A Humble Abode

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Jorge Aquino for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 12:30 PM and the following was noted: The facility has outdoor furniture with a covered shaded area for residents and visitors. LPA did not observe a swimming pool/body of water. The facility is fire cleared for six (6) non-ambulatory of which one (1) may be bedridden and a hospice waiver for six (6). The facility is currently occupying six (6) residents. The living room and dining room are neat and clean. The facility has a total of five (5) bedrooms and two (2) bathrooms. The residents' rooms are adequately furnished with appropriate lighting system. There was enough clean linen available in the cabinets. Hallways are well lit. Residents have enough personal hygiene products provided by the licensee. The bathroom was checked for cleanliness and proper operation. Towels and washcloths are not shared. Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. (continued on LIC 809-C) Knives and sharps are observed to be locked and inaccessible to residents. Laundry detergents, cleaning agents and other toxins are locked away. The facility maintains a comfortable temperature at 75°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen and observed to be fully charged and last purchased April 20, 2026. The hot water temperature was measured at 108.3°F. LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, May 22, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Jorge Aquino for a Required One (01) Year visit. LPA contacted the administrator Silica Bungabong who designated Jorge Aquino to sign and accept the report. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 10:00 AM and the following was noted: There is one entrance being utilized at the facility. Facility has five (05) bedrooms and two (02) full bathrooms. One (01) out of five (05) bedrooms is semi-private and the remaining are all private single occupancy. The facility is fire cleared for six (06) non-ambulatory of which one (01) may be bedridden and has a hospice waiver for six (06). The facility is currently occupying four (04) residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for storage. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. (continued on LIC 809-C) The living and dining room are neat and clean. The facility maintains a comfortable temperature at 72°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the living and dining area and observed to be fully charged and last purchased 04/21/2025. The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 115.3°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit. During the tour LPA observed multiple half rail beds being used by residents but without a written order from a physician indicating the need for the postural support. During record review, LPA also observed missing documentation for one (01) out of four (04) residents. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): No other health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, May 1, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Nadia Shahbazian conducted a Case Management Visit at the facility for the purpose of Records Review. LPA met with Jorge Aquino - Care Provider. LPA spoke with Administrator Silica Bungabong over the telephone. Administrator stated that she is in meetings today and unable to come to the facility. Administrator designated Jorge Aquino to sign the report. An entrance interview was conducted. LPA requested copies of the Resident Roster and the current LIC 500, and any other Staff Schedule used by the facility. LPA conducted a review of Facility Resident Records for four (4) of four (4) residents. LPA requested copies of documents including but not limited to the admission agreement, preplacement appraisal (LIC 603), all reappraisals (LIC 603A), physician’s reports (LIC 602A), functional capability assessment (LIC 9172), identification and emergency information (LIC 601), appraisal/needs and services plan (LIC 625), centrally stored medication and destruction record (LIC 622) and the Medication Administration Record (MAR) if any. In addition, LPA requested admission documents for all residents currently receiving hospice services. Per telephone call, facility Administrator agreed to scan and email the requested documents to the LPA by close of business on Wednesday, 4/9/25. An exit interview was conducted and a copy of the LIC 809 provided.the state’s words, verbatim · CDSS document, Apr 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Delfin Billedo for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 09:00 AM and the following was noted: There is one entrance being utilized at the facility. Facility has five (05) bedrooms and two (02) full bathrooms. One (01) out of five (05) bedrooms is semi-private and the remaining are all private single occupancy. The facility is fire cleared for six (06) non-ambulatory of which one (01) may be bedridden. The facility is currently occupying six (06) residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 71°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located in the kitchen, observed to be full and last inspected on 04/11/2024. (continued on LIC 809-C) The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 118.8°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication and first aid kit to be locked and inaccessible to residents. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, May 11, 2024

Allegation investigated: Staff not preventing resident from getting physically abused.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with the House Manager, Jorge Aquino, and explained the reason for the visit. --- Staff not preventing resident from getting physically abused. It was alleged that Resident #1 (R1) is being physically abused by unknown perpetrator. To investigate the allegation, on 02/16/2024, interviewed four (04) staff from 10:45 AM – 12:00 PM and interviewed three (03) out of four (04) residents from around 12:15 PM – 01:45 PM. During interviews with staff, all staff stated they have never physically harmed any resident and are not aware of any others abusing residents. (CONT. on LIC9099-C) Unsubstantiated During interviews with residents, three (03) out of four (04) residents stated they have never been physically abused by staff, including R1. LPA was unable to interview one (01) resident. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 16, 2024 · control 31-AS-20240209105707

Allegation investigated: Staff did not seek medical care for resident.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with the Licensee James Contreras and explained the reason for the visit. --- Staff did not seek medical care for resident It was alleged that the facility did not seek emergency services for resident attempting suicide. To investigate the allegation, on 11/30/2023, LPA requested records at 10:15 AM, interviewed two (02) staff from 10:45 AM – 11:30 AM and interviewed one (01) out of five (05) residents from around 11:45 AM – 12:15 PM. LPA was unable to interview all other residents. A review of Resident #1’s (R1) Physician’s Report shows that R1 is not a suicide risk. During interviews with staff, all staff stated R1 attempted suicide and admitted to not seeking emergency or medical services for R1. (CONT. on LIC9099-C) Substantiated Staff added that they intended to seek medical attention but that services were initiated the following day by a third-party representative who was made aware of the incident by R1. During interviews with resident, R1 stated they attempted to commit suicide and medical attention was initiated after the incident but is not aware of who contacted medical services. Based on interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 31-AS-20231127111119

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Dec 1, 2023

Incidental Medical and Dental Care(a) A plan for incidental medical…care..shall be developed by each facility. The plan shall…provide for assistance in obtaining such care, by compliance with the following:(2) The licensee shall provide assistance in meeting necessary medical...needs. This requirement is not met as evidenced by; Based on interviews, facility did not provide assistance in meeting necessary medical needs after a serious incident which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87465 Incidental Medical and Dental Care; The written letter must be sent to the LPA by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(6) · Plan of correction due date: Dec 1, 2023

87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, …, as specified in Section 87465, Incidental Medical and Dental Care Services... This requirement is not met as evidenced by: Based on interviews, facility did not arrange to meet residents’ health needs after a serious incident which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87464 Basic Services; The written letter must be sent to the LPA by the POC due date.

Type of visit: Case Management - Deficiencies

This LIC 809 is being created in conjunction with a complaint visit done today at the above-named address (complaint control number 31-AS-20231127111119). During the initial complaint visit, LPA Duguma discovered that facility staff did not report an incident that took place at the facility on the evening of 11/23/2023. Resident #1, who was not deemed a suicide risk, attempted to commit suicide and staff walked in, stopped the attempt, removed everything dangerous that might be used and reported the incident to their superior. A review of the departments records confirms that facility did not submit an Incident Report and facility failed to contact medical service. Failure to contact medical services was addressed on the complaint via LIC9099 and LIC9099-D. Per CCR, Title 22, Division 6, Chapter 8, the following is noted as a result of the visit: (see LIC 809-D for any deficiencies cited). No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 30, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Dec 4, 2023

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require,...(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events... (D)Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by; Based on interviews, facility did not submit incident report to the Dept. which poses a potential health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87211 Reporting Requirements; The written letter must be sent to the LPA by the POC due date.