Am Residential Care Home

Type of visit: POC

On January 6, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced plan of correction visit. Upon entry, LPA met with caregiver, Delilah Nicodemus and house manager, Rosita Padolina. The administrator, Katie Eiseman arrived shortly thereafter and assisted with the visit. During today's visit, LPA observed sharps are locked and inaccessible to residents in care and there were no medications that were transferred from its original container to a weekly organizer. However, LPA observed one of resident #1 (R1)'s medication did not have a physician order and this observation was made during the case management visit on 12/17/2025. A civil penalty of $250 is being assessed today for repeat violation. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in additional civil penalties. This report is reviewed and discussed with the administrator. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 6, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Jan 7, 2026

87465 Incidental Medical and Dental Care (e)For every prescription and nonprescription PRN medication..there shall be a signed, dated written order from a physician,.. This requirement is not met as evidenced by based on observation, record review and interviews, LPA observed one of R1 medications did not have a written physician order which poses an immediately health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2026

Plan of correction: The administrator will provide a copy of the physician's order for the medication identified. The administrator will ensure facility staff does not accept any medications from family members without a physician's order. The administrator will provide re-inservice to staff of the plan and the plan of correction shall indicate the date of completion for the in-service. The administrator will provide a copy of the plan of correction to CCL by 1/7/2026.

Type of visit: Case Management - Other

On December 17, 2025, Licensing Program Analyst (LPA) Murial Han conducted a case management visit to follow-up on the pre-licensing inspection findings that were observed for Heritage Manor. LPA met with administrator, Katie Eiseman explained the purpose of today's visit. During the pre-licensing inspection, LPA observed sharps were not locked and accessible to residents in care. During medication review, LPA observed some of resident #1 (R1), resident #3 (R3), and resident #6 (R6)'s medications did not have a written order from the physician. During the medication review, LPA also observed resident #2 (R2), resident #4 (R4), resident #5 (R5), and R6's medications were removed from its original contains and pre- poured into a weekly medication organizer. According to Staff #1 (S1), the medications were prepared for a later shift. LPA requested for a copy of the current medication list/prescription for R1, R3 and R6 to be submitted by 12/18/2025. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the administrator. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Dec 18, 2025

(a) Except as specified in subsection..the licensee shall ensure that..sharp objects,other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidence by based on observation, and interview, LPA observed sharps were unlocked and accessible to residents in care which poses an immediately health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Dec 17, 2025

Plan of correction: The administrator has relocated all the sharps to a more secured/locked storage area. The administrator will re-train staff. The administrator will provide a copy of the plan of correction to CCL by 12/18/2025 to ensure compliance and the plan shall indicate the date that the re-training of staff will be completed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(e) · Plan of correction due date: Dec 18, 2025

87465 Incidental Medical and Dental Caree)For every prescription and nonprescription PRN medication..there shall be a signed, dated written order from a physician,.. This requirement is not met as evidenced by based on observation, record review and interviews, LPA observed some of R1, R3, and R6 medications did not have a written physician order which poses an immediately health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 17, 2025

Plan of correction: The administrator will work with the responsible parties to ensure compliance. The administrator will provide a plan of correction that includes the action taken to resolve the deficiency, and the plan of correction to ensure staff is re-trained. The administrator will provide a copy of the plan of correction to CCL by 12/18/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Dec 18, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container... This requirement is not met based on observation, and interview, LPA observed R2, R4, R5, and R6's medications were transferred to a weekly medication organizer for a later shift which poses an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Dec 17, 2025

Plan of correction: The administrator will provide a plan of correction to ensure compliance and the plan shall indicate how is the facility going to prevent this from happening again and it shall include staff re-training. The administrator will provide a copy of the plan to CCL by 12/18/25.

Type of visit: Required - 1 Year

On October 2, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon entrance, LPA was greeted by caregiver Delilah Nicodermus and LPA explained the purpose of the visit. House Manager Rosita Padolina and Administrator, Katie Eiseman arrived shortly thereafter and assisted with the annual inspection. The facility is licensed for a capacity of 6 non-ambulatory residents of which 3 may receive hospice care services. There are 2 residents receiving hospice services at this time. LPA toured the facility inside and outside including the bedrooms (4 private and 1 shared rooms), 1 full- bathroom, kitchen, living room and common areas. Staff rooms are located on the 2nd floor. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathroom is equipped with grab bars, and in good condition. Facility temperature is comfortable. Hot water temperatures in the kitchen and bathroom was measured at 105- 110 degrees F. LPA observed 2-day perishables and 7-day non-perishables. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors in the facility. Fire extinguishers were last inspected on 8/8/2025. Medication, and disinfectants were observed to be locked and inaccessible to residents. At 10:20AM, during the facility tour with the house manager, LPA observed the sharps that were stored in the kitchen drawer was unlocked. A review of (6) resident files was conducted and noted on the LIC 858. A review of (4) staff files was conducted and noted on the LIC 859 and LPA observed Staff #1 (S1)'s Criminal Record Clearance transfer was incomplete. The administrator will provide a copy of the Liability Insurance to CCL by 10/3/2025. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the administrator and the house manager. A copy is provided and the appeal rights.the state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Required - 1 Year

On 10/22/2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon entrance, LPA met with caregivers Imelda Silo and Zenaida Tarrazona and LPA explained the purpose of the visit. Caregivers contacted the lead caregiver, Rosita Padolina of LPA's inspection who arrived shortly thereafter as well as the administrator, Katie Eiseman. The facility is licensed for a capacity of 6 non-ambulatory residents of which 3 may receive hospice care services. There are 3 residents receiving hospice services at this time. LPA toured the facility inside and outside including the bedrooms (4 private and 1 shared rooms), 2 full- bathrooms, kitchen, living room and common areas. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and in good condition. Facility temperature is comfortable. Hot water temperatures in the kitchen and bathroom was measured at 105- 110 degrees F. LPA observed 2-day perishables and 7-day non-perishables. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors in the facility. Fire extinguishers were last inspected on 8/8/2024. Central stored medication, toxins and sharps objects were observed to be locked and inaccessible to residents. A review of (6) resident files was conducted and noted on the LIC 858. A review of (3) staff files was conducted and noted on the LIC 859 During the tour of the facility, LPA observed a table, folding chairs and personal belongings in the garage and according to staff, the garage is being used as staff breakroom. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the administrator. A copy is provided and the appeal rights.the state’s words, verbatim · CDSS document, Oct 22, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/8/23 at 4:00PM. LPA met with Anicia Dela Cruz, Administrator and Rosita Padolina, Caregiver and stated the purpose of the visit. The Administrator Certificate was observed for Anicia Dela Cruz which expires 11/7/23. The facility is licensed for a capacity of 6 non-ambulatory residents of which 3 may receive hospice care services. There are 3 residents receiving hospice services at this time. LPA observed residents and conversed with them during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 78**F which is within the required range of 68-85*F. The hot water temperature was measured at 105.6 *F which is within the required range of 105-120*F. The most recent emergency drill was conducted 1/10/23. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed 2 staff and 2 resident files and conducted interviews during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Any addendums to the Infection Control Plan, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Emergency Disaster Plan (LIC610E), Liability Insurance, Health Screening with TB for all staff. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted, a copy of the report was given.the state’s words, verbatim · CDSS document, Oct 8, 2023