Assurecare Home

Type of visit: Case Management - Other

In conjunction with complaint investigation, Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted a case management visit to address the deficiencies unrelated to the complaint. During complaint #31-AS-20260223085152 investigation, at about 10:50a.m., LPA noted resident #1 (R1) was restrained to the wheelchair with a gait belt as postural support. The gait belt easy release buckle was on the back of the wheelchair. At about 11:00a.m. LPA interviewed staff #2-#3 (S2-S3) and indicated that the gait belt is used to prevent R1 from sliding off wheelchair. Interview with R1 revealed that did not know why they placed the gait belt on them. R1 illustrated that was not able to release the gait belt on their own during emergency. LPA interviewed Administrator and requested prescription for the postural supports. Administrator was unable to provide the document. Based on inspection, observation and interviews it was concluded that licensee did not ensure that postural support provided to resident not depriving residents’ movement. Resident was restrained to the wheelchair and had no ability to release it. Deficiencies will be cited and recorded on LIC809D. Exit interview conducted. Copy of report, and appeal rights issued.the state’s words, verbatim · CDSS document, Mar 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5) · Plan of correction due date: Mar 3, 2026

87608 Postural Supports (a) ...The facility shall provide... care for the resident in those activities... unable to do for themself. Postural supports may be used ...conditions. (5) Under no circumstances shall postural supports...limiting the use of a resident's hands or feet. This requirement is not met as evidenced by. The licensee did not ensure that postural support provided to R1 is not depriving R1s’ movement. R1was restrained to the wheelchair and had no ability to release it. This possess an immediate health and safety hazard to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: The licensee will provide in-service for postural support to ensure the safety of residents in care and will ensure care staff is schedule to assist R1. Licensee will submit in-service and staff schedule to LPA by due date.

Type of visit: Case Management - Other

In conjunction with complaint investigation, Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted a case management visit to address the deficiencies unrelated to the complaint. During Complaint Investigation, LPA Alvizar-Ettima discovered the following staff (S1) have been present without a Criminal Background Clearance and Association to this facility. Administrator indicated that S1 is her husband, visiting from Oregon and assisted Staff (S3) with the care of resident (R3) this morning (3/2/26). LPA request/received staff S1 Oregon Driver License. Administrator indicated that S1 was not associated to the facility. LPA verified using Guardian Background System Check, staff S1 names did not appeared on facility roster. S1- Tito Basubas Peregrino DOB: 01/01/1971 S1 immediately left the facility. Administrator was advice that S1 cannot return until Criminal Background Clearance and Associated to this facility. A citation and civil penalty were issued. Copy of this report was provide to Administrator.the state’s words, verbatim · CDSS document, Mar 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(b)(2) · Plan of correction due date: Mar 3, 2026

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by: Based on interview and review of Guardian Background System Check facility Staff S1 is not criminal background clearanced and association to this facility. No documentation has been submitted to Community Care Licensing. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: Administrator has agreed to completed criminal background clearance and associate Staff S1 to facility by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Adele Cahayon, and explained the reason for the visit. At approximately 11:30am, with the assistance of staff, LPA took a tour of the physical plant. The facility is a one story building. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual and interconnected. The fire extinguisher is located by the entrance. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility that is properly sealed and stored. Knives are kept locked in a kitchen drawer. Cleaning supplies are kept locked in a cabinet underneath the sink. Bedrooms: There are five (5) bedrooms, of which four (4) is used for residents and one (1) is a staff room. The bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. Passageways from resident rooms were clear of any obstruction. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied with non-slip mats and had functional fixtures. Hot water temperature was measured between 107 to 110 degrees Fahrenheit. Common Areas: These included the living room and dining area. The living room is furnished with a table, couches, recliners and a television. The table in the dining room is large enough to seat the six (6) residents. Furniture is observed to be maintained and in good repair. Floors are mopped and clean. Passageways are clear of obstruction. The auditory alarms at all exit doors were on and functional at the time of the visit. Surrounding Grounds: Pathways in the front and backyards were free of obstruction. There is furniture appropriate for outdoor use. The outdoor area was free of hazards. Laundry Room: The laundry room is located by the kitchen. There is a locked door to the laundry area that is kept locked at all times as detergents and softeners are maintained there. Garage: The garage is attached to the home. It is used as additional storage space. No resident access Staff Work Station: Staff work station is located at a corner by the dining room. There is a cabinet where both resident and staff records are filed. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to insure compliance with licensing forms. Medications: Medications are stored locked in one of the kitchen cabinets. Medication and Medication Records were review for proper storage and documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a copy of this report issued.the state’s words, verbatim · CDSS document, Oct 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Adele Cahayon, and explained the reason for the visit. At approximately 12:00pm, with the assistance of staff, LPA took a tour of the physical plant. The facility is a one story building. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual and interconnected. The fire extinguisher is located between the entrance and kitchen. It was charged on July 3, 2024. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. The laundry room is located adjacent to the kitchen. No cleaning supplies observed during inspection. Bedrooms: There are five (5) bedrooms, of which four (4) is used for residents and one (1) is a staff room. The bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 107 to 110 degrees Fahrenheit. Cleaning supplies were stored and locked. Common Areas: These included the living room and dining area. The living room is furnished with two couches, two recliners and a television. The table in the dining room is large enough to seat six (6) residents. There is also additional seating in the dining room area. The floors were mopped and clean. LPA observed furniture to be maintained and in good repair. Exit/entrance and passageways were clear of obstruction. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds: Pathways in the front and backyards were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Laundry Room: The laundry room is located adjacent to the kitchen. Detergents and cleaning supplies were observed inside the laundry room. Laundry room was locked during the visit. Garage: The garage is attached to the home. It is used as additional storage space. No resident access Staff Work Station: Staff work station is located next to the dining room. There is a cabinet where both resident and staff records are filed. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to insure compliance with licensing forms. Medications: Medications are are stored locked in one of the kitchen cabinets. Medication and Medication Records were review for proper storage and documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Dec 14, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Adele Cahayon and Fraces Alave and explained the reason for the visit. The administrator, Florence Pelegrino. At 9:15am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual and interconnected. The fire extinguisher is located between the entrance and kitchen. It is fully charged. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. The laundry room is located adjacent to the kitchen. Detergents and cleaning supplies were observed inside the laundry room, which remains locked and inaccessible to the residents. Bedrooms: There are five (5) bedrooms, of which four (4) will be used for residents and one (1) will be a staff room. The bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105 degrees Fahrenheit. Cleaning supplies are being stored in the hallway bathroom. Common Areas: These included the living room and dining area. The common areas were properly furnished. The floors were clean and had no damage or cracks. Exit/entrance and passageways were clear of obstruction. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds: Pathways in the front and backyards were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to insure compliance with licensing forms. Medications: Medications are are stored locked in one of the kitchen cabinets. Medication and Medication Records were review for proper documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Dec 8, 2023