Agape Pajarillo Care Home

Type of visit: Case Management - Annual Continuation

At approximately 1:05 PM, Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a case management - annual continuation for a required 1-year annual inspection started on 3/9/2026. LPA met with Designee Anabel Tuason. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. At approximately 1:15 PM LPA conducted a review of six (6) resident records. five (5) of six (6) residents did not have a current Appraisal Needs and Service Plans (deficiency cited). At approximately 2:00 PM LPA conducted review of three (3) staff records. All required documentation present. Facility conducts quarterly disaster drills, and the most recent drill was conducted 2/26. LPA reviewed emergency disaster plan which was last updated 3/26. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights. Facility's fire extinguishers were observed charged and last serviced 3/26. LPA observed required postings were in a prominent area. LPA observed two (2) locked shed in the backyard which were inspected and observed to contain gardening supplies and seasonal decoration. Updated copies of the following documents were gathered during this visit: Liability Insurance, LIC500 - Personnel Report, LIC308 - Designation of Responsibility Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC809D. Exit interview conducted with Designee, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Apr 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(i) · Plan of correction due date: May 1, 2026

87463(i) When there is significant change in condition... or once every 12 months, whichever occurs first, the licensee shall arrange...meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff... This requirement not met by licensee as evidenced by: Upon record review, five of six residents did not have a current Appraisal Needs and Servce plan which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 2, 2026

Plan of correction: Licenses shall submit updated copies of resident Appraisal Needs and Service Plan by Plan of Correction due date of 5/1/2026 by 5:00PM to Community Care Licensing.

Type of visit: Required - 1 Year

At approximately 12:45 PM, Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a required 1-year annual inspection and met with Designee Anabel Tuason. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for three (3), with zero (0) Hospice residents currently in care, and is approved for all non-ambulatory residents, of which two (2) may be bedridden. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 1:15 PM, LPA initiated a tour of the facility with Designee and observed the following: Facility is a one (1) story home, was a comfortable temperature, and passageways were free from obstructions. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Water temperature measured 105.2 degrees F, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food, as well as an emergency water supply. Food was found to be stored in a safe manner with open items covered. There is a shaded seating area in the backyard with outdoor space for activities. Continued LIC809C... Continued from LIC809... LPA was informed that facility will be undergoing renovations to replace flooring, doors, windows, and to make bathroom more accessible. LPA informed designee that a plan detailing exact construction and how residents safety/personal rights will be ensured shall be submitted to Community Care Licensing (CCL) as soon as possible. At approximately 2:10 PM LPA and Designee conducted a spot check of medication and medication records. Medication is centrally stored and locked. Ephraim Pajarillo Administrator Certificate 7030241740 expires 2/20/2027. LPA unable to complete Annual Visit. Annual Continuation Visit to be conducted at a later date. LPA will review items including resident files, staff files, disaster drills/emergency protocols, required postings, fire safety, and activities. Updated copies of the following documents shall be submitted to CCL by 4/6/2026: Liability Insurance LIC500 - Personnel Report LIC308 - Designation of Responsibility LIC610E - Emergency Disaster Plan No deficiencies cited. Exit interview conducted with Designee, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Mar 9, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced for the purposes of conducting a Case Management-Other visit and met with Annabel Tuason, House Manager. During this visit LPA conducted interviews and left contact information for further interviews. House manager stated that two (2) staff (S3, S4) that LPA had asked to interview were not at the facility at this time. LPA asked House Manager to give LPA contact information to S3 and S4 in order to conduct phone interviews. LPA advised facility that previous attempts at contacting the facility via phone were unanswered and voicemail was said to be full. House manager stated they would check the voicemail and clear it. No deficiencies cited. Exit interview conducted with House Manager, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 4, 2025

Allegation investigated: Licensee is not allowing resident to take possession of their personal belongings. Staff did not administer medications to resident in care according to physician's instructions.

