Ace Elderly Homes

Allegation investigated: Staff neglect resulting in unstageable pressure injuries.

On August 7, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted a subsequent unannounced complaint visit. FRANCES LIWANAG, Administrator, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, record reviews, and a tour of the facility. Investigator Dennis Douglas of the CDSS Investigation Branch conducted the investigation. Interviews with Staff member S#1 - S#5 (S1-S5), Witness #1 and #2 (W1-W2), attempted Witness #3 and Witness #4 (W3-W4), (R1’s) Admissions Agreement (dated 03/17/25), Physician’s Report LIC 602A (dated 03/25/25), Preplacement Appraisal Information (dated 03/17/26), County of Los Angeles Certificate of Death (dated 05/28/26), Unusual Incident Report LIC 624 (dated 09/09/26 and 11/26/25), Kaiser Permanente South Bay Medical Center Discharge Report (dated 09/09/25), Harbor UCLA Medical Center Medical Records, and Summerwind Hospice Plan of Care (dated 11/05/25). . (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff neglect resulting in unstageable pressure injuries. It is alleged that the staff's neglect of Resident #1 (R1) led to unstageable pressure injuries. Reports indicate that (R1) was hospitalized, and a medical examination revealed multiple wounds. Specifically, there is a 7 cm by 5 cm sacrococcygeal deep pressure tissue injury, an unstageable scapular wound measuring 3 cm by 2 cm with full-thickness tissue loss and necrotic tissue, and a 1 cm by 1 cm unstageable ankle wound with full-thickness tissue loss and eschar. No further information has been provided regarding this matter. On January 2, 2026, January 23, 2026, and February 27, 2026, between 08:00 AM and 02:30 PM, the Department conducted interviews with staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff confirmed that Resident #1 (R1) developed pressure injuries while in their care. According to (S1, S4, and S5), (R1) arrived at the facility on March 21, 2025, without any pressure injuries and showed no signs of such injuries, including the one that later developed on the upper mid-back. Throughout (R1's) residency, staff observations from (S1, S4, and S5) indicated a decline in (R1's) condition. (R1) exhibited a loss of motivation to walk, increasing weakness, and a tendency to remain in bed throughout the day. Despite being repositioned every two hours, (S2 and S3) noted that (R1) still developed pressure injuries while in care. Additionally, (S1 and S5) reported noticing redness on (R1's) back starting in August 2025, which later progressed into a pressure injury. By the time hospice care began on November 5, 2025, the injury had progressed to stage III. On February 24, 2026, March 2, 2026, and May 5, 2026, between 09:35 AM and 4:10 PM, the Department interviewed witness identified as Witness #1 (W1). (W1) reported that (R1) went into "septic shock" from an "unstageable" pressure wound that developed at the facility, where (R1) was not receiving hospice care. During the last four weeks, care was provided while (R1) was seated in a recliner, worsening the wound. On February 24, 2026, and May 05, 2026, between 03:25 PM and 04:10 PM, the Department interviewed witness identified as Witness #2 (W2). (W2) stated that (R1) had passed away on December 7, 2025, and advised contacting (W1) for further information on the matter. (Evaluation Report continues LIC 9099-C) The Department attempted to interview Witness #3 and Witness #4, but phone messages went unanswered, and they were unavailable for an interview. The Department could not interview Resident #1 (R1) because (R1) has passed away. The Department reviewed (R1’s) Admissions Agreement (dated 03/17/25), Physician’s Report LIC 602A (dated 03/25/25), Preplacement Appraisal Information (dated 03/17/26), Summerwind Hospice Plan of Care (dated 11/05/25), Unusual Incident Report LIC 624 (dated 09/09/26 and 11/26/25), Kaiser Permanente South Bay Medical Center Discharge Report (dated 09/09/25), Harbor UCLA Medical Center Medical Records, and County of Los Angeles Certificate of Death (dated 05/28/26). Based on all the information collected, the allegation of neglect