Betsy's II RCFE

Type of visit: Office

Regional Manager, Carla Nuti-Martinez, Licensing Program Manager Victoria Bertozzi, and Licensing Program Analyst Robert Frank met with Licensee, Luningning “Bot” Alicdan to conduct a Non-Compliance Conference. On of 7/31/2024 licensee agreed to be on a Non-Compliance plan for two (2) years. Areas of concern included but were not limited to the following: · Administrator Duties and Plan of Operation · Staff Training · Resident and staff records · Resident Care and Personal Rights · Insufficient Staffing · Failure to clear deficiencies timely · Medication Management Due to ongoing non-compliance concerns, the Non-Compliance Plan will be extended for a period of two (2) year. Administrator/Licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49(f), 1548, or 1568.0822 Continued from 809-C... ...Continued from 809 Licensee to ensure the following: · Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication. · Ensuring personal rights of residents in care and ensuring resident needs are met. During today's meeting findings from Complaint 21-AS-20260414093622 were amended to remove a $500.00 Civil Penalty. No deficiencies cited during today’s meeting. Exit interview conducted. Copy of report discussed and provided to Licensee Alicdan. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 5, 2026

Allegation investigated: Facility did not seek timely medical care Wrongful Eviction

At approximately 11:05 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegations and met with facility licensee Luningning Alicdan. During the course of the investigation the Department conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges that the facility did not seek timely medical treatment for a resident in care. During a routine doctor’s appointment on 11/10/2025 residents R1’s doctor noted that resident R1 was not well and contacted staff at Betsy’s II RCFE during the appointment. Staff Member S1 reported that for about one (1) month, resident R1 had not been able to feed themselves or walk. Resident R1 was sent directly from doctor’s office to the emergency room where they were subsequently diagnosed with a fracture and an infection. Continued on 9099-C... Substantiated ...Continued from 9099 Review of medical records indicates that on 11/7/2025, staff member S1 contacted Kaiser and reported that resident R1 had trouble walking for about two weeks. Prior to R1’s appointment on 11/10/2025, when witness W1 arrived at the facility they noted that resident R1 was “catatonic” and described R1 as being stuck in a seated position even when staff transferred R1 to the car from a wheelchair. During this transfer, R1 stated, “ow, ow, ow”, and R1 appeared to be in pain. Facility staff contacted witness W1 approximately one (1) week prior to the 11/10/2025 doctor’s appointment because resident R1 had swollen feet. Facility staff reported no other concerns. The facility staff had not notified W1 of resident R1 having any changes in condition or falls. During interview, staff member S2 stated they were not aware of resident R1 having any falls. This statement was contradicted by the fact that staff member S1 stated that they reported to S2 that resident R1 had a fall (but were not hurt by the fall) within their last six (6) months of care. During interview, Staff member S3 stated they were told by other staff members of resident R1 having had two (2) falls. Staff member S3 stated that they were not present at the time of the two (2) falls. Staff member S3 further stated they wanted to call 9-1-1 and have resident R1 sent out because they could tell that R1 was injured and in pain. Staff members S1 and S4 would not let staff member S3 call 911. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099Ds. Administrator/Licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49(f), 1548, or 1568.0822 Complaint alleges wrongful eviction. Facility resident R1 was taken to Kaiser Hospital on 11/10/2025. Staff at Kaiser called the facility to arrange for resident R1 to return to the facility. At this time, witness W2 was told by facility staff that R1 cannot return to the facility as the facility is being sold. Continued on 9099-C2 ...Continued from 9099-C During a facility visit on 11/13/2026 facility licensee Luningning Alicdan made the following unsolicited statements, “I told Kaiser we would not take them (R1) back.” Licensee Alicdan further stated, “I told the nurse I am not going to take them (R1) back as they (R1) have a better chance of getting the government to help them. It’s up to the social worker at Kaiser to find help for them (R1) in the community.” Resident R1 did not return to the facility on or after 11/10/2026. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-9099, LIC-9099-C, LIC-9099C-2 LIC-9099Ds, LIC-811 Confidential Names Plan of Corrections and Appeal Rights discussed and provided to Licensee Alicdan. Signature on form confirms receipt of documents. ...Continued from 9099-A Staff member S3 was told by staff member S1 and staff member S4 that resident R1 had previously fallen two (2) times; however, staff member S3 did not have any additional details of the two (2) previous falls. The time frames for the falls are unknown. Staff members S2, S3 and other staff interviewed denied any knowledge of resident R1 having a fall. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. Copy LIC-9099A, LIC-9099A-C discussed and provided to Licensee Alicdan. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 21-AS-20251112104209

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jul 31, 2026

87465 Incidental Medical and Dental Care (a) A plan...The plan shall encourage...obtaining such care, by compliance... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that staff did not seek timely medical care for resident R1 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 30, 2026

Plan of correction: Licensee will provide training for all staff members, on all shifts in Psychosocial and Physical needs of the elderly, Physical Environment and resident rights and will further provide training in California Code of Regulations 87465 Incidental Medical and Dental Care to all staff members. Proof of all training to be submitted to Community Care Licensing by POC due date of 7/31/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Aug 13, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes...When changes...are observed,...brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that staff did not report changes in the health condition for R1 to R1’s responsible party which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 30, 2026

Plan of correction: Facility to update their plan to ensure communication on all shifts related to residents in care and any/all changes of condition. Facility to provide a copy of the updated plan along with a roster of staff trained on new plan by POC due date of 8/13/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(20) · Plan of correction due date: Aug 13, 2026

87468.2 Additional Personal Rights... (20) To be protected from involuntary...evictions. A licensee shall not...evict residents for reasons other than those permitted by state law..."involuntary" means...eviction that is initiated by the licensee, not by the resident. This requirement is not met as evidenced by: Based on interview and express admission, the licensee did not comply with the section cited above in that resident R1 was not allowed to return to the facility from a doctors appointment which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 30, 2026

Plan of correction: Licensee to submit an LIC 9098 Self Certification that they have read and understand California Code of Regulations (CCR) 87224 Eviction Procedures and CCR 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities to CCL by POC due date of 8/13/2026.

Allegation investigated: Staff administered medication without a doctor's prescription Staff do not ensure that resident's medication is administered as prescribed Staff falsified resident medication administration records

Amended: Civil Penalty of $500 has been removed: Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegations and met with Licensee Luningning Alicdan. During the course of the investigation LPA conducted a facility visit, conducted interviews, collected and reviewed documents. Complaint alleges that staff administered medication without a doctor’s prescription. Witness W1 stated that while visiting resident R1 on 4/12/2026, they observed R1 to be slumped over in their chair. W1 contacted witness W2 who said to check to see if the facility had been administering Medication-1 to the resident. W2 had previously dropped off the bottle of Medication-1 for R1 at the facility. W1 then spoke with facility staff member S1 who provided the bottle of medication-1 to W1. W1 observed the amount of medication to be depleted. Continued on 9099-C... Substantiated ...Continued from 9099 Staff member S2 then arrived at the facility. W1 asked S2 to view the medication logs for medication-1. S2 provided the Pro Re Nata (PRN-given as needed) logs to W1 who photographed them. These photographs were provided to Community Care Licensing (CCL). The PRN log shows that medication-1 had been given to R1 sixteen (16) times between the dates of 3/26/2026 to 4/11/2026. R1’s medication list provided by Kaiser Permanente dated 3/23/2026 does not show medication-1 as a prescribed medication. The facility did not receive a doctor’s order for medication-1 until 4/3/2026. The PRN logs show the facility administered medication-1 that was not prescribed for R1 until 4/3/2026 on the dates of 3/26/2026; 3/27/2026; 3/28/2026; 3/29/2026; 3/30/2026; 4/1/2026 and 4/2/2026. California Code of Regulations (CCR) 87465 (e) states, “For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.” Based on LPA’s observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Complaint alleges that staff do not ensure that resident’s medication is administered as prescribed. The bottle of medication-1 listed the following instructions on its label, “Take 1/2 to 1 tablet by mouth daily for ‘redacted’ up to 3 times a week. Use sparingly.” Within the week of 3/26/2026 to 4/1/2026 LPA observed that medication-1 was administered to the resident on the dates of 3/26/2026; 3/27/2026; 3/28/2026; 3/29/2026; 3/30/2026 and 4/1/2026. As medication-1 was administered to R1 six (6) times in a week, the amount of medication administered exceeds the doctor’s orders as shown on the prescription label. In addition, the facility’s Centrally Stored Medication and Destruction Records for medication-1 were incomplete. The record was observed not to have the instructions, expiration date, date filled, prescribing physician, prescription number and number of refills listed. Furthermore, medication-1’s prescription label was observed to show that the medication should be discarded after 5/5/2022. Based on LPA’s observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Continued on 9099-C2... ...Continued from 9099-C Complaint alleges that staff falsified resident medication administration records. On 4/12/2026 while at the facility, W1 asked S2 to view the medication logs for medication-1. S2 provided the Pro Re Nata (PRN-given as needed) logs to W1 who photographed them. These photographs were provided to Community Care Licensing (CCL) by W1 on 4/22/2026. The PRN log photographed shows that medication-1 had been given to R1 sixteen (16) times between the dates of 3/26/2026 to 4/11/2026. During a facility inspection on 4/23/2026 LPA asked staff member S2 to provide the same PRN medication logs for medication-1. The logs provided to LPA by S2 on 4/23/2026 show that medication-1 was only administered to R1 two (2) times on 4/10/2026 and 4/11/2026. In an interview with staff member S2 on 4/23/2026 LPA asked staff member S2 multiple times to confirm that medication-1 had only been given to resident R1 twice. S2 confirmed to the LPA that medication-1 had only been administered to R1 twice. The PRN logs for medication-1 provided to the LPA do not match the previously photographed PRN logs with fourteen (14) instances of medication-1 administration having been omitted. Based on LPA’s observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Title 22, Division 6, Health Safety Code, Chapter 3, are being cited on the attached 9099D. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report: LIC-9099, LIC-9099-Cs, LIC-9099Ds, LIC-421IM, Plan of Corrections and Appeal Rights discussed and provided to Licensee Alicdan. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 10, 2026 · control 21-AS-20260414093622