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegations and met with Annabel Tuason, Lead Staff. During the course of this investigation LPA made observations, reviewed records, and conducted interviews. Licensee is not allowing resident to take possession of their personal belongings. – Complainant alleges “After resident moved out, licensee is refusing to return some of resident's possessions, including R1 television and a special thickening agent used to help R1 swallow, because licensee states that resident owes the facility some money”. A review of records and interviews with staff indicate licensee has held R1 personal belongings after R1 moved out of facility. LPA observed that TV was still being kept at facility after R1 moved out. Continued LIC9099C... Substantiated Staff did not administer medications to resident in care according to physician's instructions. – Complainant alleges “Staff did not give R1 their medications as needed, and staff mismanaged R1 medications”. Interviews and record review indicate that facility did not properly follow physician instructions regarding medication administration. Based on record review and interview with R1’s caregiver, medication patch used to regulate blood pressure was to be replaced every seven (7) days but was not replaced for approximately two (2) months. Based upon the observations, record review, and interviews, there is a preponderance of evidence to prove that the allegations have been SUBSTANTIATED and are valid. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D. Exit interview conducted with Lead Staff, whose signature on form confirms receipt. Continued from LIC9099A... Licensee is not ensuring resident’s health and safety. – Complainant alleges “Staff would feed R1 early in the afternoon, but after that R1 was not allowed snacks, etc. - RP added that R1 lost weight while at the facility and RP feels it is because R1 was not provided enough food. Resident fell twice, because, as one of the Home Health Nurses told RP, the bed was too high, and it posed a fall risk”. During visits on 3/24/2025, 5/19/2025, and 6/17/2025, LPA observed staff cooking and feeding residents outside of normal mealtimes if residents said they were hungry, and multiple fridges and cabinets of food were observed stocked. Interviews with residents indicate that they are given plenty of food during mealtimes and are given snacks in between. Record review and interviews indicated that facility was told by Home Health that R1 bed was too high and facility stated they would lower bed to comply. Lack of supervision. – Complainant alleges “There were no staff at the facility during the weekends - the only person on site told RP that they don’t provide care to the residents”. Review of staff schedule shows two staff on duty per day on the weekends as well as overnight staff. Interviews with residents indicate both weekend staff provide care and are able to assist them if necessary. Staff did not follow reporting requirements. – Complainant alleges R1 fell twice and “they also did not report the incidents to RP”. Interviews with R1 and complainant indicate that R1 fell twice at facility with staff having knowledge of both. Review of records indicate that no reports were made regarding falls involving R1. Interviews with staff indicate that they were not aware of any falls. Interviews with residents indicate that they did not witness any falls involving R1 and that staff will provide assistance if they witness it. Record review indicate that Administrator was aware of an incident involving R1, but did not specify what this incident was. Staff did not seek medical attention for resident. – Complainant alleges after falls “resident would lie on the floor for hours until morning staff came, but they would not seek medical attention for R1 after they found them on the floor”. During interview with R1, they claim that they did not receive medical attention after two separate falls, with one resulting in a bleeding cut on right foot. Interview with new caregiver indicate that there is a small, healed cut on the top of R1 right foot. Interview with staff indicate that 9/11 is always called if a resident is injured. Interviews with residents indicate that they receive medical attention should they require it, and staff provide them with basic aid if applicable. Continued LIC9099C... Continued from LIC9099C... Personal Rights. – Complainant alleges “Staff emotionally abused resident, and harassed R1 about paying the bills, etc”. During interviews with complainant, it was alleged that staff verbally harass R1 and spread information that resulted in stress. Interview with R1 indicate that they felt staff was disrespectful towards them and would make inappropriate jokes at R1 expense. Review of records indicate that other visitors also felt staff did not treat R1 kindly. Interview with staff indicate that they treat residents with care and do not verbally abuse them. Interviews with residents indicate that they do not feel staff are rude to them and have not witnessed staff being verbally abusive towards any other residents. Interviews with residents also indicate that they have not witnessed any staff yelling at residents or in general. Based upon observations, record review, and interviews, we have found that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations/complaint is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Lead Staff, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 21-AS-20250514163751

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 3, 2025

87465 (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement has not been met as evidenced by: Clonidine patch prescription states to be changed every seven (7) days but was not changed for approximately sixty (60) days. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: Licensee shall submit self-certification of plan to complete new medication training for all staff by Plan of Correction due date 7/3/2025. Licensee will submit proof of completed training by 7/31/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(i) · Plan of correction due date: Jul 31, 2025

87217 (i) Upon discharge of a resident, all cash resources, personal property and valuables of that resident which have been entrusted to the licensee shall be surrendered to the resident, or his responsible person. A signed receipt shall be obtained. This requirement has not been met as evidenced by: licensee holding R1 personal belongings after R1 moved out. This poses/posed a potential violation of R1’s personal rights.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: Licensee shall submit self-certification that licensee shall return all personal belongings to R1 as well as a self-certification of their understanding of regulation 87217(i) and that licensee shall not hold any resident’s personal belongs from them going forward by Plan of Correction due date 7/31/2025.