and lack of care and supervision regarding (R1) has been confirmed to have developed a stage III pressure injury by the time hospice care service was initiated, and the facility kept the resident despite having a Prohibited Health Condition without an established wound care plan. There is sufficient evidence to corroborate the allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099 D). An exit interview was conducted with FRANCES LIWANAG, and copies of the report and appeal rights were provided. *Immediate Civil Penalty issued* ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000). The Department could not interview Resident #1 (R1) because R1 has passed away. The Department reviewed (R1’s) Admissions Agreement (dated 03/17/25), Physician’s Report LIC 602A (dated 03/25/25), Preplacement Appraisal Information (dated 03/17/26), County of Los Angeles Certificate of Death (dated 05/28/26), Unusual Incident Report LIC 624 (dated 09/09/26 and 11/26/25). Further review of Kaiser Permanente South Bay Medical Center Discharge Report (dated 09/09/25), Harbor UCLA Medical Center Medical Records, and Summerwind Hospice Plan of Care (dated 11/05/25) revealed no document a hip fracture. Based on the gathered information, it appeared that the facility was unaware of falls that resulted in a hip fracture involving Resident #1 (R1) and that, when medical crises occurred, the facility acted promptly to seek medical attention. There is insufficient evidence to corroborate the allegation. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted with FRANCES LIWANAG, and copies of the reports were provided. Allegation #2: Staff did not seek timely medical attention for resident. It is alleged that staff failed to seek timely medical attention for Resident #1 (R1). Reports indicate that (R1) was admitted to Harbor UCLA Medical Center with septic shock resulting from pneumonia, as well as a newly discovered hip fracture. Further reports mentioned that the newly discovered hip fracture went unreported, and the facility did not seek timely medical care for (R1). No additional information has been provided regarding this matter. On January 2, 2026, January 23, 2026, and February 27, 2026, between 08:00 AM and 02:30 PM, the Department conducted interviews with staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff are unable to corroborate this allegation. On November 26, 2025, (R1) was admitted to the hospital due to significant shortness of breath. There were no indications of fractures, as confirmed by (S1) and (S5). Before this hospitalization, all staff members who interacted with (R1) reported no falls, except for a single incident on September 9, 2025, which resulted in a head injury, but again, there were no fractures. After the head injury, emergency services were promptly dispatched, and (R1) received timely medical attention at Kaiser Permanente and was discharged the same day, September 9, 2025. (S1) reported that on September 9, 2026, while (R1) was outside in the backyard with staff, (R1) lost balance as (R1) was about to step onto the grass and fell, hitting (R1's) head on (R1's) reading glasses, which caused a wound. 911 was called, and staff were instructed to apply pressure to the wound to stop the bleeding. (S1-S5) confirmed that the facility sought immediate medical attention for (R1) following this fall incident. On February 24, 2026, March 2, 2026, and May 5, 2026, between 09:35 AM and 4:10 PM, the Department interviewed witness identified as Witness #1 (W1). During the interview, (W1) did not mention (R1) sustaining fractures and only commented on a lack of proper care. On February 24, 2026, and May 05, 2026, between 03:25 PM and 04:10 PM, the Department interviewed witness identified as Witness #2 (W2). (W2) stated that (R1) had passed away on December 7, 2025, and advised contacting (W1) for further information on the matter. The Department attempted to interview Witness #3 and Witness #4, but phone messages went unanswered, and they were unavailable for an interview. (Evaluation Report continues LIC 9099-C)the state’s words, verbatim · CDSS document, Aug 7, 2026 · control 11-AS-20251126152629

