Betsy's Residential Care Home

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. 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. 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 documentsthe state’s words, verbatim · CDSS document, Aug 5, 2026

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

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Non-compliance and was greeted by caregiver. Administrator Edward Alicdan Jr. and licensee Luningning Alicdan were present at facility. 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. Continued on 809C... Continued from 809... · Ensuring personal rights of residents in care and ensuring resident needs are met. On 4/23/26 LPA conducted a non-compliance (NCC) visit. Deficiencies were re-cited for identified NCC areas of concern. As of today, 7/14/26, the plans of correction to clear those deficiencies are still outstanding. So, as pertains to the failure to clear deficiencies timely, the licensee has failed to clear deficiencies. LPA discussed failure with licensee. Licensee provided LPA with plans of correction that were outstanding. LPA cleared deficiencies. As pertains to resident and staff records. Resident and staff files complete. However, physician's report for resident (R1) shows resident as bedridden. Facility does not have bedridden clearance and R1 is not currently on hospice. However, LPA spoke with R1 and R1 is able to get out of the bed with assistance and is able to reposition himself while in bed when using side rails. LPA will not issue citation but licensee will get physician's report for resident (R1) updated to correct ambulatory status. As pertains to medication management LPA and S1 did a spot check of medication. No deficiencies cited. Also pertaining to medication management, deficiency of regulation 87465(h)(5) was cited on 2/11/26 because LPA and caregiver observed pre-poured medications in kitchen drawer. As of today, CCL has not received the plan of correction which required licensee/administrator to submit a LIC9098 self-certifying that facility will stop pre-pouring medications. At today's visit, licensee provided LPA with LIC9098. LPA cleared deficiency. Facility’s physical plant was not identified as a NCC area of concern. However, a deficiency of regulation 87303(a) was cited at the annual inspection. As of today, the plan of correction to clear that citation has not been received. During today's visit, licensee provided LPA with proof of correction. LPA cleared deficiency. As pertains to inadequate staffing. Facility has three (3) residents and two (2) caregivers on duty at all times per LIC500 dated 4/24/26. Per licensee, no changes to LIC500, LIC500 is current. No deficiencies cited. LPA reviewed resident documentation. No deficiencies observed. Pertaining to the other areas of concern identified in the NCC plan, such as Administrator Duties and Plan of Operation, Resident Care and Personal Rights, and failure to follow through with TSP. Facility has a certified Administrator, followed through with TSP, and observing personal rights. Exit interview conducted with licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 16, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a POC visit and was greeted by designee. Administrator Edward Alicdan Jr. was also present at facility. On 4/23/26 LPA conducted a NCC visit at facility and recited deficiencies for which the plans of correction were not completed. Deficiency of regulation 87465(h)(5) was recited with a plan of correction due date of 4/24/26. Deficiency of regulation 87303(a) was recited with a plan of correction due date of 4/24/26. As of today, 5/5/26, the plans of correction for these deficiencies have not been received. Therefore, LPA is issuing civil penalties for failure to correct. Civil penalties in the amount of $100 per day for nine (9) days, from 4/27/26 through 5/5/26, are being assessed for failure to correct deficiency of regulations 87465(h)(5) and 87303(a), for a total of $900 each. The penalty of $100 per day will continue to accrue until the plan of correction is received for each deficiency. **Civil penalties assessed in the amount of $100 per day for failure to correct deficiencies 87465(h)(5) and 87303(a), respectively (see LIC 421FCs).** 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 designee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with designee and a copy of this report was giventhe state’s words, verbatim · CDSS document, May 5, 2026

