A&A Haven Home

Type of visit: Required - 1 Year

At approximately 11:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit, and met with Staff Member, Edelyn Dacayanan. Designated Representative, Gigi Borja, arrived during visit at approximately 12:20PM. Facility has an approved fire clearance for a total capacity of 6 residents where Non-Ambulatory is allowed in Rooms 2, 3 ,5, and 6 and Bedridden is allowed in Rooms 1 and 4. Facility has an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there are 6 residents in care and 3 staff members on site. LPA reviewed the Facility's Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of facility with Designated Representative and observed the following: Facility is a one story residence with 6 resident bedrooms, two staff rooms, three bathrooms, and common areas. Facility has an Accessory Dwelling Unit (ADU) located in the backyard that is utilized as a staff break room. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility sinks were found to be in compliance with Title 22 Regulations, measuring between 105.0F and 120.0F. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Facility door alarms were tested and operational during visit. During walkthrough, it was observed that Resident 1 (R1) and Resident 6 (R6) had full bed rails on their beds. Facility's fire extinguishers were inspected December 2025. Facility's smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted June 2026. Facility's emergency disaster plan was last reviewed and updated June 2026. Facility was observed to have an adequate supply of emergency water accessible in the event they needed to shelter in place for 72 hours. Continued on LIC809C Continued from LIC809 LPA reviewed staff and resident files and resident medication. All files were all found to be well organized and thorough. Staff files had current First Aid and CPR certification and annual training. Resident files had updated assessments and appraisals. Review of R1's and R6's files showed that they were not receiving hospice services to permit the use of full bed rails. Facility removed full bed rails and added half bed rails during visit. LPA informed Designated Representative that orders for the half bed-rails will need to be obtained. Administrator Certificate for Stephanie Ellazar (7038350740) was pending with their application received as of 07/16/2026. Administrator Certificate for Regina "Gigi" Borja (7031105740) was current with an expiration date of 08/06/2027. LPA discussed with Designated Representative on ensuring that resident appraisals address behavioral expressions if they have been identified in resident medical assessments. During medication review, it was observed that facility was documenting the "fill date" as the date when the medication was provided to the facility and not the fill date identified on the pharmacy label. LPA and Designated Representative discussed documenting what is stated on the pharmacy label to maintain compliance with Title 22 Regulations. LPA discussed the following with Designated Representative: Reporting Requirements PIN regarding 911 protocols PIN regarding dementia regulations LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610E) Personnel Report (LIC 500) Liability Insurance Active and Current Administrator Certificate Documents to be submitted to Community Care Licensing (CCL) by due date of 09/14/2026. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Designated Representative. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 14, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit, and met with Staff Member, Edelyn Dacayanan. Designated Representative, Bella Nachor, arrived during visit at approximately 9:50AM. Facility has an approved fire clearance for five non-ambulatory residents and 1 bedridden resident for a total capacity of 6 residents and an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there are 5 residents in care and 3 staff members on site. At approximately 9:15AM, LPA reviewed the Facility's Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of facility with Staff Member and observed the following: Facility is a one story residence with 5 resident bedrooms, one staff room, three bathrooms, and common areas. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. 2 of 3 facility sinks were found to be within Title 22 Regulations of 105F to 120F. One facility sink located in a resident room was measured to be 125.2F (deficiency cited, LIC809D, regulation 87303(e)(2)). There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. All resident rooms were furnished per regulation with a bed, lamp, dresser, chair and bedside table. Facility has indoor/outdoor areas for visiting and activities. Facility's fire extinguishers were inspected December 2024. Facility's smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted June 2025. Continued on LIC809C Continued from LIC809 LPA observed that there is a small storage space between one resident room and the facility staff room. This space is not shown on facility's sketch. LPA was also informed that the current staff room may be converted into a private resident room. LPA requested that an updated facility sketch be submitted to Community Care Licensing (CCL) to reflect changes. A new fire clearance request will be submitted if it is determined that the staff room will be converted into a private resident room. LPA reviewed staff and resident files and resident medication. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was centrally stored and secure. Administrator Certificate for Stephanie Ellazar (6070922740) was current with an expiration date of 06/06/2026. Administrator Certificate for Bella Nachor (7008140740) was current with an expiration date of 05/27/2027. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610E) Updated Personnel Report (LIC 500) Updated Liability Insurance Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 08/02/2025. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Designated Representative. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 2, 2025

Type of visit: Prelicensing

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived announced to conduct a Pre-Licensing Change of Ownership inspection visit and met with Applicant, Stephanie Ellazar. Upon arrival, LPA was informed that there are 4 residents in care. Facility received an approved fire clearance dated 01/29/2023 that allows for five non-ambulatory residents and 1 bedridden resident for a total capacity of 6 residents. Facility also has a hospice waiver for 3 individuals. LPA conducted a walk-though of facility with Applicant and observed the following: Per facility sketch, facility is a one story residence with 5 resident bedrooms, one staff room, three bathrooms, and common areas. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility's hot water temperatures for all sinks were within Title 22 Regulations of 105F to 120F. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. All resident rooms were furnished per regulation with a bed, lamp, dresser, chair and bedside table. Facility has sufficient items for cooking and eating. Facility has a locked cabinet located in the activity room used for centrally stored medications. Facility has indoor/outdoor areas for visiting and activities. Facility's fire extinguishers was inspected November 2023. Facility's smoke and carbon monoxide detectors were tested and operational. LPA confirmed that contents of the facility's First Aid Kit were sufficient. Component III was reviewed with Applicant. No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Residential Care Facility for the Elderly. LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status. Exit interview conducted. Copy of report discussed and provided to Applicant. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 3, 2024

Type of visit: Office

Facility Type: RCFE Application Type:Initial Capacity:6 Census (if any clients in care):N/A COMP II Participants: Czarina Dumaliang, Administrator/Licensee Interview Method: Telephone interview On [05/31/2024], applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, May 31, 2024