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Aug 8, 2026

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interviews, observations, and record reviews, Licensee was aware of (R1's) pressure injuries, which developed to Stage 3, which are prohibited health conditions, and did not have a wound care plan or hospice care. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: Licensee/Administrator will review Title 22, Section 87615, and the Plan of Operation to ensure compliance. The Licensee will retrain staff on pressure injuries and submit the completed training, including staff names and completion dates, to ernand.dabuet@dss.ca.gov by the POC date of 08/08/26. *CIVIL PENALTY*

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(B) · Plan of correction due date: Aug 28, 2026

87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by: Based on interviews, observations, and record reviews, the licensee was aware of R1's change in condition, as R1's health had declined, and did not do a reappraisal for R1. This violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: Licensee/Administrator will review Title 22, Section 87463, and the Plan of Operation to ensure compliance. The Licensee will retrain staff on identifying residents' change in condition, including staff names and completion dates, to ernand.dabuet@dss.ca.gov by the POC date of 08/28/26.

Allegation investigated: Staff are not allowing a resident to have a visitor.

On 03/03/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with Staff and the purpose of the visit was explained. LPA spoke with Administrator Frances Liwanage over the phone. Investigation consisted of the following: On 03/02/2026, LPA obtained Personnel Report (dated 09/10/25), Register of Residents (no date), House Rules, Visitor Logs (01/03/26 – 03/02/26), R1 – R4’s Identification and Emergency Information, R1’s Agent Notice (02/20/26), Admission Agreement, Advanced Health Care Directive (page 2 and 12 only), Physician’s Report, Hospice Plan of Care, Personal Rights, and Theft and Loss Policy. LPA interviewed Staff #1 – 3, Witness #1, and Resident #2. On 03/02/26 5:39 PM, LPA received R1’s Advanced Health Care Directive (11/09/2021). On 03/03/26, LPA interviewed Staff #1 and #3. Note: Resident #1 is deceased. Continue to LIC9099-C. Substantiated Investigation revealed the following: Regarding the allegation, “Staff are not allowing a resident to have a visitor,” it is being alleged Staff #1 (S1) banned a family member from visiting Resident #1 (R1) by getting authorization from Witness #1 (W1). Record review of Resident #1 (R1) Advance Health Care Directive revealed Witness #1 (W1) as R1's Health Care Agent. It revealed R1’s health care agent must make health care decisions that are consistent with my instructions in this document, if any, and other wishes known by my agent. Otherwise, my agent must make health care decisions that he or she believes to be in my best interest, considering what he or she knows about my personal values. This form does not give my health care agent the authority to make financial or other business decisions. Review of My Values and Beliefs (Part 2), My Health Care Instructions (Part 3), My Hope and Wishes (Optional) (Part 4) are blank in the Advance Health Care Directive. Review of Health Care Agent’s (written) Notice revealed W1 prohibited a family member from visiting R1 as of 02/20/2026. On 03/02/26 10:36 AM, interview with W1 indicated W1 has power of attorney over R1's medical and has the paperwork (Advance Health Care Directive). Staff #1 (S1) indicated the family member came to visit and was informed that W1 said the family member could not visit R1. S1 reported the incident to W1. R1 passed away on 02/25/2026. Regarding the allegation, “Staff are not allowing a resident to have a visitor,” based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 are being cited on the attached LIC 9099D. An exit interview was conducted, plans of correction developed, and a copy of this report with the appeal rights was provided to Staff Lucia Ramos.the state’s words, verbatim · CDSS document, Mar 3, 2026 · control 11-AS-20260220132544

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Mar 18, 2026

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) To have their visitors...permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met: Based on record review and interviews, staff prohibited a visitor from visiting with Resident #1 which posed a potential personal rights risk to client in care.the state’s words, verbatim · CDSS document, Mar 3, 2026

Plan of correction: The Administrator will submit a plan of correction to regina.cloyd@dss.ca.gov by the POC due date.

Allegation investigated: Staff are over medicating a resident in care Staff did not clean resident's bedding.

On 02/19/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Ace Elderly Homes and was greeted by Administrator Francis Liwanag (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S3, residents R1-R3. LPA Calderon obtained the following records: Admission Agreement (dated 01/30/2026). Pre-placement (dated 01/30/2026). Physician report (dated 01/30/2026), Medication administration record (MAR) (02/2026), cleaning schedule (dated 02/2026), Hospice medication list (dated 08/08/2025) for R1. Toured the facility with S1 The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff are over medicating a resident in care’. This complaint alleged that the facility over medicated R1. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions between staff and residents. LPA Calderon noted staff giving medications to residents in care. Records review indicate the following: Guaranteed Hospice (dated 08/08/2025), indicates that the medication given to R1 comes from the hospice nurse. The MAR for R1 indicates that staff follow the direction of the MAR. Hospice Medication List (dated 08/08/2025) indicates the medication to be given to R1. Physician report (dated 01/30/2026) indicates that R1 has health issues and cognitive issues. Interviews indicate the following: S1 indicates that staff follows the hospice care plan and the hospice medication plan. Staff state that staff do not overmedicate R1. S1 indicates that the MAR supports the medication given to R1. 3 out of 3 staff deny the allegation. R1 could not answer any questions due to health issues. R2 could not answer any questions due to health issues. R3 indicates that staff do not give him medication R3 does not need. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff are over medicating a resident in care” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff did not clean residents’ bedding. This complaint alleged that the facility did not change R1 bedding. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions between staff and residents. LPA Calderon noted staff cleaning the facility. Records review indicate the following: The Guaranteed Hospice (dated 08/08/2025) indicates that the hospice nurse gave a bath to R1 5 times in February. Hospice nurses changed bedding 5 times in the month of February 2026. Hospice care plan (dated 08/08/2025) indicates that the hospice nurse changes the resident bedding 3 times per week. Physician report (dated 01/30/2026) indicates that R1 has health issues and cognitive issues. Interviews indicate the following: S1 states that they change the R1 bedding every day and follow the hospice care plan. 3 out of 3 staff deny the allegation. R1 could not answer any questions due to health issues. R2 could not answer any questions due to health issues. R3 indicates that staff change R3 bedding 3 times per week. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not clean residents bedding” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Francis Liwanag (S1).the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 11-AS-20260211113622