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

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Non-compliance and was greeted by caregiver. Administrator Edward Alicdan Jr. and licensee Luningning Alicdan were present at facility. Licensee advised LPA that she has received her Administrator certificate (#7002894740 expires 10/18/2027) and would like to be listed as the Administrator of record. Licensee will submit required paperwork for LPA to make change. Licensee had to leave so designee signed report. 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 Continued on 809C... Continued from 809... 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. On 2/11/26 LPA conducted a non-compliance (NCC) visit simultaneously with the facility’s annual inspection. Deficiencies were cited for identified NCC areas of concern. As of today, 4/23/26, the plans of correction to clear those deficiencies are still outstanding. So, as pertains to the failure to clear deficiencies timely, the licensee has failed to clear deficiencies. LPA discussed failure with licensee. As pertains to resident and staff records, deficiency of regulation 87458(c)(1)(A) was cited on 2/11/26 because resident (R1) did not have TB clearance on file. As of 3/4/26, R1 moved out of facility. Therefore the citation is being cleared today and will not be re-cited. As pertains to medication management, deficiency of regulation 87465(h)(6)(c) was cited on 2/11/26 because LPA and caregiver observed errors present on Centrally Stored Medication log (CSML) and current physician's orders for R1. The plan of correction required staff to complete one hour of medication management training by no later than 2/18/26. As of today, the plan of correction was not submitted to CCL. However, while present at facility staff provided LPA with completed medication training certificate issued 2/23/26. Therefore the citation is being cleared today and will not be re-cited. Also pertaining to medication management, deficiency of regulation 87465(h)(5) was cited on 2/11/26 because LPA and caregiver observed pre-poured medications in kitchen drawer. As of today, CCL has not received the plan of correction which required licensee/administrator to submit a LIC9098 self-certifying that facility will stop pre-pouring medications. Therefore, deficiency of regulation 87465(h)(5) is being re-cited today, see 809D. Facility’s physical plant was not identified as a NCC area of concern. However, a deficiency of regulation 87303(a) was cited at the annual inspection. As of today, the plan of correction to clear that citation has not Continued on 809C(2)... Continued from 809C... been received. During today's visit, LPA, staff (S1), and licensee all observed facility’s water heater closet to still have rodent droppings present and rodent droppings were also observed outside in the garage on the same side as the refrigerator where food is stored. Therefore, deficiency of regulation 87303(a) is being re-cited today, see 809D. As pertains to inadequate staffing: on 2/11/26 Administrator advised LPA that only himself or S1 have been on shift for about 2 or 3 weeks while licensee has been on of the country. However, per the NCC compliance plan all shifts must be covered by at least two [2] staff. LPA spoke to licensee over telephone while out of the country. Licensee indicated to LPA that the requirement for two [2] staff per shift is no longer needed as resident care needs have changed. However, during inspection LPA did not observe any paperwork indicating any change in resident care needs so the deficiency was cited. Today, LPA reviewed R2's most recent hospice care plan dated 4/06/26, per care plan R2 no longer requires a two person assist. So, facility is not required to staff for a two person assist. Therefore, the citation is being cleared today and will not be re-cited. However, LPA discussed with licensee and S1 the need for R2 to be repositioned every 2 hours and discussed documenting the repositioning so as to have an accounting of the times at which they were repositioned. During today’s visit, LPA and S1 did a spot check of medication. No deficiencies were observed. LPA reviewed resident documentation. No deficiencies observed. LPA did not observe or identify deficiencies pertaining to the other areas of concern identified in the NCC plan, such as Administrator Duties and Plan of Operation, Resident Care and Personal Rights, and failure to follow through with TSP. Facility has a certified Administrator, followed through with TSP, and observing personal rights. 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 designee and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 23, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Apr 24, 2026

Incidental Medical and Dental Care Services 87465 (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 LPA and caregiver observation, the licensee did not comply with the section cited above in that there were pre-poured medications in kitchen drawer, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Facility to self-certify on a LIC9098 they will immediately cease pre-pouring medications by plan of correction due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a) · Plan of correction due date: Apr 24, 2026

Maintenance and Operation 87303(a) (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on LPA, licensee and S1 observation, the licensee did not comply with the section cited above in that water heater closet has rodent droppings present, rodent droppings also observed by LPA, licensee, and caregiver outside in the garage on the same side as the refrigerator; additionally, an insulin syringe was found on the floor in the garage, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Facility to submit plan to have rodent extermintor service completed by plan of correction due date. Rodent exterminator work order and paid invoice showing rodent droppings addressed and contained to be submitted to CCL no later than 5/1/26. Facility also to submit LIC9098 self-certifying they will keep all sharps in appropriate containers by plan of correction due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Edward Alicdan Jr was present and also came out to greet LPA. LPA toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Top kitchen drawer on right side of dishwasher had pre-poured medications (deficiency cited, see 809D). All bedrooms were equipped with lighting, night stand, and chest of drawers. Extra hygiene products and linens were available. Water heater closet has rodent droppings present, rodent dropping also observed by LPA and caregiver outside in the garage on the same side as the refrigerator; additionally, an insulin syringe was found on the floor in the garage (deficiency cited see 809D). Resident bathroom had required bath mat and grab bar. Water temperature in sinks accessible to residents in care measured at 108.4 degrees F in hall bath and 109.2 degrees F in kitchen which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 6/27/25. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted 12/22/25. Facility has a backup generator for use during a power outage. Continued on 809C... Continued from 809.. LPA conducted review of three (3) staff records. No deficiencies. All required documentation present. LPA conducted review of three (3) resident records. Resident (R1) did not have TB clearance on file (deficiency cited, see 809D). LPA and caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA reviewed current medications list for R1 and compared to Centrally Stored Medication Log (CSML). The following errors were observed: Vitamin C should be administered 2 times per day but listed on CSML as only one, Aspirin present on current orders but not listed on CSML, Multivitamin with iron listed on current orders but not listed on CSML, Senna listed on current order as 17.2mg but listed as 8.6mg on CSML, insulin dose listed as 75 units in the morning and 40 units in the evening. Entry for 75 units in the morning present on CSML but not the 40 units in the evening (deficiency cited, see 809D). Edward Alicdan Administrator Certificate 6039689740 expires 10/2/27. All fees are current as of this time. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report Liability Insurance 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 Admin. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Admin and a copy of this report was given. Exit interview conducted with Admin and a copy of this report given.the state’s words, verbatim · CDSS document, Feb 11, 2026