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Jul 13, 2026

87465 Incidental Medical and Dental Care (e) For every prescription and non prescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, ... This requirement is not met as evidenced by: Based on interviews & record review, the licensee did not comply with the section cited above in that the facility administered medication-1 that was not prescribed for R1 until 4/3/2026 was administered seven (7) times between the dates of 3/26/2026-4/2/2026. which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: Licensee and all facility staff who assist with the self-administration of medicine shall complete eight (8) hours of in-service training on Medication Management and medication related issues. Licensee to provide proof of training and all training curriculum to Community Care Licensing by POC due date of 7/13/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 13, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that medication-1 was administered to R1 six (6) times in a week, the amount of medication administered exceeds the doctor’s orders as shown on the prescription label which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: Licensee is to have a 3rd party pharmacy or pharmacy consultant complete a full audit of the facility’s medications and medication management program. Licensee to provide Community Care Licensing the name of the 3rd party pharmacy or pharmacy consultant, audit findings and the date on which the audit will be conducted to Community Care Licensing by POC due date of 7/13/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(6)(E) · Plan of correction due date: Jul 13, 2026

87465 Incidental Medical and Dental Care (h)The following... to medications which are centrally stored: (6) The licensee shall be responsible...is maintained for at least one year and includes: (E) The prescription number...This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that the facility’s Centrally Stored Medication and Destruction Records were observed not to have the prescription number which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: Licensee to submit completed Centrally Stored Medication and Destruction Records for all facility residents to Community Care Licensing by POC due date of 7/13/2026.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1550(c) · Plan of correction due date: Jul 13, 2026

1550 Licenses or administrator...The department may...suspend or revoke, any license,...(c) Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above in that the PRN logs for medication-1 provided to the LPA do not match the previously photographed PRN logs with fourteen (14) instances of medication-1 administration having been omitted which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: Licensee to take their required twenty (20) hours of annual training from a vendor approved by Community Care Licensing. Proof of all twenty (20) hours to be submitted to Community Care Licensing by POC due date of 7/13/2026.

Type of visit: Case Management - Legal/Non-compliance

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a Non-compliance inspection. On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as: · Administrator Duties and Plan of Operation · Staff Training · Resident and staff records · Resident Care and Personal Rights · Insufficient Staffing · Failure to clear deficiencies timely · Medication Management · Failure to follow through with TSP Licensee was to ensure the following: · Follow through with responding to and participating with the Technical Support Program · Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication. · Ensuring personal rights of residents in care and ensuring resident needs are met. Today, LPA conducted the Non-Compliance inspection. Licensee found to be in compliance as pertains to responding to and participating with the Technical Support Program. Continued on 809-C... ...Continued from 809 NCC LPA reviewed records pertaining to compliance with areas including staff training records, maintaining staff and resident records. During today's physical plant inspection, LPA made the following observations: LPA inspected four (4) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. LPA reviewed one (1) staff files for a new staff member whose file had not been previously reviewed.. One (1) of one (1) staff files was observed to be with all required documentation including First Aid and CPR certification and proper training documentation. LPA audited Medication for five (5) residents. LPA observed one (1) instance of a medication not having been listed in the resident's PRN (take as needed) medication log. LPA observed one (1) instance of a medication not being listed in the resident's Central storage logs. These deficiencies are being cited today on complaint 21-AS-20260414093622. LPA observed all other medications to be centrally stored, secure and with proper documentation. Deficiencies being cited today are for Complaint 21-AS-20260414093622 findings. Exit interview conducted. Copy of report discussed and provided to Licensee Alicdan. Signature on form confirms receipt of documentsthe state’s words, verbatim · CDSS document, Jul 10, 2026

Type of visit: Case Management - Legal/Non-compliance

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a Non-compliance inspection. Administrator Edward Alicdan, arrived at approximately 9:15 AM. Licensee Luningning Alicdan arrived at 11:25 AM. On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as: · Administrator Duties and Plan of Operation · Staff Training · Resident and staff records · Resident Care and Personal Rights · Insufficient Staffing · Failure to clear deficiencies timely · Medication Management · Failure to follow through with TSP Licensee was to ensure the following: · Follow through with responding to and participating with the Technical Support Program · Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication. · Ensuring personal rights of residents in care and ensuring resident needs are met. Today, LPA conducted the Non-Compliance inspection. Licensee found to be in compliance as pertains to responding to and participating with the Technical Support Program. Continued on 809-C... NCC...Continued from 809 LPA reviewed records pertaining to compliance with areas including staff training records, maintaining staff and resident records. During today's physical plant inspection, LPA made the following observations: In the storage room in the common area LPA observed an unsecured prescription medication. This deficiency will be cited. As this same deficiency was previously cited within the past year (1/13/2026) a Civil Penalty of $1000 will be issued. At approximately 11:45 AM, LPA reviewed five (5) resident files. Two (2) of five (5) resident files (for residents R1 & R2) were observed not to have signed Personal Rights documents. One (1) of five (5) resident files (for residents R2) was observed not to have a Pre-Placement Appraisal. LPA reviewed five (5) staff files. One (1) of five (5) staff files (for staff member S2) was observed not to have proof of the required twenty (20) hours of annual training. One (1) of five (5) staff files (for staff member S2) was observed to have a Medical Assessment or proof of a negative Tuberculosis (TB) test. These deficiencies will be cited. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, LIC 811 Confidential Names, LIC 9098 Self Certification, LIC 421IM and Appeal Rights discussed and provided to Licensee Alicdan. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 6, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Jun 3, 2026

1569.625 Staff training; legislative findings; contents (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training... This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that one (1) of (5) staff members (S2) did not complete their 2025 annual training which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Licensee to submit proof that staff member S2 has completed their annual training to Community Care Licensing (CCL) by POC due date of 6/3/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Jun 3, 2026

87411 Personnel Requirements – General (f) All personnel, including the licensee and administrator, shall be in good health...shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months... This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that staff member S2 did not have a medical assessment or proof of a negative TB test in their personal record which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Licensee to submit proof that staff member S2 has received a medical assessment and proof of a negative TB test to CCL by POC due date of 6/3/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(b)(1)(A) · Plan of correction due date: May 27, 2026

87468 Personal Rights (b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1... This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that residents R1 & R2 did not have signed personal rights documents in their records which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Licensee to submit signed personal rights document for residents R1 & R2 to Community Care Licensing (CCL) by POC due date of 5/27/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87457(c) · Plan of correction due date: May 27, 2026

87457 Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs... This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that resident R2 did not have a completed and signed pre-placement appraisal in their records which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Licensee to submit a completed and signed pre-placement appraisal for resident R2 to CCL by POC due date of 5/27/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 7, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that a prescribed medication was left unsecured in the storage room in the common area of the facility which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Licensee to submit proof that all staff members have undergone medication management training after 5/6/2026 to Community Care Licensing by POC due date of 5/7/2026.

Type of visit: Required - 1 Year

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a 1-Year Required Visit. Administrator Edward Alicdan, arrived at approximately 9:15 AM. Licensee Luningning Alicdan arrived at 11:25 AM. Betsy's II RCFE is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a large single story ranch house. The facility has a plan of operation for dementia care and programming on file. The facility has an approved fire clearance and total capacity for thirteen (13) residents of which eleven (11) residents may be non-ambulatory, and two (2) residents may be bedridden. Facility has an approved hospice waiver for three (3) residents. Facility has approval to have a locked perimeter. Upon arrival, LPA was informed that there were eight (8) Residents in care. LPA reviewed the Facility's Staff Roster and observed that staff member S1 was not associated to the facility in the Guardian Background Check system as required per regulations. The facility will be cited for this deficiency and a Civil Penalty of $500 will assessed for this violation. All other staff members were observed to be background cleared and associated to the facility per regulation. At approximately 9:10 AM, LPA toured the facility. All exits were clear and unobstructed. Facility fire extinguishers were last serviced and tagged in June, 2025. The automatic sprinkler system was serviced in 11/2025. The facility's fire alarm system was inspected and tagged in 5/2026. The facility was sufficiently lighted. LPA inspected eight (8) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted on 3/31/2026. Continued on 809-C... ...Continued from 809 Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. During todays inspection of the physical plant LPA Frank made the following observations: In the storage room in the common area, LPA observed that there was a can of paint and paint remover accessible to residents as the storage room was unlocked. In the sink to the immediate left of the storage room LPA observed unsecured cleaning products. Additionally, in the facility's office area a can of spray paint was observed to be unsecured. This deficiency will be cited. As this same deficiency was previously cited within the past year (10/24/2025 & 1/13/2026) a Civil Penalty of $250 will be issued. In the same storage room noted above, LPA observed an unsecured prescription medication. This deficiency will be cited in the facility's Non-Compliance Inspection Report which is being completed today, 5/6/2026. In the kitchen cabinets to the left of the stove top, LPA observed the area to have a build up of grease and to be extremely dirty. The facility will be cited for this deficiency. Room number one (1) was observed to have a strong odor of urine. The resident of room one (1) is using incontinence products. The odor was observed to be strongest near the residents bed. At approximately 11:45 AM, LPA reviewed five (5) resident files. Two (2) of five (5) resident files (for residents R1 & R2) were observed not to have signed Personal Rights documents. One (1) of five (5) resident files (for residents R2) was observed not to have a Pre-Placement Appraisal. LPA reviewed five (5) staff files. One (1) of five (5) staff files (for staff member S2) was observed not to have proof of the required twenty (20) hours of annual training. One (1) of five (5) staff files (for staff member S2) was observed not to have a Medical Assessment or proof of a negative Tuberculosis (TB) test. The resident records and staff file deficiencies will be cited in the facility's Non-Compliance Inspection Report which is being completed today, 5/6/2026. Continued on 809C2... ...Continued from 809-C LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, LIC 811 Confidential Names, LIC 9098 Self Certification, LIC 421FC, LIC 421BG and Appeal Rights discussed and provided to Licensee Alicdan. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 6, 2026