Type of visit: Required - 1 Year

On 11/01/2025, the California Department of Social Services (CDSS) Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator, Francis Liwanag. The purpose of the visit was explained, and the LPA was allowed entry to the facility. This facility is licensed to serve 6 non-ambulatory adults ages 60 and above, of which 1 may be bedridden. The facility has a hospice waiver for 2 residents. A total of 6 residents are currently residing in this facility. Facility Layout: The facility is a one-story house located in a residential street. The home consists of 4 resident bedrooms; 2 full bathrooms; 1 great room with a kitchen area, office space, dining table, living room area; 1 attached garage; and1 backyard patio area with shaded seating. Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there are no security bars or weapons on the premises. Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to residents in care. There is fire extinguisher in the kitchen area. Great Room: There is a landline telephone in the office area. In the living room area there are activities in the living area such as bingo, cards, Jenga, etc. Resident Bedrooms: 4 out of 4 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Bathrooms: Toilets, showers, and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries were accessible to residents. Medications: were inaccessible to residents in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. 6 out of 6 Medication Administration Records (MARs) were reviewed. 6 out 6 residents did not have documented nonprescription (PRN) medication with time the PRN medication was taken, the dosage taken, and the resident's response. Garage: Has a laundry area, storage area, and staff break area. Miscellaneous: Documents are posted as mandated. The last fire drill was conducted on 10/05/2025. The last quarterly emergency/disaster drill was conducted was on 07/02/2025 and it was on fire, power outage, and flood. The facilities liability insurance is current. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. 5 staff records were reviewed, 4 out of 5 staff records had required documentation. 2 out of 5 staff records did not have CPR certificate. 1 out of 5 staff records did not a health screening report. 6 resident records were reviewed, 6 out of 6 resident records had required documentation. Technical advisories are being provided regarding CPR certificates, Medications, Resident Appraisals, and Hospice. A technical violation is being provided regarding maintaining staff records complete and current. A deficiency is being cited based on observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding PRN medications. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator, Francis Liwanag.the state’s words, verbatim · CDSS document, Nov 1, 2025

Type of visit: Case Management - Other

On 09/10/2025, Licensing Program Analyst (LPA) Jose Calderon conducted a Case Management visit at this facility. LPA met with designated administrator Francis Liwanag who allowed entry in this facility. LPA Calderon informed Administrator Liwanag the purpose of the visit is to conduct a records review. Investigation revealed the following: LPA conducted a tour of the entire facility. During the inspection, LPA observed the following: (4) bedrooms (2) bathroom, kitchen, living room, den, patio, and garage LPA observed all (6) residents residing at this home requiring assistance with assisted daily living (ADLs) This property address is licensed to Ace Elderly Homes formally Santa Fe Home III #198602162. LPA Calderon requested a copy of the LIC500/Guardian Employee Roster and checked 6 residents and 4 staff records. No deficiencies cited during today's visit. An exit interview was conducted with Administrator Francis Liwanag, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 10, 2025