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

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Non-compliance and was greeted by Administrator Edward Alicdan Jr. LPA is conducting Non-compliance in conjunction with annual inspection. All deficiencies cited will be cited on the annual inspection, except for deficiency cited for inadequate staffing, citation issued on this report. 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... Continued from 809,,, As pertains to Administrator duties and qualifications: as of 11/5/25 Edward R. Alicdan is now the Administrator for the facility. Edward R. Alicdan Administrator certificate number 6039689740 expires 10/2/27. As pertains to staff training: Staff all have current training. Files complete. As pertains to resident and staff records: Resident (R1) did not have TB clearance on file. Deficiency cited on annual inspection. As pertains to Resident Care and Personal Rights: LPA visited room #4 and found it to be clean and free from incontinence odors. LPA visited all rooms of residents and found them to be free of incontinence odors as well. Facility overall free from incontinence odors. As pertains to inadequate staffing: Per Admin, only himself and one other caregiver have been on shift for about 2 or 3 weeks while licensee has been on of the country. However, per the NCC compliance plan all shifts must be covered by at least two [2] staff. LPA spoke to licensee over telephone while out of the country. Licensee indicated to LPA that the requirement for two [2] staff per shift is no longer needed as resident care needs have changed. However, during inspection LPA did not observe any paperwork indicating any change in resident care needs (deficiency cited, see 809D). As pertains to failure to clear deficiencies timely: Licensee has not had any outstanding deficiencies to clear in a timely manner, so licensee found to be in compliance with clearing deficiencies timely. As pertains to medication management: LPA did spot check of medication. LPA and caregiver reviewed Centrally Stored Medication log (CSML) and current physician's orders for R1. LPA and caregiver observed errors present on CSML. Deficiency cited on annual inspection. Additionally, LPA and caregiver observed pre-poured medications in kitchen drawer. Deficiency cited on annual inspection. LPA and caregiver went over PRN MAR for R2. PRN MAR complete, including today's entry. As pertains to following through with TSP: licensee has followed through with TSP successfully. 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, Feb 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 12, 2026

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement is not met by licensee as evidenced by: Based on LPA interview, facility does not currently have at least two [2] staff present on all shifts, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: Facility to submit plan to ensure all shifts have at least 2 staff present by plan of correction due date. Facility to submit current LIC500 showing at least 2 staff present on all shifts by no later than 2/18/26.

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

Licensing Program Analyss (LPA) Christi Coppo arrived unannounced to conduct a Non-compliance and was greeted by licensee 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... Continued from 809,,, Today, LPA toured facility and found it to be clean and at a comfortable temperature. As pertains to Administrator duties and qualifications: during LPA's last non-compliance visit at facility on 7/1/25 licensee was cited for not having a current Administrator certificate. Again the licensee was cited on 8/6/25 for not having a current Administrator certificate. As of today, she still does not have a current Administrator certificate. However, as of 11/5/25 Edward R. Alicdan is now the Administrator for the facility. Edward R. Alicdan Administrator certificate number 6039689740 expires 10/2/27. LPA discussed with licensee that she will be taking over again as Administrator once her paperwork is mailed in on 11/19/25. LPA verified all training hours current. LPA will make change of Administrator once all paperwork is submitted to CCL. As pertains to staff training: Staff all have current training. Files complete. As pertains to resident and staff records: All staff current in CPR/1st Aid. All staff have Health Screen present with TB clearance. Resident files complete. As pertains to Resident Care and Personal Rights: LPA visited room #4 and found it to be clean and free from incontinence odors. LPA visited all rooms of residents and found them to be free of incontinence odors as well. Facility overall free from incontinence odors. As pertains to inadequate staffing: LPA reviewed Guardian roster and found all active employees associated to the facility. LPA reviewed LIC500 and found at least 2 people on shift for day shift, evening shift, and NOC shift. As pertains to failure to clear deficiencies timely: Licensee has not had any outstanding deficiencies to clear in a timely manner, so licensee found to be in compliance with clearing deficiencies timely. As pertains to medication management: LPA did spot check of medication and verified that facility is no longer pre-pouring medications. LPA and caregiver reviewed Centrally Stored Medication log (CSML) and current physician's orders for R1. LPA and caregiver observed bottle of Ondansetron 4mg to be present in R1's medications but not listed on current physician's orders. LPA and caregiver observed Calcium Continued on 809C(2)... continued from 809C... Citrate-Vitamin D3 315mg-5mcg on R1's current physician's orders but not listed on the CSML, medication discontinuation not present. LPA advised if a medication is not listed on CSML but is listed on current physician's orders, a discontinuation order must be in the resident's file (deficiency cited, see 809D). LPA and caregiver went over PRN MAR for R2. Last date of entry on PRM MAR was 10/29/25, administered before R2 receives a bed bath. R2 receives a bed bath 2 days per week, last bath given yesterday 11/5/25. PRN entry not logged. Additionally, PRN MAR does not list any outcomes for R2 (deficiency cited, see 809D). As pertains to following through with TSP: licensee has followed through with TSP successfully. 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 licensee and a copy of this report was giventhe state’s words, verbatim · CDSS document, Nov 6, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(3) · Plan of correction due date: Nov 13, 2025