Allegation investigated: Personal Rights: Staff Member Yelled at Resident in Care

At approximately 12:25 PM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegation. Licensee, Luingning “Bot” Alicdan arrived at 1:00 PM. During the course of the investigation LPA conducted a facility visit, conducted interviews, collected and reviewed documents. Complaint alleges a staff member yelled at a resident in care. A witness reported that they saw a facility resident (resident R1) sitting on the floor of their room and that a staff member (staff member S1) was yelling at them telling them to “shut up” and “don’t move” as they were using a Hoyer lift to get the resident off of the floor. When the witness questioned staff member S1 they were told, “get out of here, mind your business”. Continued on 9099C... Unsubstantiated ...Continued from 9099 The facility submitted a LIC-624 Unusual Incident/Injury Report stating that the resident slipped off of their chair. LPA interviewed resident R1. When asked if the staff have ever yelled at them resident R1 stated, “No, I don’t remember. I would have yelled back at them if they had”. LPA asked resident R1 if they have ever been dropped or hurt while transferring with staff assistance. Resident R1 stated, “no”. LPA asked resident R1 if staff have ever treated them maliciously or if staff have yelled at them. Resident R1 stated, “no”. LPA asked resident R1 if they have any complaints about living conditions or any complaints about how they are being treated. Resident R1 replied, “no, but if I have a problem with anything, I tell them”. LPA interviewed several other facility residents. The other residents stated that they have never witnessed any staff yelling at them or other residents. When LPA interviewed staff members, they stated that they have not yelled at residents but sometimes talk loudly as some residents are hearing impaired. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during today's visit. Exit interview conducted. Copy of LIC9099 and LIC9099-C discussed and provided to Licensee, Luingning “Bot” Alicdan. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 4, 2026 · control 21-AS-20260115120823

Type of visit: Case Management - Other

At approximately 9:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to initiate a Complaint Investigation for complaint 21-AS-20260115120823. During file review, LPA observed a Deficiency unrelated to the complaint investigation. LPA observed that resident R1 was given a "Level of Care" rate increase. The notice of the level of care rate increase was dated 2/15/2024 with the rate increase beginning 3/1/2024. Resident R1 signed and dated the notice on 2/24/2024. California Health and Safety Code 1569.655(a) states, "If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days’ prior written notice to the residents or the residents’ representatives setting forth the amount of the increase and the reason or reasons for the increase, including a description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident." The notice of level of care rate increase given to the resident stated that the increase was not for an actual change of the resident's care level, but instead due to an increase in costs to provide services. As the required sixty (60) day notice was not given to the resident, this deficiency will be cited. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, LIC 811, Plan of Corrections and Appeal Rights discussed and provided to Caregiver Nicadao. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 21, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655(a) · Plan of correction due date: Feb 18, 2026

1569.655 Increase in fee rates for elderly residents; 60 days’ written notice standing amount of reasons for increase;...(a) If a licensee of a residential care facility for the elderly increases the rates,... the licensee shall provide no less than 60 days’ prior written notice. This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that resident R1 was not given the regulated sixty (60) day advanced notice of the rate increase which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 21, 2026

Plan of correction: Licensee or administrator will submit an LIC 9098 self certifying that they have read and understand Health and Safety Code (HSC) Regulation 1569.655. Licensee will further provide a list of all residents, and notifications provided to those residents who received a rate increase or level of care increase in 2024, 2025 and 2026 to Community Care Licensing by POC due date of 2/18/2026.

Type of visit: Case Management - Legal/Non-compliance

At approximately 8:55 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a Non-compliance inspection. Licensee Luningning Alicdan arrived at 9:10 AM. On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as: · Administrator Duties and Plan of Operation · Staff Training · Resident and staff records · Resident Care and Personal Rights · Insufficient Staffing · Failure to clear deficiencies timely · Medication Management · Failure to follow through with TSP Licensee was to ensure the following: · Follow through with responding to and participating with the Technical Support Program Continued on 809-C... ...Continued from 809 · Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication. · Ensuring personal rights of residents in care and ensuring resident needs are met. Today, LPA conducted the Non-Compliance inspection. Licensee found to be in compliance as pertains to responding to and participating with the Technical Support Program. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA reviewed records pertaining to compliance with areas including staff training records, maintaining staff and resident records, and pre-pouring of medication. During today's physical plant inspection, LPA made the following observations: -Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. -LPA observed that a storage room in a common area was unlocked and that there were unsecured toxins and insulin hypodermic needles in the room. This deficiency will be cited. As this same deficiency was previously cited within the past year (4/24/2025 & 10/24/2025) a Civil Penalty of $250 will be issued. -An over the counter (OTC) medication was observed to be unsecured in a resident's room. During file review LPA observed that the resident (R3) was not allowed to administer their own prescription or PRN (pro re nata) medications. This deficiency will be cited. As this same deficiency was previously cited within the past year a Civil Penalty of $250 will be issued. During today's inspection, LPA reviewed three (3) residents files and two (2) staff files. During file review, LPA observed the following: -One (1) of three (3) residents' files (for resident R1) was observed not to contain any emergency contact information. This deficiency will be cited. -One (1) of three (3) residents' files (for resident R2) was observed not to contain an LIC 603 Preplacement Appraisal. This deficiency will be cited. Continued on 809-C2... ...Continued from 809-C -One (1) of three (3) residents' files (for resident R3) was observed not to have a licensed medical professional's order or prescription for a PRN (pro re nata) medication. Resident R3 is not allowed to administer their own prescription or PRN medications. This Deficiency will be cited. -One (1) of two (2) staff files was observed not to contain a Medical Assessment or proof of a negative tuberculosis test. This Deficiency will be cited. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809Ds, 811 Confidential Names, LIC 421FCs, Plan of Corrections and Appeal Rights discussed and provided to Caregiver Nicadao Wilhelfortes . Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(8) · Plan of correction due date: Jan 27, 2026

87506 Resident Records (b)Each resident’s record shall contain at least the following information: (8)Names, address, and telephone numbers of the resident’s representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency. This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that 1 of 3 residents records (for R1) did not contain Emergency Contact Information which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 13, 2026

Plan of correction: Licensee to submit a signed LIC 601 Identification and Emergency Information form for resident R1 to Community Care Licensing (CCL) by POC due date of 1/27/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87457(c) · Plan of correction due date: Jan 27, 2026

87457 Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs... This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that 1 of 3 residents files (for resident R2) did not contain an LIC 603 Preplacement Appraisal Information form which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 13, 2026

Plan of correction: Licensee to submit a signed LIC 603 Preplacement Appraisal Information for Resident R2 to Community Care Licensing by POC due date of 1/27/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jan 14, 2026

87465Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that over the counter PRN medication was observed to be unsecured in Room #2 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 13, 2026

Plan of correction: licensee will submit an LIC 9098 Self Certification stating that ALL medications will not be left unsecured by POC due date of 1/14/2026. Additionally, Licensee will re-train ALL staff members in Medication Management. Proof of training to be submitted to Community Care Licensing by no later than 1/28/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(1) · Plan of correction due date: Jan 14, 2026

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing..(1)There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication... This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that PRN medication was provided to Resident R3 without a licensed medical professional's order or prescription, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 13, 2026

Plan of correction: Licensee will submit an LIC 9098 Self Certification stating that ALL medications will not be left unsecured by POC due date of 1/14/2026. Additionally, Licensee will re-train ALL staff members in Medication Management. Proof of training to be submitted to Community Care Licensing by no later than 1/28/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Jan 14, 2026

87309 Storage Space and Access (a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...and other similar items which could pose a danger to residents are in locked storage...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that unsecured toxins and insulin syringes were observed in a storage room which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 13, 2026

Plan of correction: Licensee will submit an LIC 9098 Proof of Correction self certifying that all toxins and insulin syringes will kept secured at the facility in the future to Community Care Licensing (CCL) by POC due date of 1/14/2026.

