A1 Senior Care 4

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with administrator Daisyree Tacandong during today's inspection. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 5 resident rooms, 1 staff room, 2 bathrooms, kitchen, common living spaces, backyard and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. Hot water was measured at 109 degrees LPA reviewed 3 of 6 resident files and 2 staff files. LPA reviewed medications of two residents comparing with Centrally Stored Medication Record and physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. LPA observed a copy of current liability insurance. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jun 17, 2026

Allegation investigated: Providing a modified diet without a doctors order Length of time between dinner and breakfast does not meet regulation

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA spoke with administrator Daisyree Tacandong during today’s inspection. LPA investigated allegation, “Providing a modified diet without a doctors order”. The department interviewed relevant parties, staff, and residents in care, and reviewed documentation. Interviews with relevant party indicated that administrator modified R1’s diet by giving them thickened liquids without the consent of the following primary care physician. Relevant party believes it negatively impacted R1’s health. LPA interviewed administrator, a registered nurse, in which she stated that they did start R1 on thickened liquids due to R1 choking when drinking thin liquids. Administrator stated that she was afraid R1 was going to have adverse health effects due to choking on liquids. A doctor appointment occurred in January 2026 and administrator asked for family to request a speech therapist before administrator could discontinue the thickened liquids. Continuation on 9099-C. Unfounded R1 was discharged from the facility prior to a therapist coming out to the facility. Administrator did not receive physician order to add thickener to R1’s liquids, but administrator was working in her scope of practice, and a physician order is not required to add thickener to resident’s water. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated allegation, “Length of time between dinner and breakfast does not meet regulation”. The department interviewed relevant party, administrator, and current residents in the facility. Relevant party indicated that dinner was being served at 3 PM, and no food or liquid was provided to residents until the following morning. Administrator stated that breakfast is served around 7-7:30 AM, Lunch around 11:30 AM and dinner around 4:30- 5 PM, and snacks are available and served throughout the day and evening. LPA interviewed caregiver who stated the same timeline. LPA interviewed 1 current resident, and they stated breakfast is served around 7:15 AM, Lunch around 11:30 AM and dinner was served around 4:30-5 PM. Resident stated there is sufficient food, and snacks served throughout the day. LPA toured the kitchen area and observed 2-day perishable and 7-day non-perishable amount of food. Due to the information gathered, LPA finds allegation to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 59-AS-20260206122928

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 8, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and record review the licensee did not provide sufficient staffing for R1 which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Administrator to send LPA a statement of understanding that the facility will be staffed according to resident's care needs. Statement to be sent into CCL by 5/8/26.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived at the facility and met with Administrator, to conduct a Pre- Licensing visit. The facility has a fire clearance for six (6) non-ambulatory residents. Administrator has an active certificate (#7016032740 with expiration date 05/16/2026). LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and two (2) bathrooms for resident use. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 106.7 degrees F. LPA observed facility has the ability to prepare and store food, to lock away cleaning products and other toxins, and lock medications to make inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit and fire extinguisher are maintained and ready for emergency use. Component III was completed. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.the state’s words, verbatim · CDSS document, Jun 17, 2025