A Home for You

Type of visit: Required - 1 Year

On 11/14/2025 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon entry, LPA was asked to sign in and had their temperature taken by staff. LPA was greeted by the Administrator Merlita Nepomuceno. LPA Rios explained the purpose of the visit. At 9:00 a.m., LPA and Administrator conducted a physical plant tour of the facility, both inside and outside. The following observations were made: LPA observed required postings were displayed on the walls leading to the common areas. A closet by the entrance was observed containing emergency food and water, a fully stocked first aid kit, flashlights, and an overflow supply of pantry food. The attached garage is through a staff room that is maintained locked. Inside the attached garage, LPA observed a washer and dryer, a locked cabinet containing cleaning products and chemicals, and a deep freezer with an overflow supply of food. In the kitchen, LPA observed the appliances and fixtures were in good working condition. LPA observed a sufficient supply of two days perishable food and seven days non-perishable food. Cookware, cutlery, and dishware were observed to be in good repair. Residents' medications were observed locked in a kitchen cabinet. On a kitchen wall LPA observed a fire extinguisher, fully charged with purchased date 09/01/2025. A carbon monoxide detector located by the kitchen was tested by staff and was observed operational. There are four (4) bedrooms designated for residents' use. One (1) room is shared. Resident bedrooms were furnished with beds, night stand, chairs, dressers, bedding and linens. The bedrooms have sufficient lighting and storage. Exit doors with auditory alarms were observed operational. There are two (2) bathrooms designated for residents. One (1) bathroom is located in the shared room and is for private use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (1) of two (2) bathrooms at 10:58 a.m. and read 113 degrees Fahrenheit, within regulation. The common areas, include the living and dining rooms. They were clean, clear of clutter, and appropriately furnished. The furniture was observed to be in good repair. A fireplace in the living room was secured with a screen. A telephone was accessible to residents on the kitchen peninsula and a television along with games were readily available for resident use. No tripping hazards were observed. The outdoor area was free of hazards and has a covered patio with outdoor furniture. LPA observed a locked shed used for storage. Passageways to the emergency exit was free from obstructions. The smoke detectors are interconnected. LPA observed a staff test a smoke detector at 11:02 a.m. The smoke detector alarms went off through out the facility. LPA reviewed facility records, including but not limited to the Certificate of Liability Insurance, the Infection Control Plan (last reviewed by the licensee representative on 07/31/2025), the Emergency and Disaster Plan (LIC 610E, reviewed on 10/02/2025). From approximately 9:30 a.m. to 11:00 am., LPA reviewed staff files and resident records. LPA conducted a file review of three (3) staff records to insure forms and training are up to date and compliance with licensing forms. LPA conducted a file review of four (4) resident records to insure compliance of licensing forms. LPA and administrator reviewed centrally stored medication and medication records for proper documentation. Facility also keeps a Medication Administration Record (MAR). Pursuant to Title 22, Division 6, Chapter 8 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A copy of the report Issued.the state’s words, verbatim · CDSS document, Nov 14, 2025

Type of visit: Required - 1 Year

On 10/28/2024 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the Administrator Merlita Nepomuceno. LPA Rios explained the purpose of the visit to the administrator. Facility has an approved fire clearance for five (5) non ambulatory residents and one (1) bedridden resident for a total capacity of six (6). Facility has a hospice waiver for six (6). At 12:26 p.m. LPA and administrator Merlita conducted a physical plant tour and the following was observed: Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Cleaning products were stored in a locked cabinet under the kitchen sink. Medication stored in a locked kitchen cabinet. Bedrooms: There are four (4) bedrooms designated for residents' use. One (1) room is shared. Resident bedrooms were furnished with beds, night stand, chairs, dressers, bedding and linens. The bedrooms have sufficient lighting and storage. Bathrooms: There are two (2) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (1) of two (2) bathrooms at 1:47 p.m. and read 113.5 degrees Fahrenheit, within regulation. Common Areas: These included the living area and dining area. The common areas were clean and properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. (Continued to LIC809-C) The smoke alarms are battery operated and interconnected. LPA observed a carbon monoxide detector by kitchen. A caregiver tested smoke and carbon detectors at 1:30 p.m. and they were observed to be functioning properly. The fire extinguisher is located in the kitchen with purchase date 05/24/2024. Surrounding Grounds: The outdoor area was free of hazards and has a covered patio with outdoor furniture. LPA observed a shed used for storage. Laundry/Garage: A staff room that is maintained locked leads to the laundry room which leads to the attached garage. Detergents and cleaning products are kept in the laundry room locked in a cabinet. Resident Files/Medications: At 12:36 p.m. LPA conducted a file review of four (4) resident records to insure compliance of licensing forms. LPA and administrator reviewed centrally stored medication and medication records for proper documentation. Facility also keeps a Medication Administration Record (MAR). Staff Files: At 1:50 p.m. LPA also conducted a file review of four (4) staff records to insure forms and training are up to date and compliance with licensing forms. Pursuant to Title 22, Division 6, Chapter 8 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A copy of the report Issued.the state’s words, verbatim · CDSS document, Oct 28, 2024

Allegation investigated: Staff did not meet the needs of the resident. Illegal Eviction.