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine...own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided ...(3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement not met by licensee as evidenced by: based on LPA and caregiver observation PRN outcomesvand entry dates of PRN adminsitration for R2 not documented, which poses a potential health, safety or personal rights risk to residents.the state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: Facility to self-certify that they will list outcomes for all PRNs administered for all residents by plan of correction due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(6) · Plan of correction due date: Nov 13, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement not met by licensee as evidenced by: based on LPA and caregiver observation, Calcium Citrate-Vitamin D3 315mg-5mcg not listed on the CSML for R1, which poses a potential health, safety or personal rights risk to residents.the state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: Facility to conduct at least 1 hr of medication management training for staff by plan of correction due date.

Type of visit: POC

Licensing Program Analyss (LPA) Christi Coppo arrived unannounced to conduct a POC Case Management and was greeted by caregiver. Licensee Luningning Alicdan arrived later. 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 On 7/1/25 LPA conducted a Non-compliance visit at the facility. Two areas of concern for which the licensee is on non-compliance were identified as being deficient: Administrator qualification and duties and staff training. During this visit, a citation was issued for deficiency of Health and Safety Code (HSC) 1569.625(b)(2) as staff (S2 and S3) did not have the annual required number of staff training hours completed . A plan of correction was issued for licensee to have staff S2 and S3 complete the required Continued on 809C.... Continued from 809... number of annual training hours. The plan of correction due date by which the training was to be completed was 7/22/25. Licensee submitted the plan of correction for HSC1569.625(b)(2) by the plan of correction due date. Deficiency has been cleared. At the same visit on 7/1/25, LPA also issued a citation for deficiency of regulation 87465 Administrator qualifications and duties, as licensee does not have a current Administrator certificate. A plan of correction was issued, requiring Administrator to submit copy of their current Administrator certificate. Plan of correction due date was 7/22/25. As of today, licensee still does not have an active Administrator certificate nor have they hired a qualified administrator. So, deficiency is being re-cited today (see 809D). Due to logistic reasons, licensee will not be able to obtain an administrator certificate until 12/2025. LPA and licensee discussed plan to hire an administrator. Licensee has enrolled two [2] of her staff in the Administrator certificate classes, both of which begin on 8/19/25. LPA advised that the facility cannot be without an administrator while waiting for the staff to complete their training courses. Licensee advised LPA they are having an extremely difficult time finding a qualified RCFE administrator, but that they have not ceased efforts. Licensee is in consistent contact with LPA concerning this deficiency of regulation. LPA advised licensee that having consistent deficiencies pertaining to the areas of concern for which they were placed on non-compliance may lead to further action by CCL, such as civil penalties and/or revoking their license. 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 giventhe state’s words, verbatim · CDSS document, Aug 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Aug 27, 2025

87405(a) Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. This requirement not met as evidenced by: Based on LPA and and licensee interview and record review, the licensee did not comply with the section cited above in that Administrator does not have an actively current Administrator certificate or Administrator, which poses an immediate health, safety or personal rights risk to residentsthe state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee to submit to CCL Adminsitrator paperwork for Administrator candidate once candidate is selected. Paperwork to include: LIC215, LIC500, LIC308, LIC501, detailed employment/education history, and copy of Admin certificate

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

Licensing Program Analyss (LPA) Christi Coppo arrived unannounced to conduct a Non-compliance and was greeted by caregiver. 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 from 809,,, Today, LPA toured facility and found it to be clean and at a comfortable temperature. As pertains to Administrator duties and qualifications: on 6/19/25 LPA Frank notified Administrator Luninging Alicdan of the following: They said your application to recertify your Administrators certificate was missing hours. They said they tried to contact you several times with no response. As such the application has been closed. Please contact them immediately as your facilities currently don’t have a certified Administrator. As of today, CCL has not received a response from Administrator and their certificate is still expired. With LPA present Admin called Admin cert unit but was unable to reach an agent. Admin explained she owed $10 and sent that $10 on 6/24/25, but has yet to hear anything else (deficiency cited, see 800D). As pertains to staff training: S2 and S3 do not have the required number of hours of training completed (deficiency cited, see 809D). As pertains to resident and staff records: All staff current in CPR/1st Aid. All staff have Health Screen present with TB clearance. All required resident documentation present. As pertains to Resident Care and Personal Rights: LPA visited room #4 and found it to be clean and free from incontinence odors. LPA visited all rooms of residents and found them to be free of incontinence odors as well. Facility overall free from incontinence odors. As pertains to inadequate staffing: LPA reviewed Guardian roster and found all active employees associated to the facility. LPA reviewed LIC500 and found at least 2 people on shift for day shift, evening shift, and NOC shift. As pertains to failure to clear deficiencies timely: Licensee has not had any outstanding deficiencies to clear in a timely manner, so licensee found to be in compliance with clearing deficiencies timely. As pertains to medication management: LPA did spot check of medication and verified that facility is no longer pre-pouring medications. As pertains to following through with TSP: licensee has followed through with TSP. 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, Jul 1, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Jul 22, 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 is not met as evidenced by: Based on LPA and caregiver observations, the licensee did not comply with the section cited above in that S2 and S3 did not have the required number of training hours completed, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: Facility to submit current and completed training certificates in the requried number of hours by plan of correction due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Jul 22, 2025