Type of visit: Case Management - Legal/Non-compliance

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a Non-compliance inspection. Licensee Luningning Alicdan arrived at 9:05 AM. On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as: · Administrator Duties and Plan of Operation · Staff Training · Resident and staff records · Resident Care and Personal Rights · Insufficient Staffing · Failure to clear deficiencies timely · Medication Management · Failure to follow through with TSP Licensee was to ensure the following: · Follow through with responding to and participating with the Technical Support Program Continued on 809-C... ...Continued from 809 · Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication. · Ensuring personal rights of residents in care and ensuring resident needs are met. Today, LPA conducted the Non-Compliance inspection. Licensee found to be in compliance as pertains to responding to and participating with the Technical Support Program. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA reviewed records pertaining to compliance with areas including staff training records, maintaining staff and resident records, and pre-pouring of medication. LPA conducted interviews and made observations pertaining to Administrators ensuring of personal rights of residents in care and ensuring resident needs are met. The facility is being cited for not having a currently certified Administrator. As this is the third (3) time the facility is being cited (8/6/2025 & 8/22/2025) for this deficiency within one (1) year a Civil Penalty of $250.00 is being assessed. During today's inspection, LPA made the following observations: -Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. -A bottle of Povidone/Iodine was observed to be unsecured in a resident's bathroom. In addition, LPA observed that the door to the laundry room was unlocked. Within the laundry room, there were unsecured toxins. LPA further observed that the storage room in a common area was unlocked and that there were unsecured toxins in the room. These deficiencies will be cited. As this same deficiency was previously cited within the past year (4/24/2025) a Civil Penalty of $250 will be issued. -In a kitchen cabinet two (2) condiment items that were required to be refrigerated after opening, were left unrefrigerated in a kitchen cabinet. This deficiency will be cited. As this same deficiency was previously cited twice (2) times within the past year (4/24/2025 & 6/11/2025) a Civil Penalty of $250 will be issued. Continued on 809-C2... ...Continued from 809-C -In the common area, next to the storage room, a parabolic dish heater was observed to not have a protective screen to prevent the risk of burns or fire. This deficiency will be cited. The licensee unplugged and removed the heater during today's inspection so the deficiency will be cleared. -In the cabinet immediately outside of the kitchen area, across from a bathroom, food products and cleaning products were observed to be stored together. This deficiency will be cited. -In the common area, next to the storage room a cabinet with prescription items was observed to be unlocked and accessible to residents. As this same deficiency was previously cited twice (2) times within the past year (6/11/2025 & 8/22/2025) a Civil Penalty of $250 will be issued. During today's inspection, LPA reviewed four (4) residents files and two (2) staff files. LPA observed an incomplete LIC 624 Unusual Incident report in resident R4's personal records. This LIC 624 was not sent to Community Care Licensing (CCL) within the required seven (7) days from the date of the incident. Additionally, LPA observed that a required LIC 9186 Client Death Report had not be filled for resident R5. These deficiencies will be cited. As this same deficiency was previously cited within the past year (4/24/2025) a Civil Penalty of $250 will be issued. LPA observed that two (2) of two (2) staff files had all required documentation including First Aid and CPR certification and proper training documentation. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809Ds, 811 Confidential Names, LIC 421FCs, Plan of Corrections and Appeal Rights discussed and provided to Licensee Alicdan. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Oct 27, 2025

87309 Storage Space and Access (a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...and other similar items which could pose a danger to residents are in locked storage...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that unsecured toxins were observed in a residents bathroom, the laundry room and the storage room which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Licensee will submit an LIC 9098 Proof of Correction self certifying that all toxins will kept secured at the facility in the future to Community Care Licensing (CCL) by POC due date of 10/27/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Oct 27, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that a medication cabinet in common area, next to the storage room was unlocked, which poses a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Licensee will submit LIC9098 to CCL self certifying that all medications will be kept in a safe and locked place. Licensee will further self certify that it has been discussed with all employees that both prescription and PRN medications be secured at all times. This to be done by POC Due Date of 10/27/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(e)(1)(A) · Plan of correction due date: Oct 27, 2025

87307 Personal Accommodations and Services (e)The licensee shall supervise residents as needed...when residents are in proximity to or when there is use of the following items:(1)... heaters,...and other heating devices.(A)Heating devices shall have protective mechanisms...in order to reduce the risk of burns or fire. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that in the common area, next to the storage room, a parabolic dish heater was observed to not have a protective screen which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Licensee removed heater during today's inspection. Deficiency cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Oct 27, 2025

87405 Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person... This requirement is not met as evidenced by Based on record review, the licensee did not comply with the section cited above in that the facility does not have a currently certified Administrator which poses an immediate health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Licensee will provide the documents required to make a currently certified administrator the active Administrator of the facility to Community Care Licensing by the POC due date of 10/27/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(23) · Plan of correction due date: Nov 14, 2025

87555:General Food Service Requirements(b)The following ...requirements shall apply: (23) All readily perishable foods... capable of supporting...progressive growth of micro-organisms which can cause food infections..shall be stored...at appropriate temperatures. This requirement is not met as evidenced by:Based on observation, the licensee did not comply with the section cited above in that that two (2) condiments that were required to be refrigerated after opening, were left unrefrigerated in a kitchen cabinet. which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Licensee will submit an LIC 9098 self certifying that they have trained all staff in food service safety to Community Care Licensing by POC due date of 11/14/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(25) · Plan of correction due date: Nov 14, 2025

87555 General Food Service Requirements (b)The following food service requirements shall apply: (25)Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in In the cabinet immediately outside of the kitchen area, across from a bathroom, food products and cleaning products were observed to be stored together. which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Licensee to store all cleaning products away from food products. Licensee will submit an LIC 9098 self certifying that they have trained all staff in food service safety to Community Care Licensing by POC due date of 11/14/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 7, 2025

87211Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...for the resident within seven days...This report shall include the resident's name, age....(A) Death of any resident... This requirement is not met as evidenced by:Based on observation and record review, the licensee did not comply with the section cited above in that an LIC 624 Unusual Incident report for R4 and an LIC 9186 Client Death Report for R5 was not sent to CCL which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Licensee to submit both the an LIC 624 Unusual Incident report for R4 and an LIC 9186 Client Death Report for R5. Licensee will also submit an LIC 9098 Proof of correction form self certifying that in the future they will submit all forms per CCR 87211 in the required time frame to Community Care Licensing by POC due date of 11/7/2025.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Robert Frank arrived unannounced for a Case Management visit. The facility is being cited for not having a currently certified Administrator. As this is the second time the facility is being cited for this deficiency within one (1) year a Civil Penalty of $250.00 is being assessed. During today's visit, LPA observed that a magnetic key for a medication cabinet in common area, next to the storage room was unsecured next to the cabinet. LPA has a photograph of the unsecured magnetic key. This deficiency will be cited. As this is the second time the facility is being cited for this deficiency within one (1) year a Civil Penalty of $250.00 is being assessed. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, LIC 421FCs, Plan of Corrections and Appeal Rights discussed and provided to Caregiver Nicadao. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Aug 25, 2025

87405 Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in that the facility does not have a currently certified Administrator which poses an immediate health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Aug 22, 2025

Plan of correction: Licensee will provide the documents required to make a currently certified administrator the active Administrator of the facility to Community Care Licensing by the POC due date of 8/25/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Aug 25, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that the magnetic key for a medication cabinet in common area, next to the storage room was unsecured next to the cabinet, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2025

Plan of correction: Licensee will submit LIC9098 to CCL self certifying that all medications wll be kept in a safe and locked place. Licensse will further self certify that it has been discussed with all employees that both prescription and PRN medications be secured at all times. This to be done by POC Due Date of 8/25/2025.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Robert Frank arrived unannounced for a Case Management visit. The facility is being cited for not having a currently certified Administrator. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections and Appeal Rights discussed and provided to Caregiver Nicadao. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 5, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Aug 6, 2025

87405 Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in that the facility does not have a currently certified Administrator which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Licensee will provide the documents required to make a currently certified administrator the active Administrator of the facility to Community Care Licensing by the POC due date of 8/6/2025.

Type of visit: Required - 1 Year

At approximately 9:20 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a 1-Year Required Visit and was greeted by Staff Member, Laurel Roque. Licensee/Administrator, Luingning “Bot” Alicdan, arrived during the visit at approximately 9:50 AM. Facility serves older adults and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 13 residents of which 11 residents can be non-ambulatory, and 2 residents can be bedridden. Facility has an approved hospice waiver for 3 individuals. Facility has approval to have a locked perimeter. Upon arrival, LPA was informed that there were twelve (12) Residents in care and 3 staff members on-site. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:50 AM, LPA toured the facility with Administrator Alicdan. All exits were clear and unobstructed. Facility fire extinguishers were last serviced and tagged in May, 2024. Fire extinguisher servicing and inspection is scheduled for 6/27/2025. The automatic sprinkler system was serviced in 5/2025. The facility was sufficiently lighted. LPA inspected eight (8) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. LPA observed that six (6) various dressings and sauces that were required to be refrigerated after opening, were left unrefrigerated in a kitchen cabinet. This deficiency will be cited. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted on 5/19/2025. Continued on 809-C... ...Continued from 809 The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. At approximately 11:30 AM, LPA reviewed five (5) resident files. Three (3) resident files were observed to not have current Needs & Service Plans. This deficiency will be cited on the corresponding Non-Compliance inspection. LPA reviewed four (4) staff files. Two (2) staff members were observed not to have current 1st Aid and CPR training. Three (3) staff members were observed not to have initial training documents. These deficiencies will be cited on the corresponding Non-Compliance inspection. LPA observed a medication cabinet in common area, next to the storage room, to be unlocked. This deficiency will be cited on the corresponding Non-Compliance inspection. LPA spot checked Medication for three (3) residents. LPA observed all medications to have proper documentation. The facility does not handle resident’s monies for personal and incidental items. Luningning Alicdan’s Administrator Certification 7002894740 is pending renewal. Administrator bureau received application on 10/10/2023. LPA requested the following documents be submitted to Community Care Licensing by 7/11/2025: LIC 500 Personnel Report LIC 308 Designation of Responsibility LIC 610E Emergency Disaster Plan Proof of Liability Insurance Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, LIC 421FC, Plan of Corrections and Appeal Rights discussed and provided to Licensee/Administrator Alicdan. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 11, 2025

