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We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Required - 1 Year

On 08/27/2026 at 10:30 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Paul Rivera and explained the purpose of the visit. Administrator, Banaag Yamsun, arrived around 1:00 PM. The facility’s fire clearance was approved for capacity for four (4) all non ambulatory residents. LPA toured facility with Paul and Banaag including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of four (4) total bedrooms which all 4 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 09/18/2025. Emergency Disaster Plan was last posted on 08/10/2026. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/16/2026. LPA reviewed 4 residents records. LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/03/2026: LIC 308 Designation of Administrative Responsibility - Reviewed LIC 309 Administrative Organization - Reviewed LIC 500 Personnel Report - Reviewed LIC 610E Emergency Disaster Plan - Reviewed Liability Insurance No deficiencies were cited during this inspection Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 27, 2026

The state marks this report as 16 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 7/30/2025 at 10:15 am, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct 1-Year Annual Required inspection. LPA spoke with Administrator (AD), Banaag Yamsuan via telephone and LPA told AD that they arrived to conduct the visit. AD arrived to the facility at 10:45 am and LPA explained the purpose of the visit. The facility’s fire clearance was approved for four (4) Non-ambulatory residents. Hospice waiver for two (2) residents. LPA toured facility with the AD including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) total bedrooms which 4 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 8/22/2024. Emergency Disaster Plan was last posted on 09/04/2024. First aid kit was observed to be complete. (Continued from LIC809...) LPA reviewed four (4) residents records and six (6) staff records. LPA reviewed a sample of resident’s medications. LPA reviewed four (4) resident's P & I. The following forms will be updated and submitted to CCLD by 8/6/2025: LIC610D: Emergency disaster plan (last page) LIC500: (Personnel Record) No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 30, 2025

Type of visit: Case Management - Incident

LPA Carol Fowler arrived on 6/03/2025 at 11:00am, attempted to conduct a Case Management visit regarding an incident that was reported to CCLD on 5/28/2025. There was no one at the facility. LPA later spoke with Banaag Yamsun and LPA was informed that residents are at day program and staff was out grocery shopping. On 6/03/2025 at 1:45pm, Licensing Program Analyst (LPA) Carol Fowler conducted an announced Case Management visit regarding an incident that was reported to CCLD on 5/28/2025. LPA met with Paul Rivera, Lead Care Giver and explained the purpose of the visit. The incident reported occurred on 5/27/2025. The report stated on 5/27/2025, S2 administered the wrong evening medications to R1 from R2 medications box. After S2 realized the error, S2 immediately notified R1's PCP and nursing manager in charge (S3). The PCP instructed S2 to withhold all evening medications and monitor vital signs every 15 minutes and overnight and report any deviations from R1's baseline. The deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jun 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(d) · Plan of correction due date: Jun 16, 2025

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: This requirement was not met as evidenced by staff mismanaging residents' medications which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: Administrator agreed to get staff medication training by an authorized vendor and submit documentation to CCLD by POC date.

Type of visit: Required - 1 Year

On 09/04/2024 at 11:30 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Banaag Yamsun and explained the purpose of the visit. The facility’s fire clearance was approved for four (4) Non-ambulatory. Hospice waiver for two (2) residents. Administrator certificate # 6019296740 expires 07/01/2025. LPA toured facility with Banaag including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of four (4) total bedrooms which 4 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/22/2024. Emergency Disaster Plan was last posted on 09/04/2024. First aid kit was observed to be complete. LPA reviewed 4 residents records. LPA reviewed 3 staff records and 2 of 3 have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications. LIC809-C Continued... LIC809-C Continued... The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/11/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan - Reviewed Copy of current Liability Insurance Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Sep 4, 2024

The state marks this report as 11 pages; the online copy we transcribed has 9. You can request the full file from the county licensing office.