. S2 and S3 stated S1 verbally abused R1 and said derogatory remarks. S2 and S3 stated that S1 would hide the reclining chair remote so R1 would not be able to use the recliner because S1 would get upset and wanted R1 to sleep in his/her room. S2 and S3 stated on one occasion observed R1s diaper fall off and he/she kicked it to avoid walking on it and S1 grabbed diaper and threw it back toward R1s walkway. ADM stated she was not aware of the behavior and staff had not reported any of the incidents because S1 would threaten them that he/she was the boss. During visit LPA toured the facility and observed residents eating lunch. LPA determined this Case Management closed. Deficiencies are being cited during today's visit see LIC809D. This report was reviewed with Daniel Mabunay and a copy of the signed report was provided. Appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 29, 2026

87468.1 Personal Rights of residents in all facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights.(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement is not met as evidenced by: Based on interviews the licensee did not comply with the section cited above. S1 used intimidation tactics toward R1 and verbally abused R1. This poses/posed a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 28, 2026

Plan of correction: ADM will submit a letter of understanding of regulation and conduct staff trainings on Residents Rights. ADM will submit POC by due date 09/29/2026 to LPA via e-mail.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 7, 2026

87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency... including, (1) A written report shall be submitted to the licensing agency ... within seven days ...(D)Any incident which threatens the welfare, safety or health of any resident ...The requirement was not met as evidenced by: Based on the records reviewed, the facility did not send the incident report of resident R1 within 7 days of the incident occurrence, this poses a potential health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 28, 2026

Plan of correction: ADM will ubmit a letter of understanding of regulation and conduct training on Mandatory reporting by POC due date 10/07/26.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced case management visit. LPA announced the purpose of the visit. LPA met with Licensee Jona Romauldez. On 07/02/26 the department received an SOC341 for an incident that occurred on 06/16/26. During visit LPA interviewed 3 staff including Licensee and interviewed 1 Resident. LPA obtained pertinent documentation. LPA determined the incident requires further investigation. No deficiency was cited as per California Code of Regulations Title 22. This report was reviewed with Staff Arralee Marasigan who signed on Licensees behalf who had a previous appointment a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 8, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with staff S1, Ma Hernando. During the visit, LPA observed 6 residents and 2 staff. LPA explained the purpose of the visit. LPA was informed by S1 that previous Administrator Juliet Morillo no longer works at the facility. S1 stated she is the new administrator. S1 stated she would send a copy of the documents required to process the change in Administrator. LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 3 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. LPA observed a pool in the backyard of the facility. LPA inspected the black gate surrounding the pool. LPA noted the gate to be secure and the pool as inaccessible. 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 116 degrees F in resident bathrooms. Fire extinguisher was serviced in June 18, 2025. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on December 10, 2025. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA requested to review staff S2's training records. S1 stated S2's staff training records are currently not available for LPA to review. LPA provided S1 with an updated License reflecting the updated hospice clearance. LPA also provided annual file review letter, requesting updated documents be sent to CDSS by March 2, 2026. LPA provided PIN 25-05-ASC Updated Medical Assessment for Residential Care Facilities for the Elderly (LIC 602A) Form and advised Licensee to use the updated Medical assessment form. A deficiency is being cited during today's visit. This report was reviewed with Staff Ma Hernando and a copy of the signed report was provided. Appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 19, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Santino Fortes conducted an unannounced annual inspection, and met with ADM Mary Abcede. ADM stated facility has 3 staff and 6 clients. LPA toured the facility inside and out. There were 5 resident rooms (1shared/4single), 1 staff room, 1 living room, dining area, and Kitchen. LPA observed resident rooms each with a chair, night stand, sufficient lighting and chest of drawers. Room temperature was 72.5* F. Hot water temperature: Bathroom, 119.3*F, Bathroom 119.1* F and kitchen 119.1* F. LPA observed first aid kit missing scissors but was added during visit. Smoke and carbon monoxide detectors functioned properly when tested. Fire extinguishers were serviced on 7/17/24. Last fire drill was on 3-5-25. Restrooms observed to have non skid flooring. LPA observed 2 days perishable food supply and 7 days non-perishable food supply. Refrigerator temperature was 48* F and Freezer temperature 10*F. LPA observed medication storage, knives storage, and cleaning product storage locked and inaccessible to clients in care. The front & back yards of the facility were inspected. Exits and walkways were unobstructed. Pool observed with 2 locked gates. The garage is used to store care items, beds, wheelchairs and emergency supplies. LPA observed Facility License and Resident Personal rights posted. LPA reviewed facility records for 3 staff, 6 clients and observed to be complete. LPA reviewed 6 client’s medications, centrally stored medication records and observed to be complete. No cash is managed for residents. No deficiencies were cited during today's visit as per California Code of Regulations Title 22. Exit interview was conducted with Mary Abcede. This report was reviewed and a copy was provided to ADM for signature.the state’s words, verbatim · CDSS document, Apr 8, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Lead Staff (LS) Michael Delumen. LPA Rai observed 3 staff and 6 residents at the facility. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed an outdoor pool with fenced perimeter and padlock on gate. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the resident bedrooms. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 111.4 degrees Fahrenheit - 112.6 degrees Fahrenheit. The water temperature in the kitchen sink was 113.6 degrees Fahrenheit. Fire extinguisher was observed and inspected on 06/19/2023. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 3/6/2024. LPA Rai reviewed facility records for 3 staff and 3 residents. LPA Rai reviewed resident medications and central stored medication records. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Lead Staff (LS) Michael Delumen and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 17, 2024