Type of visit: Case Management - Legal/Non-compliance

At approximately 9:20 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a Non-compliance inspection and was greeted by Staff Member Laurel Roque. Administrator Luningning Alicdan arrived at 9:50 AM. On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as: · Administrator Duties and Plan of Operation · Staff Training · Resident and staff records · Resident Care and Personal Rights · Insufficient Staffing · Failure to clear deficiencies timely · Medication Management · Failure to follow through with TSP Licensee was to ensure the following: · Follow through with responding to and participating with the Technical Support Program Continued on 809-C... ...Continued from 809 · Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication. · Ensuring personal rights of residents in care and ensuring resident needs are met. Today, LPA conducted the Non-Compliance inspection. Licensee found to be in compliance as pertains to responding to and participating with the Technical Support Program. LPA reviewed records pertaining to compliance with areas including staff training records, maintaining staff and resident records, and pre-pouring of medication. LPA conducted interviews and made observations pertaining to Admin's ensuring of personal rights of residents in care and ensuring resident needs are met. During the Inspection LPA observed a medication cabinet in common area, next to the storage room, to be unlocked. This deficiency will be cited. This deficiency was previously cited on 4/24/2025. A Civil Penalty is being assessed for $250.00 for this repeat violation. During records review. LPA observed the following: -Residents R2, R3 and R5 did not have a current Appraisals/Needs & Service Plans on file. This deficiency will be cited. This deficiency was previously cited on 4/24/2025. A Civil Penalty is being assessed for $250.00 for this repeat violation. -LPA further observed that staff members S1, S2, S3 and S4 did not have required number of training hours on file. This deficiency will be cited. This deficiency was previously cited on 4/24/2025. A Civil Penalty is being assessed for $250.00 for this repeat violation. -LPA observed that staff members S2 and S4 did not have current First Aid certification on file. This deficiency will be cited. Continued on 809-C2... ...Continued from 809-C Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809Ds, LIC 421FCs, Plan of Corrections and Appeal Rights discussed and provided to Licensee/Administrator Alicdan. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jun 12, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that a medication cabinet in common area, next to the storage room was unlocked, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee will submit LIC9098 to CCL self certifying that all medications wll be kept in a safe and locked place. Licensse will further self certify that it has been discussed with all employees that both prescription and PRN medications be secured at all times. This do be done by POC Due Date of 6/12/2025.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.625(b)(2) · Plan of correction due date: Jun 12, 2025

§1569.625 Staff training; legislative findings; contents (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S1, S2, S3 and S4 did not have required hours of training on file, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee to submit plan to conduct training for S1, S2, S3 and S4 in the required number of hours required by regulation, based on staff members'' start dates, by plan of correction due date. Training reocrds to be submitted no later than 7/3/20255.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jul 2, 2025

87463 Reappraisals (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that R2, R3 and R5 all did not have current appraisals on file, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee to submit completed current reappraisals for R2, R3 and R5 to Community Care Licensing by POC due date of 7/2/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: Jul 2, 2025

87411 Personnel Requirements – General (C)(1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that staff members S2 and S4 did not have current First Aid training certification in their files which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee to Submit proof that staff members S2 and S4 have been certified in First Aid to Community Care Licensing by POC due date of 7/2/2025.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analysts (LPAs) Christi Coppo and Robert Frank arrived unannounced to conduct a Non-compliance and was greeted by Administrator Luningning Alicdan. On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as: · Administrator Duties and Plan of Operation · Staff Training · Resident and staff records · Resident Care and Personal Rights · Insufficient Staffing · Failure to clear deficiencies timely · Medication Management · Failure to follow through with TSP Licensee was to ensure the following: · Follow through with responding to and participating with the Technical Support Program · Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication. · Ensuring personal rights of residents in care and ensuring resident needs are met. Continued on 809-C... Continued from 809... Today, LPAs conducted the Non-Compliance inspection. Licensee found to be in compliance as pertains to responding to and participating with the Technical Support Program. LPAs reviewed records pertaining to compliance with areas including staff training records, maintaining staff and resident records, and pre-pouring of medication. Staff members S1, S2 and S3 did not required hours of training on file (deficiency cited, see 809D). S3, S4, and S5 did not have Health Screens on file (deficiency cited, see 809D).R1, R2, R3, R4, and R5 all did not have current appraisals on file (deficiency cited, see 809D). LPAs conducted interviews and made observations pertaining to Admin's ensuring of personal rights of residents in care and ensuring resident needs are met. Prescription and PRN medications were observed to be unsecured in the following rooms 10, 8, and 9. LPAs also observed there were unsecured medications and sharps (lancets), as well as sharps disposal container, in the cabinet next to the dining room table (deficiency cited, see 809D). LPAs observed prescription medication had its label partially removed in R3's room number four (4) (deficiency cited, see 809D). LPAs observed golf ball sized bruised knot on R4's left hand side forehead. R4 reported that they fell and hit their head but that it doesn't hurt. Admin advised that R4's POA decided R4 did not need to go to the hospital. LPAs advised Admin that facility must call EMS and let them determine if the resident needs to have medical attention, if the resident then refuses that is their right but the EMS must be called first. LPAs also advised that an Incident Report must be submitted for any incident which threatens the welfare, safety or health of any resident, R3 reported to LPAs that two [2] times since New Year's Eve the Admin had to call 911 to help them with breathing issues. However, per LPAs' observation, no Incident report was submitted reporting the emergency services for R3. Admin could not produce an Incident report for either R3 or R4 (deficiency cited, see 809D) LPAs observed an oxygen tank in storage closet that was not secured to the wall or in an oxygen cradle (deficiency cited, see 809(D). LPAs observed that the hot water was both below and above the Title 22 regulation of being between 105 and 120 degrees F in room seven (7) and one (1) (deficiency cited, see 809D). Continued from 809-C LPAs observed door to laundry room from facility unlocked; LPAs observed unsecured cleaning products in metal cabinet found unlocked in laundry room (deficiency cited, see 809D). In the laundry room LPAs observed a large container of eggs on a shelf that were left unrefrigerated (deficiency cited, see 809D). LPAs observed an open can of cat food that was moldy in room three (3). LPA's observed an HVAC intake vent in the front hallway that was covered in dust/dirt and a grease like substance. LPAs observed many small unsealed or tied trash bags full of soiled incontinence briefs in laundry room with eggs (deficiency cited, see 809D). LPAs observed an extremely strong urine odor in room five (5) and odor in room two [2B] (deficiency cited, see 809D). LPAs observed S6 to be providing care to residents. S6 has fingerprint clearance and is associates to the facility; however there is no file on premises for S6. Admin explained S6 is their family member and is now living here. LPAs advised that all staff providing care to residents must have training, Health Screen and TB clearance on file as well as First Aid/CPR. Admin provided LIC500 to LPAs which indicated Admin is scheduled Monday-Friday 1pm-3pm and Monday-Friday 7pm-7am. LPAs advised that Admin duties must performed on business days within business hours such that they have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility. Admin advised LPAs that they are very close to closing escrow with a buyer for the facility. LPAs advised residents will need a 60 day notice and it will need to be submitted to CCL as soon as issued. Admin to contact LPA for further instructions on required items for change of facility ownership. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given..the state’s words, verbatim · CDSS document, Apr 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Apr 25, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that prescription and PRN medications were accessible to residents in rooms 10, 8, 9, and in dining and laundry room, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Licensee will submit LIC9098 to CCL self certifying that all medications wll be kept in a safe and locked place. Licensse will further self certify that it has been discussed with all employees that both prescription and PRN medications be secured at all times.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.625(b)(2) · Plan of correction due date: Apr 25, 2025

§1569.625 Staff training; legislative findings; contents (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S1, S2 and S3 did not required hours of training on file, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Licensee to submit plan to conduct training for S1, S2, and S3 in the required number of hours required by regulation, based on staff members'' start dates, by plan of correction due date. Training reocrds to be submitted no later than 5/2/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87618(b)(3)(E) · Plan of correction due date: May 1, 2025

87618 Oxygen Administration ...the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation oxygen tank in storage closet not secured to wall or in cradle, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Admin immediately removed oxygen tank from storage closet and placed in a cradle in resident's room. Deficiency cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: May 1, 2025

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health...Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S3, S4, and S5 did not have Health Screens on file, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Licnesee to submit pictures of or completed Health Screens for S3, S4, and S5, to CCL by plan of correction due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: May 1, 2025

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed intake vent in front hallway covered in dust/dirt and a grease like substance, which poses an immeidate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Photos of cleaned vent to be submitted no later than 5/2/25.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(e)(2) · Plan of correction due date: Apr 25, 2025

87303 Maintenance and Operation (e)Water supplies and plumbing fixtures shall be maintained... (2)Faucets used by residents...shall deliver hot water...of not less than 105 degree F and not more than 120 degree F. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that which poses an immeidate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Facility to submit plan to record water temperature for 2 weeks showing water tempertaure within regulation by plan of correction due date. Two week water log to be submitted no later than 5/9/25. Log to be submitted with picture of thermotoer in running water with temperature visible.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(f) · Plan of correction due date: May 2, 2025

87303 Maintenance and Operation (f)All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed unsealed/ tied trash bags full of soiled incontinence briefs in laundry room with eggs, which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Licensee immediately discarded trash bags. Deficiency cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(23) · Plan of correction due date: Apr 25, 2025

87555 General Food Service Requirements(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation large container of eggs left on a shelf unrefrigerated in laundry room, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Licensee immediately removed eggs and put them inside the house in refrigerator. Deficiency cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Apr 25, 2025

87309 Storage Space and Access (a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and 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 not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that door to laundry room from facility unlocked; LPAs observed unsecured cleaning products in metal cabinet found unlocked in laundry room, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Licensee to submit LIC9098 self-certifying laundry room door will remain locked and/or keep all cleaning supplies and toxins inaccessible to residents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: May 1, 2025

87463 Reappraisals (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R1, R2, R3, R4, and R5 all did not have current appraisals on file, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Licensee to submit completed current reappraisals for R1, R2, R3, R4, and R5 by 5/2/25

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 1, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency ...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that licensee did not submit to CCL an Incident Report for R3 or R4 after they experienced incidents that required one be submitted, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Licensee to submit LIC9098 self-certifying they will submit incident reports to CCL for all residents when required by regulation by plan of correction due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87625(b)(3) · Plan of correction due date: May 1, 2025

87625 Managed Incontinence (b)...the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed an extremely strong urine odor in room five (5) and odor in room two [2B], which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Licensee to submit LIC9098 self-certifying they will keep residents and the facility free from incontinence odors by plan of correction due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(4) · Plan of correction due date: May 2, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R3's prescription medication had it's label partially removed, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Licensee to submit LIC908 self certifying that they will not alter prescription medication labels by plan of correction due date.

