Active Senior Home Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual inspection. LPA was greeted and granted entry by Caregiver Tedjo Pranoto. Administrator Aurica Bintintan arrived on premise to assist with the inspection. Administrator Aurica Bintintan has a valid certificate expiring March 25, 2028. The following was observed during the inspection: This is a single story residential home. Facility is approved for six non-ambulatory and maintains a hospice waiver for five. During today's visit, LPA observed five residents and two residents under hospice care. Facility is meeting the conditions and limitations specified on the license. LPA observed two caregivers on duty and verified fingerprint clearance and association statuses. LPA observed two private staff bedrooms, one private staff bathroom in the primary bedroom, four private resident bedrooms, one shared resident bedroom, and five resident bathrooms. All resident bedrooms have the required furnishings and ample lighting. The bathrooms are found to be in compliance equipped with grab bars and slip resistant mats. The hot water temperature measured at 110.0, 113.3, 115.2, 114.2, and 113.8 degrees Fahrenheit in the resident bathrooms. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed ample two day supply of perishables and seven-day supply of non-perishable food. LPA toured the exterior portion of the facility. LPA observed the outdoor passageway is free of hazard and obstruction. The two sheds in the passageway holds emergency disaster supplies, food, water, first aid, incontinence supplies, medical equipment, and cleaning solutions which are inaccessible to the residents. The two exit gates are operational, and there are sufficient seating and shading. The fire extinguisher was purchased on August 20, 2026. The auditory devices and dual functioning smoke/carbon monoxide detectors were tested and found operational. The facility is at a comfortable temperature range. The Emergency Disaster Plan (LIC610E) was reviewed. Emergency supplies including food and water are stored in the shed. Disaster drills are conducted quarterly with the last date on July 24, 2026. LPA observed the Complaint Poster (PUB475) posted in the correct size in the entry way. LPA audited six residents' and two personnel files in which no discrepancies were found. Medications were audited for two of six residents. Discrepancies found with administration and documentation for one of two residents' medications reviewed. Based on the observations made during today's visit, a deficiency is being cited, and an advisory is being issued. An exit interview was conducted with Administrator Aurica Bintintan, and a copy of this report including the appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Sep 4, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 18, 2026

87465 Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on observation and record review of two residents' medications, it was noted per the MAR that Quetiapine & Hydroxizine were administered for R2 when in fact the bubble packs were missing. This poses a potential Health, Safety, and/or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 4, 2026

Plan of correction: Adminstrator and staff will receive medication training and will forward proof of training to LPA via email by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA was greeted and granted entry by Caregiver Tedjo Pranoto followed by Licensee/Administrator (Admin) Aurica Bintintan after explaining the purpose of the visit. The facility is a single story structure located in a residential neighborhood. Facility operates within the conditions and limitations specified on the license. LPA observed two caregivers on duty providing care to six residents of which one is under hospice care. The Administrator's Certificate for Aurica Bintintan expires on March 25, 2026. The following was observed during the inspection: There are five resident bedrooms and five resident bathrooms. There are two additional staff bedrooms and one private staff bathroom in the master room. All common areas were inspected including the attached two car garage. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for each residents' personal belongings were observed. Bathrooms were found to be in compliance, clean, and operational. The hot water temperature measured at 115.5, 117.3, 117.6, 118.7, and 117.5 degrees Fahrenheit in the resident bathrooms. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food. LPA toured the exterior portion of the facility. LPA observed the outdoor passageway is free of obstructions. The sheds which holds continence supplies, medical equipment, and cleaning solutions in the passageway is inaccessible to the residents. The two exit gates were operational. LPA observed sufficient seating and shading. The fire extinguisher was purchased on September 5, 2025 per review of the receipt. The auditory devices and smoke/carbon monoxide detectors were tested and operational except one auditory device in the room of Resident #3 (R3). LPA observed the emergency disaster supplies including food/water in the garage. Emergency evacuation drills are being conducted quarterly in review of one out of two personnel files with the last date on July 16, 2025. LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size posted in the entry way. LPA conducted interviews, and audited six residents' files and two personnel files in which no discrepancies were noted with the resident files. However, the Health Screening Report (LIC503) was not available for Staff #2 (S2). Medications were audited for six residents. Discrepancies noted. Based on the observations made during today's visit, a deficiency is being cited and Advisory Notes are being issued. An exit interview was conducted with Licensee/Administrator Aurica Bintintan, and a copy of this report including the LIC811, LIC9102s, and the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Sep 5, 2025

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the reason of the visit. Administrator Aurica Bintintan was also present and assisted with the visit. During the inspection, LPA and staff conducted a tour of the physical plant and observed the following: The facility is a one-story home with four private and one shared bedrooms in addition to two staff rooms for use by the live-in caregiving staff and administrator. There are five bathrooms throughout the facility, either accessible through the hallways or en-suite in the bedrooms. All bathrooms are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. LPA observed all beds have linen and blankets. Multiple beds are observed to be equipped with full bed rails and another one with half rails. Physician orders and hospice plans of care reviewed as well as physician order for the half rails. Consultation provided. There are currently six residents admitted to the facility, four of which is receiving hospice care. Bathrooms faucets and toilets are operational. Water temperature was measured to be within acceptable temperature range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Drills are conducted quarterly however they are not systematically documented. Consultation provided. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke and carbon monoxide detectors tested operational. Fire extinguisher present is fully charged and has been replaced in 2024. There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on both sides of the property. The route of egress is free of obstructions. There are no bodies of water on the premises. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 Medication, cleaning products and sharp items are confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed to be accurate and up to date with the resident's prescription orders. LPA reviewed six resident files and three staff files. Two staff and one resident interviews conducted. Resident records include all necessary components. All staff members on the facility's roster are confirmed to be cleared and associated with this particular licensed location. Training records, health screenings and CPR training are on file and up to date. Training provided meets the regulatory requirements for initial and annual training. Based on observation and records reviewed, one resident receiving hospice care is observed to be and have been assessed as bedridden. The current fire clearance for the facility does not include a provision for bedridden residents. Type A citation issued. Based on the observations made during today’s inspection, one type A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. Three Advisory Notes issued along with consultations provided to the licensee. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.the state’s words, verbatim · CDSS document, Sep 25, 2024

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.