87405(a) Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. This requirement not met as evidenced by: Administrator does not have an actively current Administrator certificate. This poses an immediate health, safety or personal rights risk to residentsthe state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: Administrator to submit copy of current Administrator certificate.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Christi Coppo and Elias Magdaleno arrived unannounced to conduct a required Annual inspection and was greeted by licensee Luningning Alicdan. At approximately 9:30am LPAs and licensee toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Garage cabinet containing cleaning supplies was unlocked, LPAs discussed with licensee cabinet must remain locked at all times. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. Extra hygiene products and linens were available. LPAs observed resident room 2 had commode full of waste and urine, with very strong odor filling the room. LPAs observed resident room 4 to have strong odor from urine as well. LPAs discussed with licensee importance of keeping facility and residents free from odors of incontinence (deficiency cited see 809D). Hallway floor in front of water heater closet outside of main hall bath has water damage. Per licensee, water damage caused by leaking water heater that was recently replaced. LPAs and licensee observed the laminate flooring was uneven as a result of damage and bowed inward under weight (deficiency cited see 809D). Resident bathroom had required bath mat and grab bar. Water temperature in sinks accessible to residents in care measured at 119.3 degrees F in hall bath and 117.6 degrees F in room 1A/1B which are within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 5/31/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted 12/5/24. Facility has a backup generator for use during a power outage. Continued on 809C... Continued from 809... At approximately 11:30am LPAs conducted review of five (5) staff records. Three (3) of five (5) staff (S1, S2, S3) did not have First Aid (deficiency cited see 809D). Two (2) of five (5) staff (S2, S3) were not associated with facility. However, licensee has previously discussed with LPA issue they are encountering with Guardian and being locked out/not able to access their account. LPA previously advised licensee that when they experience a pinch with Guardian to notify LPA and send LPA form LIC9182 so that LPA can associate the staff member to the facility. Licensee agrees and will immediately send LIC9182 to associate S1 and S2. Both S1 and S2 had fingerprint clearance and proof of clearance on file. At approximately 1:10pm LPAs conducted a review of six (6) resident records. No deficiencies. At approximately 3:00pm LPAs and licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies. Luningning Alicdan Administrator Certificate 7002894740 expired 10/10/2023, LPAs verified licensee is in pending renewal stauts. All fees are current as of this time. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report Liability Insurance 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 Caregiver. 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, Feb 14, 2025

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

Licensing Program Analysts (LPAs) Christi Coppo and Elias Magdaleno 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 809C... Continued from 809... Today, LPAs conducted an annual inspection in conjunction with the Non-Compliance inspection. Licensee found to be in compliance as pertains to Administrator duties and plan of operation and pre-pouring of medication. Licensee has followed through with TSP. Licensee found out of compliance pertaining to personal rights of residents in that LPAs observed resident room 2 had commode full of waste and urine, with very strong odor filling the room. Staff (S3) advised LPAs that they will wait until after resident (R2) is finished with breakfast. R2 was eating breakfast in their room where commode full of waste and urine was also present. LPAs advised that waste and urine should be immediately discarded as soon as possible, letting it sit for extended periods of time is not conducive to a healthy environment; additionally, the facility must be kept free of incontinence odors. LPAs observed resident room 4 to have strong odor from urine as well. LPAs discussed with licensee and again discussed the importance of keeping facility and residents free from odors of incontinence, deficiency cited on Annual inspection. LPAs found two [2] staff (S2 and S3) not associated to the facility. However, licensee has previously discussed with LPA issue they are encountering with Guardian and being locked out/not able to access their account. LPA previously advised licensee that when they experience a pinch with Guardian to notify LPA and send LPA form LIC9182 so that LPA can associate the staff member to the facility. Licensee agrees and will immediately send LIC9182 to associate S1 and S2. Both S1 and S2 had fingerprint clearance and proof of clearance on file. Licensee found out of compliance with staff training as three [3] out of five [5] staff (S1, S2, and S3) did not have First Aid training on file, deficiency cited on Annual inspection. Licensee has not had any outstanding deficiencies to clear in a timely manner, so licensee found to be in compliance with clearing deficiencies timely. LPAs reviewed LIC500 and find that licensee is in compliance pertaining to staffing. Licensee in compliance with resident records with the following exception: Resident (R1) has a physician’s report dated 1/16/24 with a DX of dementia; however, resident is on hospice. LPAs reviewed hospice care notes which are current as of 2/12/25. LPAs discussed with Admin getting a current hospice care plan with current dates from hospice company. All deficiencies referenced cited on annual inspection (see 809Ds). Exit interview conducted with licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Feb 14, 2025