Type of visit: POC

LPA arrived unannounced to conduct a plan of correction visit and met with caregiver. LPA reached Licensee Luningning Alicdan via phone and discussed items including but not limited to: plans of corrections that have not been fulfilled, plans of corrections due for citations issued today, and civil penalties assessed today. On 10/30/24 citations were issued for the following deficiencies with respective plans of correction: 87405(a) - Licensee to submit LIC500 showing what hours she is allocating for caregiving and what hours she is allocating to Admin duties. Hours reflected must be sufficient as indicated in the regulation. On 10/31/24 Admin submitted to CCL LIC500 showing Admin working 2 hours per day, Monday through Friday. Today 11/13/24, LPA discussed licensee being present at facility a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified and free from other responsibilities such that they can attend to the administration duties required as necessitated by the care needs of residents and requirements of staff (i.e. arranging doctor visits, updating care plans, and conducting staff training) Licensee agrees to submit updated LIC500 showing more than 10 hours per week dedicated to Administrating duties. Licensee will submit updated LIC500 by 11/18/24. HSC1569.625(b)(2) - Facility to submit proof of online training for all staff Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 10/31/2024. On 10/31/24 licensee submitted training log with title of “on-line training” but did not specify the training topics covered. Licensee hand wrote “I have to enroll them again at CCO to the next training. I will call CCO and enroll them on Monday.” Today 11/13/24, LPA discussed with licensee the annual training of staff for this facility. LPA and licensee discussed that three [3] employees have 18,14, and 13 hours of the 20 required per regulation. LPA asked licensee if any more training hours had been completed since the last citation issued on 10/30/24. Licensee advised no additional training has been completed because licensee unable to log in on CCO website. Licensee explained that she has trouble navigating online services and keeping track of passwords. So, LPA could not verify with licensee that all staff have completed at least 20 hours of annual training (deficiency cited, see 809D. **civil penalty assessed**) Continued on 809C... Continued from 809... 87303(e)(2) - Licensee to submit a water temperature log for the next 10 days. Temperature to be checked twice a day for all sinks starting on 06/20/2024. Log to include location of sink and time documented. Log to be submitted to CCL for review and approval by POC due date 10/31/2024. On 10/31/24 licensee submitted water temperature log but did not include location of sink and time documented. Today 11/13/24, LPA tested water temperature in the sink in the kitchen, in the main bath on side B, and rooms #1,#4, and #7. Licensee requested LPA use facility thermometer to get temperature readings in addition to LPA's state issued thermometer. LPA took water temperature readings using both LPA's thermometer and facility's thermometer. Water temperature readings were captured on video. Water temperatures measured at 111.5 degrees in kitchen, 128 degrees F in the main bath on side B, 109.4 degrees F in room #1, 109.1 degrees F in room #4, and 130 degrees F in room #7. The water temperature readings in the main bath on side B and in room #7 are not within the allowable range of 105 to 120 degrees F (deficiency cited, see 809D. **civil penalty assessed**) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with caregiver and a copy of this report was given.the state’s words, verbatim · CDSS document, Nov 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Nov 14, 2024

1569.625(b)(2)...training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training...four hours of which shall be specific to postural supports, restricted health conditions, and hospice care.. This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 10/30/2024, which poses an immediate health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Nov 13, 2024

Plan of correction: Facility to submit proof of staff enrollment for all staff on CCO website to CCL by plan of correction due date. Licensee to submit completed annual staff training totalling 20 hours no later than 11/27/24. civil penalty assessed

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(e)(2) · Plan of correction due date: Nov 14, 2024

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be... (2) Faucets used by residents ...shall deliver hot water. Hot water temperature controls shall be maintained ... to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C)... This requirement was not met by licensee as evidenced by: water temperature over 120 degrees F in two [2] out of five [5] sinks measured, which poses an immediate health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Nov 13, 2024

Plan of correction: Facility to submit plan to regulate water tempertaure such that it remains within the regualtion requirements and submit phopgraphic proof of complaince with regualtion. Licensee agrees to submit photographs of water temperature readings with therometer itself and its reading present in picture. Picture to include number of room and/or location of where water temperature is being measured. Licensee agrees to take at least two readings per day, in rooms identified in 11/13/24 report, beginning on 11/14/24. Licensee will come to CCL Santa Rosa regional office to show all water temperature reading pictures on 11/26/24. civil penalty assessed.

Type of visit: Office

Regional Manager, Carla Nuti-Martinez, Licensing Program Manager Victoria Bertozzi, and Licensing Program Analyst Christi Coppo met with Licensee, Bot Alicdan to conduct a Non-Compliance meeting. This meeting serves as the first quarterly NCC meeting. On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as: Administrator Duties and Plan of Operation Staff Training Resident and staff records Resident Care and Personal Rights Insufficient Staffing Failure to clear deficiencies timely Medication Management Failure to follow through with TSP Licensee is to ensure the following: Follow through with responding to and participating with the Technical Support Program Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication. Ensuring personal rights of residents in care and ensuring resident needs are met. As of today, 10/30/2024, licensee has fulfilled following through with responding to and participating with the Technical Support Program. Continued on 809C... As of today, 10/30/2024, licensee has not ensured compliance with maintaining staff and resident records as evidenced by LPA's recent observations made during the complaint investigation conducted on 10/24/2024 and outstanding deficiencies from Annual Inspection conducted on 6/19/2024. During investigation conducted on 10/24/2024, LPA found that two [2] staff members, S1 and S2 were not associated to the facility. This deficiency was previously cited during the annual visit on 6/19/2024 for the same two [2] staff S1 and S2. The deficiency remains outstanding as the plan of correction was not satisfied. The outstanding deficiencies from 6/19/2024 are: · Criminal Record Clearance; 87355(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: o Civil Penalty Issued. Licensee was to submit proof of Guardian roster indicating staff were associated. This plan of correction was not satisfied as licensee submitted note stating that they were unable to associate staff members to Guardian along with staff information. · Incidental Medical and Dental Care Services; 87465(h)(4) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. o Licensee was to submit in-service training on how to document centrally stored medications. This plan of correction was not satisfied as licensee submitted copy of regulation · Incidental Medical and Dental Care Services; 87465(h)(5) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. o Licensee was to submit submit in-service training reviewing items that are inaccessible to residents in care. This plan of correction was not satisfied as licensee submitted copy of regulation and stated that medication was not transferred between containers during LPA visit. LPA observed medications pre-poured in little dishes located in the cabinet dining room. Continued on 809C(2)... Continued from 809C... · Care of Persons with Dementia; 87705(f)(2) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. o Licensee was to submit in-service training reviewing regulation and items to be inaccessible to residents in care. This plan of correction was not satisfied as licensee submitted copy of regulation. · Other Provisions Health and Safety Code; 1569.625(b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. o Licensee was to submit written plan on how they will ensure annual training is conducted timely. Licensee was to also submit proof of completed annual training for all staff. This plan of correction was not satisfied as licensee submitted note stating that all staff have been signed up for CCO (Community Care Options) Training and submitted the following certificate hours for staff: § Elizabeth Alicdan (26 hours) § Erwin Alicdan (18 hours) § Andrea Dela Chica (14 hours) § Wilhelfortes “Willi” Nicdao (13 hours) · Maintenance and Operation; 87303(e)(2) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). o Licensee was to submit water temperature log for 10 days, starting 06/20/2024 and include location of sink and time documented. This plan of correction was not satisfied as licensee did not submit water log to CCL in either their submitted packet or by email. Continued on 809C(3) Continued from 809C(2)... As of today, 10/30/2024, licensee has not ensured compliance with ensuring personal rights of residents in care and ensuring resident needs are met. On 10/182024 CCL received a complaint for the facility with allegations of Licensee does not ensure sufficient staffing to meet residents’ care needs. Staff did not respond to resident's request for assistance in a timely manner. Resident was left unattended after a fall for an extended period of time. Facility has bed bugs. All allegations were substantiated. Therefore, the licensee has not ensured compliance with ensuring personal rights of residents in care and ensuring resident needs are met. The following regulation deficiencies are being re-cited today : Criminal Record Clearance: 87355(e) Incidental Medical and Dental Care Services: 87465(h)(4) Incidental Medical and Dental Care Services; 87465(h)(5) Care of Persons with Dementia; 87705(f)(2) Other Provisions Health and Safety Code; 1569.625(b)(2) Maintenance and Operation; 87303(e)(2) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 30, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Oct 31, 2024

87355(e) All individuals subject to a criminal record review...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 was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses a potential health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: Licensee submitted LIC9182 for CCL to associate. Deficiency cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Oct 31, 2024

(a) All facilities shall have a qualified and currently certified administrator.... The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility... This requirement is not met by licensee as evidenced by: failure to clear deficiencies timely and deficeinces pertaining to: staff training, staff records, and resident's care needs and personal rights, which poses a potential health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: Licensee to submit LIC500 showing what hours she is allocating for caregiving and what hours she is allocating to Admin duties. Hours reflected must be sufficient as indicated in the regulation.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87705(f)(2) · Plan of correction due date: Oct 31, 2024

87705(f)(2) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses an immediate health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: Facility to in-service training for all staff to review how to document centrally store medications. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date 10/31/2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR1569.625(b)(2) · Plan of correction due date: Oct 31, 2024

1569.625(b)(2)...training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training...four hours of which shall be specific to postural supports, restricted health conditions, and hospice care... This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses an immediate health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: Facility to submit proof of online training for all staff Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 10/31//2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(4) · Plan of correction due date: Oct 31, 2024

87465(h)(4) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses a potential health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: Facility to conduct in-service training for all staff to review how to document centrally store medications. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 10/31/2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(5) · Plan of correction due date: Oct 31, 2024

87465(h)(5) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses a potential health, safety, and/or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: Facility to conduct in-service training for all staff reviewing that pre-poured medications are not allowed. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 10/31/2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Oct 31, 2024

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).. Based on observations made, the Licensee did not comply with the section cited above. 7 of 13 facility sinks were found to be out of Title 22 regulations of 105F to 120F measuring between 120.5F and 126.8F. This poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: Licensee to submit a water temperature log for the next 10 days. Temperature to be checked twice a day for all sinks starting on 06/20/2024. Log to include location of sink and time documented. Log to be submitted to CCL for review and approval by POC due date 10/31/2024

Allegation investigated: Licensee does not ensure sufficient staffing to meet residents’ care needs. Staff did not respond to resident's request for assistance in a timely manner. Resident was left unattended after a fall for an extended period of time. Facility has bed bugs.