Type of visit: Office

On 1018/24, a virtual meeting was held via Microsoft Team by the El Segundo Adult and Senior Regional Office. Present during the meeting were Licensing Program Manager (LPM) Janae Hammond, Licensing Program Analyst (LPA) Ernand Dabuet, and applicant Evangeline Agatep. The purpose of today's meeting was to obtain clarifications for the facility change of ownership and operations. The meeting discussed the following: Clarification on change of ownership for Santa Fe Home III (applicant can not hold lease until applicant obtained license). The license is not transferable for Santa Fe Home III. Pre-License Visit conducted 10/17/24 by LPM Jose Calderon. LPM to follow up with CAB for Ace Elderly Home License. Applicant completed Comp III. New Admissions Agreement for Resident (change to Ace Elderly Home). Change of all Licensing Documents from Santa Fe to Ace Elderly Home. Staff Fingerprints (association) only associated with Santa Fe Home III will automatically transfer. Staff Health Screening (make note of the change of ownership) Several facilities will be held by administrator - Casa Del Sur & Ace Elderly Home The meeting concluded at 10:47 am. An exit interview was conducted with Evangeline Agatep, and a copy of the report was emailed for signature.the state’s words, verbatim · CDSS document, Oct 18, 2024

Type of visit: Prelicensing

On 10/17/2024 around 8am Licensing Program Analysts (LPA) Jose Calderon conducted an announced face to face visit with Administrator Evangeline Agatep for purpose of a pre-licensing evaluation for Ace Elderly Home. The requested capacity is for 6 adult residents of which there is 2 are bedridden and in hospice care. 4 ambulatory Adult Residents. Currently there are 4 adult residents living at the facility. Facility is a 4 bedroom, 2 bathrooms, one-story house. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a backyard with a covered patio for shade. The patio contained 1 small table and 4 chairs. Outdoor passageways, walkways, driveways, steps, and patios are free from obstructions. LPA Calderon did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Residents Bedrooms: All 4 Bedrooms are for ambulatory/non-ambulatory clients. Bedroom’s #1 and #2, #3 and #4 has one bed each, one chair, one-night stand, one lamp. There are dressers within the closet for each resident. Bedrooms #1, #2 #3 and #4 all comply with the requirement of 8 cubic feet of space. Bathrooms: Have a working toilet, wash basins, and walk-in shower. Bathroom #1 & 2 walk-in showers have grab bars. LPA Calderon observed adequate lighting in hallway leading to bathrooms. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hall closet. Emergency Phone Numbers, Exit Plan & Menu: The telephone system is a land line and operable. Emergency Disaster Plan and "See something, say something Let Us Know" was noted. 2 Fire Extinguisher 1 mounted on the wall in the kitchen and the second in the hallway. Food Service: Dishes, cups, and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked cabinet located in the kitchen area. Food supply is adequate; 7 days of dry food was found in the kitchen pantry which consisted of dry pasta, canned foods. Facility did have 7 days of emergency water located in the garage. Smoke Detectors: 5 smoke detectors are hard wired operated & working. 2 Carbon monoxide detector 1 located and mounted in the hallway and kitchen is operational. Appliances: Gas Stove, oven, microwave, washer, and dryer working. Refrigerator in the kitchen has a measured temperature of at least 41 degrees Fahrenheit for appropriate food storage. Freezer is at 19 degrees Fahrenheit. The residence is equipped with central air and heat and each client bedroom is individually climate controlled. Toxins: Locked/stored in the storage room located in the kitchen. Water Temperature: Bathrooms water temperature tested in #1 at 114 F. and #2 113 F. degrees, kitchen sink temperature tested at 115 F degrees. Medications, First-Aid Kit & Book: Medication administration records storage area, and first aid kit has been inspected, which are stored in locked kitchen cabinet, available for staff use but inaccessible to clients. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use. LPA Calderon did not observe any pet or bodies of water at the facility. LPA Calderon observe delayed egress, no chain locks, or dead bolts on exits. LPA Calderon did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. Pool/Jacuzzi & Pets: LPA Calderon did not observe any pet or bodies of water at the facility. Fire clearance: Fire Clearance was approved on 09/12/2024 for 2 bedridden/4 ambulatory clients with no special instructions. LPA Calderon did not observe delayed egress, no chain locks, or dead bolts on exits. LPA Calderon did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. Component III: (10/17/2024) about how to operate the facility within substantial compliance was reviewed by the licensee at this time. The licensee did not have any questions regarding component III for the LPA. An exit interview was conducted, and a copy of this report has been furnished to the applicant Administrator Evangeline Agatep by hand. Accordingly, LPA Jose Calderon will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Oct 17, 2024

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of Ownership Capacity: 6 Census (if any clients in care): 5 COMP II Participants: EVANGELINE AGATEP Interview Method: Telephone interview On September 19, 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 the understanding of the California Code Title 22 Regulations. 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. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Sep 19, 2024