Allegation investigated: Staff left resident in soiled depends/linens for an extended period of time

At approximately 9:30am, Licensing Program Analyst (LPA) Christi Coppo and Alicdan Luningning met at the Santa Rosa Regional Office and LPA delivered findings regarding the above allegation. Complaint alleges staff left resident in soiled depends/linens for an extended period of time. Reporting party was informed that resident at facility was found by a witness in soiled briefs and linens, appearing that the soiling occurred overnight. Photographic evidence of soiling was provided to CCL during CCL investigation. LPA interviewed witness that observed resident in soiled briefs on a prior occasion and LPA observed resident in soiled briefs when conducting investigation. LPA also observed resident’s room to have a strong smell of urine when conducting the annual inspection at facility in February of 2024. In February, licensee explained that the reason for the strong urine smell was due to resident frequently urinating. Continued on 9099C... Substantiated Continued from 9099... Facility caregiver stated to interviewed witnesses, that resident frequently urinates. Witnesses interviewed explained that licensee advised them of the same thing, that this resident frequently urinates so they cannot always be kept clean and dry. LPA interviewed licensee and caregiver at facility, both explained that resident frequently urinates and is on an incontinence brief changing schedule. Resident is on a changing schedule as they require medication previous to their being changed because they experience pain when being repositioned. Caregiver explained that the resident gets changed by our schedule which is: between 9am and 10am after morning shift caregiver serves all other residents’ breakfast, at noon if resident needs it, at 4pm, at 8pm, then at 10pm or midnight depending on when afternoon caregiver leaves the facility. So, between 10pm or midnight until 9am the next day resident is not changed. Per review of resident’s hospice care plan, resident is to be repositioned every 3 to 4 hours for pressure relief. Hospice care plan also specifies that resident is to have an incontinence check every 3 to 4 hours to mitigate skin breakdown. However, per interview with licensee and caregiver, resident is not attended to for anywhere between 9 and 12 hours overnight. Therefore, based on LPA's observations, photographic evidence, 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 LIC9099D.the state’s words, verbatim · CDSS document, Jul 31, 2024 · control 21-AS-20240705095753

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(2) · Plan of correction due date: Aug 1, 2024

87625(b)(2) Managed Incontinence (b) In addition to Section 87611...the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night This requirement is not met as evidenced by: Based on evidence obtained during investigation, the licensee did not comply with the section cited above in that licensee did not ensure incontinence needs were met per hospice care plan, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 31, 2024

Plan of correction: Facility to update care plan for resident per hospice care plan and send LIC500 showing sufficient staff to meet care and incontinence needs.