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegations. Complaint alleges: licensee does not ensure sufficient staffing to meet residents’ care needs, staff did not respond to resident's request for assistance in a timely manner, and resident was left unattended after a fall for an extended period of time. LPA met licensee in the driveway upon arrival and told her of the allegations. Licensee immediately identified the resident that fell as being R1. Licensee was working the NOC shift that night. She heard R1 yell around 9:45pm. Licenseee said she went right to R1's room. Licensee walked in R1's room and R1 was on the floor, by their bed. Licensee did assessment to see if R1 was bleeding. Continued on 9099C... Substantiated continued from 9099... Licensee explained she tried to get R1 up by herself, but she couldn’t because R1 is too heavy and so she gave him a pillow and blanket. Licensee explained to LPA that R1 did not have a skin tear or anything as a result of falling and the room was clean; no feces or urine present on the walls or in R1's room. Licensee said she then left R1's room to call caregiver (S3) to come and help her get R1 off of the floor. S3 was not present at the facility, S3 was in Windsor at the time of licensee's call. Licensee advised LPA that S3 arrived approximately 30 minutes later. After arriving, S3 helped R1 up from the floor and put R1 back in bed. So, based on interview with licensee, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Complaint alleges facility has bed bugs. Per LPA interview with licensee, licensee is aware of on-going bed bug issue at facility. LPA and licensee spoke to most recent pest exterminator (E3) via telephone. Per LPA and licensee interview with E3, the facility was recently treated on 10/4/24 for bed bugs found in rooms 7, 8, 9, and 10. Per E3, the treatments given were a pest spray and a steam treatment. LPA clarified if steam treatment was the same as heat treatment and exterminator said no, that the two are different treatments. E3 said heat treatment would probably be the next step, where the company would tarp the house and do an all encompassing heat treatment on the entire facility. E3 said however that heat treatment is not covered under the licensee's current warranty and that it would be an additional cost. E3 further explained that they are unsure of the next steps to take that would be best to solve the issue since it seems so pervasive. So, E3 gave LPA and licensee their managers' phone number to call and inquire. LPA and licensee called both managers' phone numbers but were unsuccessful in reaching either one. Subsequently, LPA toured the facility and obtained photographic evidence of bed bugs still present in facility. LPA found bed bugs in room 10B and outside of rooms 8,9, an 10 in the hallway under a table stand in a sticky box. Based on LPA observation and photographic evidence, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies cited on the attached LIC 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with licensee. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given. **Civil penalty assessed for repeat deficiency within 12 months.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 21-AS-20241018130423

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 6, 2024

87468.2 Additional Personal Rights of Residents... (a) ... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) to care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: Based on LPA interview with licensee and photographic evidence obtained,This requirement was not met by license as evidenced by: LPA interview with licensee indicating R1 fell on to the floor but licesee could not pick R1 up unasssited. R1 waited at least 30 minutes before receiving assistance, which poses a immediate health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: Facility to submit plan to provide adequate staffing such that staff are sufficient in numbers, qualifications, and competency to meet all residents' needs by plan of correction due date during business hours. If plan is found to be adequate by CCL, then facility to then submit LIC500 reflecting that facility has staff sufficient in numbers, qualifications, and competency to meet all residents' needs no later than 11/01/2024. If the plan is not found to be acceptable, licensee will come in to Regional Office for compliance meeting with CCL management.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 6, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include... procedures for the safety and well-being of residents, employees and visitors. This requirement was not met by license as evidenced by: Facility on-going issue of bed bugs present at facility is known by licensee and LPA obtained photographic evidence, which poses an potential health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: Licensee to ensure facility is free from bed bugs by plan of correction due date. Given that previous spray and steam treatments did not work, licensee agrees to tarp and treat facility with heat and/or perform the service recommened by exterminator E1 or E2 that will be most effective to ensure facility is free from bed bugs. *civil penalty assessed for repeat violation within 12 months*

Allegation investigated: Facility not administering medication per physician orders, neglect resulting in resident death

At approximately 9:00AM, Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings regarding the above allegation. Facility not administering medication per physician orders, Neglect resulting in resident death – Complaint alleges that resident, R1 was given an incorrect medication causing R1 to require emergency intervention and eventually passing away at the hospital. Statement from Licensee indicated that they misspoke when reporting to emergency personnel and the resident was not given an incorrect medication. Review of medical records do not show that an overdose was a reason for or contributed to R1’s death. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 3, 2024 · control 21-AS-20240801170623

Allegation investigated: Licensee is not addressing pests at facility

At approximately 9:00AM, Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegation. Complaint alleges licensee is not addressing pests at facility. LPA spoke with licensee and licensee said she knows about the bed bugs and that she has someone coming tomorrow to take care of them. LPA asked licensee about alleged on-going bed bug issue at facility. Licensee said she does not know why they keep having an issue, she has Terminex spray every quarter. Previously, the pest company wanted to tent the home for 3 days and licensee explained she could not relocate all the residents for that amount of time. LPA and licensee discussed that only heat treatment will kill bed bugs. Licensee advised she understands that now and is having heat treatment completed. Licensee informed LPA that during the bed bug treatment she will have the residents out on the patio for the two hours it will take. Continued on 9099C... Substantiated Continued from 9099... Based on interview with licensee, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies cited on the attached LIC 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with licensee. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 21-AS-20240926120125

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 10, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include... procedures for the safety and well-being of residents, employees and visitors. This requirement was not met by license as evidenced by: Facility on-going issue of bed bugs present at facility is known by licensee, which poses an immediate health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 3, 2024

Plan of correction: Facility to submit work order and paid invoice for bed bug treatment by professional company by plan of correction due date.

Type of visit: Office

Regional Manager, Carla Nuti-Martinez, Licensing Program Manager Victoria Bertozzi, and Licensing Program Analyst Christi Coppo met with Licensee, Bot Alicdan to conduct a Non-Compliance Conference. Parties discussed multiple areas of concern including but not limited to the following: Administrator Duties and Plan of Operation Staff Training Resident and staff records Resident Care and Personal Rights Insufficient Staffing Failure to clear deficiencies timely Medication Management Failure to follow through with TSP Licensee to ensure the following: Follow through with responding to and participating with the Technical Support Program Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication. Ensuring personal rights of residents in care and ensuring resident needs are met. Licensee agrees to be placed on a non-compliance plan for a period of two years. Licensee has agreed to Technical Support Provider (TSP) service. CCL will submit a TSP referral No deficiencies cited.the state’s words, verbatim · CDSS document, Jul 31, 2024

Type of visit: Required - 1 Year

At approximately 8:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Member, Andrea Dela Chica. Licensee/Administrator, Bot Alicdan, arrived during visit at approximately 9:00AM. Facility serves older adults and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 13 residents of which 11 residents can be non-ambulatory, and 2 residents can be bedridden. Facility has an approved hospice waiver for 3 individuals. Facility has approval to have a locked perimeter. Upon arrival, LPA was informed that there were 9 Residents in care and 2 staff members on-site. At approximately 8:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were not associated to the facility per regulation. LPA confirmed on the Guardian website that the two staff members were background cleared but not were associated to the facility as required (deficiency cited, see LIC809D and LIC421BG, regulation 87553(e)). At approximately 9:25AM, LPA conducted a walk-though of the facility with Licensee. Per Facility sketch, facility is a one story building with 11 bedrooms, 11 bathrooms, and common spaces. LPA observed the following: facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for 7 of 13 facility sinks were found to be out of compliance with Title 22 Regulations of 105 to 120 degrees Fahrenheit, measuring between 120.5F to 126.8F (deficiency cited, see LIC809D, regulation 87303(e)(2)). During walkthrough, LPA observed the following toxins, hazards, and medications to be accessible: unlocked knife drawer in the kitchen, Disinfectant cleaner in the bathroom, bed bug repellent in a cabinet located in the dining room. LPA also observed blood sugar monitors and sharps located in the facility's dining room drawer, and 3 bottles of cough syrup, 1 bottle of Pepto Bismol and 1 bottle of Tums in a resident's room. Review of resident's LIC602 stated that resident has a dementia diagnosis and is unable to manage their own medications (deficiencies cited, see LIC809D, regulation 87705(f)(2)). Licensee immediately collected all toxins and ensured that they were locked and inaccessible. Licensee also removed medications from resident's room. Continued on LIC809C Continued from LIC809 LPA observed that a window in a resident's room needed replacing. Per LPA observation, the window was being propped up by a fake piece of fruit. Further observation showed that the window was loose and could not withstand its weight when opened (see technical violation, LIC9102, regulation 87303(a)). LPA observed that some resident rooms had garbage cans with lids, while other resident rooms did not have garbage cans with lids (see technical violation, LIC9102, regulation 87303(f)(3)). LPA also observed prepoured PM medications in a locked cabinet. Per conversation with Licensee and Staff Member, the PM medications were poured this morning. Review of visit conducted on 06/01/2023 indicated that the facility was issued a technical advisory and therefore was aware that pre-pouring medication was against regulation (deficiency cited, see LIC809D, regulation 87465(h)(5)). Facility's fire extinguishers were last inspected May 2024. Smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted May 2024. At approximately 11:30AM, LPA reviewed staff files, resident files, and resident medications. Review of staff files showed that Staff Member 3 (S3) was missing their Health Screening (LIC503) report and proof of negative TB test. 3 of 4 staff members did not have annual 2023 training completed (deficiencies cited, see LIC809D, Regulation 87411(f), and Health and Safety Code, 1569.625(b)(2)). Per discussion with Licensee, all staff have been signed up for online training. 3 of 4 staff files had current First Aid and CPR certification. Per discussion with Staff Member 1 (S1), their certification card is at home but they always work with Staff Member 2 (S2) at the facility. Review of S2's file indicated that they had current first aid/cpr certification (see technical violation, LIC9102, 1569.618(c)(3)). Review of resident files showed that 3 of 9 resident files were missing their reappraisal assessments. Of the 9 residents, 2 residents with a diagnosis of dementia were missing updated annual Physician Reports. 9 of 9 resident files were missing their Needs and Services Plan. 1 of 9 files was missing their Pre-Appraisal Assessment (deficiencies cited, see LIC809D, regulation 87705(c)(5), regulation 87467(a)(2), and regulation 87467(a)). Licensee understands that Pre-Appraisal assessments should be conducted prior to residents moving into the facility. Licensee also understands that assessments and appraisals should be conducted annually for residents with a dementia diagnosis. LPA reviewed 4 of 9 resident medications. During review, LPA observed that some medications were not centrally stored as required. LPA observed that some medications were either not logged or had incorrect dates logged (deficiency cited, see LIC809D, regulation 87465(h)(4)). Administrator Certificate for Luningning (Bot) Alicdan (6010428470) expired 10/18/2023. Review of Guardian's website showed that Licensee/Administrator's name is not on the pending list or active list. Per Guardian website, renewal applications are being reviewed for the week of 11/06/2023. Licensee informed LPA that they submitted payment for their renewal in 2023. Continued on LIC809C Continued from LIC809C LPA requested the following documentation to update the facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 07/19/2024. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An Immediate Civil Penalty in the total amount of $200 is being assessed for a lack of staff association as required for S1 and S2 (See LIC421BG).** Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), LIC421BG (Civil Penalties for Caregiver Background Check) Plan of Corrections, and Appeal Rights discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 19, 2024