Licensing Program Analyst (LPA) Evelin Rios conducted a subsequent complaint visit for further investigation and to deliver determinations on the allegations mentioned above. LPA met with the administrator Merlita Nepomuceno and the purpose of the visit was explained. On todays visit LPA Rios conducted further interviews with Nathan via telephone at 11:18 a.m. and interviewed Marlita again at approximately 11:40 a.m. Allegation #1: Staff did not meet the needs of the resident. It is alleged resident #1 (R1) could not feed themselves and staff did not assist. To investigate the allegation on 11/06/2020 due to the COVID-19 pandemic, LPA Shanahan meet with Nathan Nepo via Facetime. On 10/10/2023 LPA Rios met with administrator Merlita Nepomuceno at the facility and spoke with the licensee Nathan Napo via telephone. LPA Rios also interviewed staff present and attempted interviews with residents at approximately 12:40 p.m. At 3:40 p.m. LPA Rios obtained and reviewed, R1’s, Appraisal/Needs and Services Plan, Physician’s Report, Reappraisal, Unusual Incident/Injury Report and facility Progress Notes. (Continued to LIC9099-C) Unsubstantiated R1's, Physician's Report dated 03/04/2020 revealed R1 was "able to feed self", Appraisal dated 03/04/2020 reported R1 did not need help with eating. Interviews with the licensee revealed R1 had started to refuse to eat and he notified R1's family. According to the licensee, the facility had open communication with R1's family, informing them of R1's refusals. LPA reviewed facility progress notes from 03/20/2020 to 10/10/2020, notes revealed R1's refusals and the times R1's "family was made aware". According to the licensee, staff assisted R1 with eating but it was not "total care". Furthermore, interviews with the administrator and other staff revealed R1 had refused assistance for various things such as repositioning, incontinent care and eating. According to the licensee, due to residents decline in health and change in condition a Reappraisal and Appraisal/Needs and Services dated 10/07/2023 were conducted and facility noted R1 needed help with eating. R1 was transferred out of the facility on 10/10/2020. LPA Rios attempted to contact R1's family but was unsuccessful. Based on the information obtained, there was insufficient evidence to corroborate the allegation staff did not meet the needs of the resident. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation #2: Illegal Eviction. It is alleged the licensee refused to take the resident #1 (R1) back on two different occasions when R1 was discharged from the hospital. To investigate the allegation LPA conducted interviews with the licensee and the administrator on 10/10/2023 and 10/17/2023. According to the licensee, R1 was never evicted. On the first occasion the facility was notified by the hospital that R1 was ready for discharge but the facility felt R1's wound was not getting better. Licensee notified R1's family, that it would be best for R1 to be in a "24/7 nursing care". Licensee states they did admit R1 back to the facility after both of R1's hospital discharges and continued to encourage R1's family to consider skilled nursing services because the facility and the wound care nurse believed R1's wound was not improving and the facility could not "address R1's current needs". According to licensee an eviction notice was not issued and unnecessary because R1's family decided to transfer R1 to "another board and care". Based on the information obtained, there was insufficient evidence to prove that R1 was Illegally Evicted. Therefore, the allegation is deemed Unsubstantiated at this time. Administrator advised and a copy of this report issued.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 31-AS-20201102093332

Type of visit: Required - 1 Year

On 10/10/23 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the Administrator Merlita Nepomuceno. LPA observed covid-19 signs at the front door and required postings were observed on a wall by the living area. LPA Rios explained the purpose of the visit to the administrator. At 10:20 a.m. LPA and administrator Merlita conducted a physical plant tour to ensure the health and safety of the residents in care. The following was observed: Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet in the kitchen. Cleaning products were stored in a locked cabinet under the kitchen sink. Medication stored in a locked kitchen cabinet. Bedrooms: There are four (4) bedrooms of which four (4) are designated for residents' use. Three of the bedrooms are currently occupied. Bedroom #3 is currently vacant. Rooms occupied by residents were properly furnished with appropriate beddings and linens with sufficient lighting. LPA observed a full bed rail on resident #1's (R1's) bed. Bathrooms: There are two (2) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (1) of two (2) bathrooms at 10:40 a.m. and read between 105 and 120 degrees Fahrenheit. Common Areas: These included the living area and dining area. The common areas were clean and properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. (Continued to LIC809-C) The smoke alarms are battery operated and interconnected. LPA observed a carbon monoxide detector by the living area and kitchen. Staff #1 (S1) tested smoke and carbon detectors at 10:43 a.m. and were observed to be functioning properly. The fire extinguisher is located in the kitchen with purchase date 07/14/23. Surrounding Grounds: The outdoor area was free of hazards and has a covered patio with outdoor furniture. LPA observed a shed used for storage. A staff room that is maintained locked leads to the laundry room which leads to the garage. LPA observed a deep freezer with food. Detergents and cleaning products are kept in the laundry room locked. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms at 12:08 p.m. LPA's record review for resident #1 (R1), R1 had an order for a full bed rail but R1 is not terminally ill according to R1's physician's report. According to Licensee Nathan, R1 is receiving Hospice service for palliative care. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms at 12:35 p.m. Medications: At 1:43 p.m. LPA and administrator reviewed medication and medication records for proper documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiency observed during the visit refer to LIC809-D. Exit Interview Conducted. Appeal Rights provided. A copy of the report Issued.the state’s words, verbatim · CDSS document, Oct 10, 2023