Bay Osos RCFE I

Type of visit: Required - 1 Year

At 8:15am on 02/19/2026, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the facility annual inspection. LPA met with Alternate Administrator, Rosemarie Luna, announced who he is and the reason for the visit. Assigned Administrator Rodolfo Pacaoan is currently out of the country. This is a four bedroom, two bathroom, facility with two living rooms, dining room and kitchen, there is an out door area in the back and front of the facility with seating and shade for residents with visitors and activities. Three of the bedrooms are double resident occupancy and the forth bedroom is dedicated for overnight staff. LPA observed resident bedrooms to be properly furnished with proper linin and utilities in working operations. LPA observed liquid soap and paper towels in the two bathrooms that are available to all clients and staff. LPA noted that during the physical tour over the counter medication was discovered unsecured in bedroom #2 and a subsequent citation was issued (87465(h)(2)). LPA noted that files and medication are locked in a lockable filing cabinet adjacent to secondary living room. LPA noted that there is a complete first aide kit and a working fire extinguisher between the dining room and the secondary living room. LPA observed at least two days of perishable foods and at least seven days of nonperishable foods on hand for six residents and staff. LPA tested carbon monoxide detectors and smoke detectors all to be functioning. LPA noted that all hallways, door ways, and exits were free and clear of debris. LPA conducted a file review of staff and resident files. LPA reviewed facility emergency disaster plan and infection control plan. LPA verified facility liability insurance. Alternated Administrator and LPA conducted a full review of the annual care tools module and noted no other violation than the one mentioned above. At this time there is a single violation and no other issues during this annual facility inspection. Exit interview, report read, appeal rights and report provided.the state’s words, verbatim · CDSS document, Feb 19, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin arrived at 10:30 a.m. to conduct a one-year annual visit to the facility above. LPA met with Administrator Rodolfo Pacaoan and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility has 3 resident bedrooms, 1 caregiver bedroom and 2 bathrooms. Facility currently occupies 3 residents. LPA was authorized to enter and inspect facility. The facility had a smoke and carbon monoxide detector that was tested and working properly during visit. Facility has fire extinguisher that was last serviced in May of 2024. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats and flooring. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in cabinet in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use and front patio has plenty of shade. The facility has telephone and internet service for resident use. Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on November 3, 2025. The facility is approved for a capacity of six. The fire clearance is granted for 6 non-Ambulatory of which one may be bedridden. Hospice is approved for three. (Continued on LIC 809-C) Staffing: The facility currently employes 3 full time staff, and three Administrators. Staff files were reviewed. Current Administrator Certificate expires January 16, 2025, but all documentation has been submitted to the application bureau and is pending update. Back-up administrator license expires in July of 2026. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2024. Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Facility does submit incident reports to the department when required. LPA reviewed three resident files for signed Admission Agreements, updated medical assessment and updated annual services and needs record. All files we complete. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables, to meet the food service requirement. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Disaster Preparedness: The current emergency disaster forms were posted. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does not currently have residents receiving Home Health services or Hospice services. Exit interview conducted, copy of report provided.the state’s words, verbatim · CDSS document, Jan 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin arrived at 10:30 a.m. to conduct a one-year annual visit to the facility above. LPA met with Administrator Rodolfo Pacaoan and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility has 3 resident bedrooms, 1 caregiver bedroom and 2 bathrooms. Facility currently occupies 3 residents. LPA was authorized to enter and inspect facility. The facility had a smoke and carbon monoxide detector that was tested and working properly during visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in cabinet in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use and front patio has plenty of shade. The facility has telephone and internet service for resident use. Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on November 3, 2025. The facility is approved for a capacity of six. The fire clearance is granted for 6 non-Ambulatory of which one may be bedridden. Hospice is approved for three. (Continued on LIC 809-C) Staffing: The facility currently employes 3 full time staff, and three Administrators. Staff files were reviewed. Current Administrator Certificate expires January 16, 2025, but all required documents have been submitted and approval is pending at the application bureau. Other back-up administrator certificate expires in July of 2026. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2024. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed five resident files for signed Admission Agreements. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirement. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Disaster Preparedness: The current emergency disaster forms were posted. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does not currently have residents receiving Home Health services or Hospice services. Exit interview conducted, copy of report provided.the state’s words, verbatim · CDSS document, Jan 15, 2025

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erika Miller arrived at 3:50 p.m. to conduct a one-year annual visit to the facility above. LPA Miller met with Administrator Rodolfo Pacaoan and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility has 3 resident bedrooms, 1 caregiver bedroom and 2 bathrooms. Facility currently occupies 3 residents and employs 6 full time staff, 4 part time staff and three Administrators. LPA Miller was authorized to enter and inspect facility. The facility had a smoke and carbon monoxide detector that was tested and working properly during visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in cabinet in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use and front patio has plenty of shade. The facility has telephone and internet service for resident use. Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on November 3, 2024. The facility is approved for a capacity of six. The fire clearance is granted for 6 non-Ambulatory of which one may be bedridden. Hospice is approved for three. (Continued on LIC 809-C) Staffing: The facility currently employes 6 full time staff, 4 part time staff and three Administrators. Staff files were reviewed. Current Administrator Certificate expires January 16, 2025. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed five resident files for signed Admission Agreements. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen staff are observed for personal hygiene and food sanitation practices. Disaster Preparedness: The current emergency disaster forms were posted. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does not currently have residents receiving Home Health services. Exit door alarms are working. Exit interview conducted, copy of report provided.the state’s words, verbatim · CDSS document, Feb 12, 2024