The state marks this report as 12 pages; the online copy we transcribed has 9. You can request the full file from the county licensing office.

Allegation investigated: Neglect/lack of supervision resulting in stage 4 pressure injury Staff did not follow doctor’s orders for resident in care Staff did not follow resident’s hospice care plan Staff did not provide proper medication assistance to resident in care Staff did not ensure resident’s incontinence needs were met in a timely manner Staff did not treat resident with respect

LPA Coppo met with Licensee/Administrator, Luningning "Bot" Alicdan in the Santa Rosa Regional Office to deliver findings regarding the above complaint allegations. Neglect/lack of supervision resulting in stage 4 pressure injury – Complaint alleges that facility staff was not moving resident into more comfortable positions to relieve level 3 to 4 pressure injuries and that wound care was not being done. Pressure injury was documented on resident’s hospice care plan and per plan, resident was provided wound care by the hospice agency. Evidence indicating that staff were failing to reposition resident was unavailable. Staff did not follow doctor’s orders for resident in care – Complaint alleges that a doctor's order had been put in place for resident to get up to use the bathroom. Per complaint, Licensee refused to follow the order and told resident to go to the bathroom in their incontinence brief. Continued on LIC9099C Unsubstantiated Doctor’s order was not provided. Hospice care plan indicated resident was “bedbound” and used incontinence briefs. Evidence indicating that staff failed to toilet resident per a doctor’s order could not be confirmed. Staff did not follow resident’s hospice care plan – Complaint alleges that staff continued to provide food and water to resident in conflict with the hospice care plan. Per complaint, hospice was concerned that resident would aspirate. Review of hospice care showed that hospice instructed the use of straws to be discontinued the day prior to resident passing but document review and interviews did not indicate that hospice instructed facility staff to not provide food and water. Staff did not provide proper medication assistance to resident in care - Complaint alleges that staff were not providing resident medications as prescribed by the doctor due to staff’s belief that the medication would cause death. Additionally, Complaint alleges that resident was not given a specific medication for many months due to staff not filling the prescription. Evidence to support this allegation was not provided. Hospice care notes indicated that resident’s family expressed concern that resident was not being given pain medication, but it was not mentioned in the notes whether hospice confirmed this. Staff did not ensure resident’s incontinence needs were met in a timely manner– Complaint alleges that resident was left in their own stool for many hours stating that during an incontinence brief change, resident had a bowel movement that staff did not want to address so staff closed the incontinence brief, leaving the resident in their own stool. Per interview, resident was observed with two briefs on, both saturated with feces that had been liquid and then dried, indicating resident was left for multiple hours. Unable to confirm this information. Staff did not treat resident with respect – Complaint alleges that Licensee yelled at resident and was disrespectful. Additionally, complaint alleges that after refusing to follow doctor’s orders, Licensee told resident that if they didn’t like it at the facility, they should leave. Interviews conducted where one individual described staff yelling but not at a person while others indicated that staff do not yell. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited.the state’s words, verbatim · CDSS document, Mar 29, 2024 · control 21-AS-20231120142521

Allegation investigated: Staff physically abuses resident in care Staff are not meeting resident's care needs Staff speaks to resident in an inappropriate manner Staff withholds food from resident Staff does not properly check resident's blood sugar and administering insulin

Licensing Program Analysts Victoria Bertozzi and Christi Coppo arrived unannounced to deliver findings regarding the above complaint allegations and met with Licensee, Luningning (Bot) Alicdan. Staff physically abuses resident in care – Complaint alleges that Licensee handled a resident roughly by tugging, pushing, pulling and kicking a resident. Complaint also alleges that a staff threw a resident across the room. LPA conducted interviews with noted resident(s) and other potential witnesses but was unable to confirm through interviews whether staff handled a resident roughly. Staff are not meeting resident's care needs – Complaint alleges that facility provides “constipating meals” so that residents will have less frequent bowel movements and therefore less incontinence brief changes, Complaint also alleges that residents are only given one incontinence brief per day. Continued on LIC9099C Unsubstantiated Continued LIC9099 Per interviews, residents are provided meals with fruits and vegetables. LPAs observed sufficient incontinence products for residents and per interviews, residents are able to communicate when they need their incontinence brief changed. LPA was unable to confirm through interview that residents are not being provided regular incontinence care. Staff speaks to resident in an inappropriate manner – Complaint alleges that Licensee spoke to a resident in a loud, rude and disrespectful way. LPA interviewed multiple residents who did not report that staff spoke to them in a loud, rude or disrespectful manner. Staff withholds food from resident - Complaint alleges that staff are instructed to not bring food to a resident “as punishment”. LPA conducted interviews and was unable to confirm that food is being withheld from residents. Staff does not properly check resident's blood sugar when administering insulin – Complaint alleges that resident who is insulin dependent get their blood sugar tested and injection given by staff without staff properly cleaning the skin and not ensuring that resident is receiving the correct dose. Facility does not currently have a resident on insulin. Former insulin dependent resident was not available for interview. Regulation does not allow residents to receive an injection from someone who is not an appropriately skilled professional. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 21-AS-20230803103840

Allegation investigated: Staff are not properly trained to care and supervise residents Staff does not ensure facility is free of pests and rodents Staff is mismanaging resident's medication logs

Licensing Program Analysts (LPAs) Victoria Bertozzi and Helena Rummonds arrived unannounced to deliver findings regarding the above allegations and met with caregiver, Williforte Nicdao. Backup Administrator, Edward Alicdan was available by phone. Licensee/Administrator, Luningning "Bot" Alicdan was unavailable. During investigation LPAs conducted interviews, made observations and reviewed files. Staff are not properly trained to care and supervise residents – Complaint alleges that a new staff who was not trained was left “in charge” while Licensee was out of town. LPA confirmed through document review that not all staff are trained per regulation. Per interview with Licensee, untrained staff worked alone with residents in care. Continued on LIC9099A Substantiated Continued from LIC9099 Staff does not ensure facility is free of pests and rodents – Complaint alleges that facility has a rat, cockroach, spider and bed bug infestation resulting in residents and staff getting bed bug bites on them. LPA was able to confirm through interviews and observation that facility has insects inside of the facility but was not able to identify the type of insects. Facility has routine service by a vendor but it is unclear if they conduct treatment inside the facility. Staff is mismanaging resident's medication logs – Complaint alleges that medication is prepared a week in advance and that medications are not logged correctly. Per interview and LPA observation, medications are being prepared in advance, however, it does not appear that medications are being poured a week in advance. Review of the Centrally Stored Medication Log revealed that staff had input incorrect information including medication fill date, dosage amount and prescribing doctor. Based on LPA observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 21-AS-20230803103840

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c) · Plan of correction due date: Oct 11, 2023

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met based on record reviews showing that staff was not trained per regulation. This is an immediate risk to the Health and Safety of residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Licensee will submit a planned training schedule to LPA that will ensure that staff are trained per regulation no later than POC due date, 10/11/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(2) · Plan of correction due date: Oct 11, 2023

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not med based on interview and observation showing that facility has insects inside the facility. This is an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Licensee to send a written plan how they will ensure that there are no insects or rodents in the facility no later that 10/11/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Oct 16, 2023

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. No medications shall be transferred between containers. This requirement is not met as evidenced by: based on observation and interview facility is pre-pouring medication.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Licensee to submit self certification that they will no longer be pre-pouring medications by POC due date of 10/16/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(6) · Plan of correction due date: Oct 24, 2023

87465 Incidental Medical and Dental Care (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident... includes: (A)The name of the resident for whom prescribed. (B) The name of the prescribing physician., (C) The drug name, strength and quantity., (D) The date filled., (E) The prescription number and the name of the issuing pharmacy., (F) Instructions, if any, regarding control and custody of the medication.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Licensee to audit medications and update centrally stored log so that it is accurate and submit self certification to LPA showing it is completed by POC due date of 10/24/2023.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.