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: POC

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Luningning Alicdan. On 5/16/2024 LPA Coppo conducted a Case Management to address Licensee’s failure to respond to and work with CCL’s Technical Support System (TSP) in order to gain compliance with regulations for which they received deficiency citations on 2/8/2024. Deficiencies issued on 2/8/2024 were re-cited. Upon LPA arrival at facility on 5/16/2024 LPA and caregiver observed unlocked medication cart in living room and also observed unlocked hallway closet containing toxins. Two civil penalties were issued for repeat citations of these deficiencies: 87465(h)(2) and 87705(f)(2), respectively. The CCL report issued on 5/16/2024 reiterated CCL’s finding that facility's training materials provided by Licensee do not meet regulation. Licensee was to submit updated training materials that meet regulation by 5/23/2024. Additionally, once the submitted training materials were approved by CCL, licensee was to conduct required training in order to fulfill respective plan of corrections for deficiencies cited and re-cited on 5/16/2024. As of today, 5/31/2024 CCL has not received from facility any training materials submitted for approval. However, licensee submitted to CCL on 5/28/2024 LIC9098s self-certifying that training was conducted by licensee on May 18, 2024 and May 19, 2024, respectively, to fulfill plan of corrections for deficiencies: 87465(h)(2) and 87705(f)(2). The plan of correction for deficiencies 87465(h)(2) and 87705(f)(2) stated “Facility to submit to CCL a plan to train staff to properly store medications. Plan due by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 5/31/2024. Training log to include name of trainer, name of course, staff attendees and hours completed.” Due to facility not having approved training materials to conduct training, the plans of correction for deficiencies 87465(h)(2) and 87705(f)(2 have not been fulfilled. Civil penalties are being assessed in the amount of $100 per day for failure to correct deficiencies 87465(h)(2) and 87705(f)(2). Continued on 809C... Continued from 809... Per CCL and licensee agreement during office meeting on 3/29/2024, licensee was to review and submit their Plan of Operation to ensure facility's compliance with Title 22 regulations going forward. As of 5/16/2024 licensee had not provided CCL with Plan of Operation and the deficiency was cited on 5/16/2024. On 5/28/2024 CCL received from licensee an outline of their plan of operation, not the pertinent portion that addresses training. However, the plan of correction issued by LPA did not specify that the portion of the plan of operation being requested specifically pertains to training. Therefore, LPA is giving an extension for deficiency 87208(a) until 6/7/2024. LPA and Licensee discussed choosing a vendor for training from the vendor list that LPA emailed to licensee on 5/7/2024, as they are already approved and therefore licensee will not need to submit training materials for CCL to approve. Should licensee chose an approved vendor, licensee will notify LPA of selection choice no later than 6/10/2024. Should licensee not choose an already approved vendor, licensee will need to submit training materials to CCL for approval no later than 6/10/2024. Once training materials are either approved or an approved vendor is chosen, licensee to complete trainings in order to fulfill plans of correction for deficiencies re-cited on 5/16/2024. Licensee will have employees complete the trainings required in order to fulfill plans of correction for deficiencies re-cited on 5/16/2024 by 6/24/2024. **Civil penalties assessed in the amount of $100 per day for failure to correct deficiencies 87465(h)(2) and 87705(f)(2), respectively (see LIC 421FC).** 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 Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, May 31, 2024

Type of visit: Case Management - Other

At approximately 11:15am Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and was greeted by caregiver. Licensee Edward Alicdan arrived later. Facility currently has 6 residents in care, one of which is on hospice, which is allowable per the facility's Hospice Waiver. Upon arrival at facility LPA and caregiver observed unlocked medication cart in living room (deficiency cited and civil penalty issued for repeat violation within 12 months, see 809D and LIC421FC). Upon arrival LPA and caregiver observed unlocked hallway closet containing toxins (deficiency cited and civil penalty issued for repeat violation within 12 months, see 809D and LIC421FC). LPA reviewed Physician's Report for new resident R1 and found it not to be signed by a physician. Per licensee, the unsigned Physician's report is the only one retained by facility for resident (deficiency cited, see 809D). On 3/29/2024 Licensee came to the SRRO for an informal meeting to discuss recent citations and corresponding plans of corrections not fulfilled. Licensee expressed interest in participating in CCL’s Technical Support System (TSP) in order to gain compliance with regulations for which they received deficiency citations. On 4/4/2024 CCL’s Technical Support Program analyst reached out to Licensee to confirm interest in participation, no response was received. On 4/22/2024 LPA received notification from Technical Support Program analyst advising they have not received a response from licensee to date. TSP analyst advised the licensee that signed participation agreement must be received by 4/25/24. On 5/1/2024 the Technical Support Program analyst sent a closure letter to the licensee, closing the referral due to lack of response by the licensee. Citations issued on 2/8/2024 were cleared during office meeting because Licensee agreed to TSP. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies issued on 2/8/2024 are being re-cited (deficiencies cited, see 809D). Continued on 809C... Continued from 809... Per agreement during office meeting with licensee on 3/29/2024, licensee was to review and submit their Plan of Operation to ensure facility's compliance with Title 22 regulations going forward. As of today, 5/16/2024 licensee has not provided CCL with review of Plan of Operation (deficiency cited, see 809D). 87208 Per agreement during office meeting with licensee on 3/29/2024, licensee was to send over Health Screen, Training, and 1st Aid/CPR for new employee at Fallen Leaf Dr. As of today, CCL has not received the required documentation (deficiency cited, see 809D). CCL review of facility's training materials provided by Licensee do not meet regulation. Licensee to submit updated training materials that meet regulation by 5/23/2024. Once training materials are approved by CCL, licensee to conduct required training in order to fulfill respective plan of corrections for deficiencies cited and re-cited today. 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. Failure to correct the cited deficiencies, 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 $250 has been issued for repeat violation of regulation 87465(h)(2) and an immediate civil penalty in the total amount of $250 has been issued for repeat violation of regulation 87705(f)(2). See LIC421FC** Exit interview conducted with Licensee and a copy of this report was giventhe state’s words, verbatim · CDSS document, May 16, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: May 30, 2024

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year... This requirement was not met by licensee as evidenced by: Based on LPA observation the Physician's Report for new resident R1 was not signed by a physician. Per LPA interview with licensee, the unsigned Physician's report is the only one retained by facility for R1, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Facility to submit pictures of Physician's report for R1 that is signed by their physician by plan of correction due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87208(a) · Plan of correction due date: May 30, 2024