Type of visit: Required - 1 Year

At approximately 9:30 AM, Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection and was greeted by Anabel Tuason, Caregiver. Administrator was at a patient evaluation and was unable to attend, Anabel Tuason is designated to sign and receive this report. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for three (3), with one (1) Hospice resident currently in care and is approved for all non-ambulatory residents of which two (2) may be bedridden. At approximately 10:05 AM, LPA initiated a tour of the facility with Caregiver and observed the following: Facility is a one-story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were last inspected 7/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Water temperature measured 108.5 Degrees F in kitchen sink, 106.1 Degrees F in shared bathroom, and 105.2 Degrees F in master bathroom, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a 2-day supply of perishable and 7-day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered, as well as an emergency water supply. There is a shaded seating area in the backyard with outdoor space for activities. LPA observed three locked sheds in the backyard which LPA inspected and observed the content to be decorations, winter coats belonging to staff, gardening supplies, and emergency supplies. Facility telephone was tested and operational during inspection. Continued 809C... Continued from 809... At approximately 11:10 AM LPA conducted review of four (4) staff records. All required documentation present. At approximately 11:40 AM LPA conducted a review of four (4) resident records. Three (3) of four (4) residents records did not contain an LIC 625 - Appraisal Needs and Service Plan. Deficiency Cited. At approximately 12:30 PM LPA and Caregiver conducted a spot check of medication and medication records. Medication is centrally stored and locked. LPA observed that Administrator submitted a re-certification request on 2/1/2025. LPA and Caregiver discussed facility's Infection Control Plan and Emergency Disaster plan, last updated 1/2025. Facility’s last quarterly disaster drill was conducted on 02/15/2025. The following updated documentation was received during this visit: Liability Insurance LIC500- Personnel Report LIC308- Designation of Responsibility Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Caregiver. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Caregiver and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 24, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Residents Level of care not met

Licensing Program Analyst (LPA), Araceli Canela arrived unannounced, for the purpose of gathering more information and delivering findings, regarding the above listed allegation. LPA met with Care staff, Anne Tuason and once again toured the home, made observations and took statements. It was alleged residents level of care is not met, and that R1 is not being assisted; remains in bed and not getting to medical appoitnments. LPA observed R1 active in the facility on both occasions, making phone calls and setting up medical appointments. R1 stated their POA sets some appointments but R1 is also capable of doing them. If they need assistance from staff, they receive it. Staff disclosed R1 likes to set up their own appointments, but staff will assist if they ever need help. R1 has a coming up eye appoitnment in which facility staff will take R1 to the appointment. Facility staff or R1's POA take turns assiting R1 to medical appoitnmets. Although the allegation may be true, based on the above information, and records reviewed, there is not a preponderance of evidence to prove or, disprove, the allegation did occur. Therefore, it is UNSUBSTANTIATED at this time. No citation issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 4, 2024 · control 21-AS-20240625100810

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced and met with care staff, Anne Tuason. During a complaint investigation LPA discovered facility had no staff with proof of current CPR training. Staff S1 who was the only one present during LPAs arrival had proof of First Aid that expires 8/23/2024, but no CPR. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Jul 2, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.618(c)(3) · Plan of correction due date: Jul 23, 2024

H&S 1569.618(c)(3) Administration and management of residential care facilities; substituted qualifications; employee scheduling- (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement was not met as evidenced by: The facility failed have a staff present in the facility who has CPR training. This is a potential risk to the health & safety of residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2024

Plan of correction: Facility to send in written plan on how they will make sure they have at least 1 staff with proof of CPR training. Plan of correction due by 7/28/2024 attention LPA A Canela

Type of visit: Required - 1 Year

LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Caregiver Anabel Tuason. This facility has a fire clearance for four non-ambulatory and two bedridden residents. There are four private rooms and one shared room. The shared room has a full private bathroom. There is a caregiver room. There are a couple of common areas and the kitchen and dining room. There is an ample supply of perishable and nonperishable food. LPA reviewed staff and resident records. The following was observed during today's visit. -Staff don't have training records. Per Title 22 regulations Personnel Records 87412(c) (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. A couple of topics were discussed. Licensing fees are due by April 19, 2024. The following shall be updated and submitted to Community Care Licensing Division by May 1, 2024: -LIC 308 designation of administrative responsibility -liability insurance -LIC 500 facility personnel or staff schedule Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 16, 2024