87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation. This requirement was not met by licensee as evidenced by: Per agreement during office meeting with licensee on 3/29/2024, licensee was to review and submit facility's Plan of Operation. Licensee has not submitted Plan of Operation to CCL, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Facility to submit to CCL the facility's Plan of Operation by plan of correction due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 17, 2024

87465 (h) The following requirements shall apply to medications...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 med cart in living room was unlocked which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Facility to submit to CCL a plan to train staff to properly store medications. Plan due by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 5/31/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed. A civil penalty in the amount of $250 is being assessed for repeat violation within 12 months.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(2) · Plan of correction due date: May 17, 2024

87705 (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication... cleaning supplies and disinfectants. This requirement was not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that the hallway closet containing toxins was unlocked and accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Facility to submit plan on how they will store toxins to be in compliance by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 5/31/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed. A civil penalty in the amount of $250 is being assessed for repeat violation within 12 months.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Jun 6, 2024

87465 (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: LPA observation, the licensee did not comply with the section cited above as unlocked drawer in kitchen contained pre-poured medication. Due to Licensee’s failure to respond to and work with CCL's TSP to correct identified concerns, deficiencies are being re-cited.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Facility to train staff to properly store medications. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees, and hours completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(f)(2) · Plan of correction due date: Jun 6, 2024

87303(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that syringe for insulin was found accessible, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Facility to train staff to properly store syringes. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a)(11) · Plan of correction due date: Jun 6, 2024

87412 (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening...This requirement is not met as evidenced by: Based on LPA record review, the licensee did not comply with the section cited above in that staff (S1) did not have health screen, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Facility to submit to CCL health screen with clear TB for S1 and S3 by plan of correction due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.625(b)(2) · Plan of correction due date: Jun 6, 2024

HSC 1569.625 (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually... This requirement is not met as evidenced by: Based on LPA record review, the licensee did not comply with the section cited above in that training records for staff not available, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Facility to submit proof of training to CCL for S1, S2, and S3 by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9) · Plan of correction due date: Jun 6, 2024

87555(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that opened food items in refrigerator were not covered or labeled, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Facility to conduct staff training on how to properly store opened food items. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(23) · Plan of correction due date: Jun 6, 2024

87555(b) The following food service requirements shall apply: (23) All readily perishable foods...capable of supporting... growth of micro-organisms...shall be stored in covered containers at appropriate temperatures. 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 bowl of cooked pasta left out overnight, which posed a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Facility to conduct staff training on how to properly store cooked food items. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(f)(1) · Plan of correction due date: Jun 6, 2024

87705 (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that kitchen drawer containing sharp knives not locked, which poses/posed a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Facility to conduct staff training on how to properly store sharp knives and items that could danger residents by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed.

Type of visit: Office

Licensing Program Manager Victoria Bertozzi and Licensing Program Analyst Christi Coppo conducted an informal office meeting, and met with Licensee/Administrator, Luningning "Bot" Alicdan. This informal meeting is being conducted to discuss concerns identified in regards to the following areas: Physical plant issues Staff training Personal rights Medication Resident Records Bedridden fire clearance LPM offered TSP services, Licensee expressed interest in participating in the Department's Technical Support Program. LPM will obtain further information regarding the program. Licensee must review Title 22 regulation and their Plan of Operation to ensure compliance. Continued non-compliance may result in a Non-Compliance Plan. Licensee and LPA discussed new employee at Fallen Leaf and Licensee will send over Health screen, training, 1st Aid and CPR. Exit interview conducted with Licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 29, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Licensees (Bot) and Edward Alicdan arrived later. Facility currently has 3 residents in care one of which is on hospice, which is allowable per the facility's Hospice Waiver. . At approximately 9:00am LPA and Licensee toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. LPA and Licensee observed the following food items to not be covered or labeled: sliced cake, 1/2 of a tomato, brown liquid in a cup, and red sauce in a bowl. Per Title 22 regulation 87555(b)(9) General Food Service Requirements - (b) The following food service requirements shall apply: (9)Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service (deficiency cited, see 809D). LPA and Licensee observed one bowl of cooked pasta on stove top in cooking pot not properly covered. Per Licensee, pasta left out overnight and during the day before, at room temperature. Per Title 22 regulation 87555(b)(23) 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 (deficiency cited, see 809D). LPA and Licensee observed kitchen drawer containing sharp knives not locked. Per Title 22 regulation 87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s) (deficiency cited, 809D). All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. LPA and Licensee observed rash bins in residents rooms are not covered. Per Licensee, trash bin in R2's room contained soiled brief for at least 2 days. Per Title 22 regulation 87303(f)(3) Maintenance and Operation (f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof (deficiency cited, see 809D). Continued on 809C... Continued from 809... Resident bathrooms had required bath mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 112.2 and 114 degrees F respectively, which is within the allowable range of 105 to 120 degrees F. LPA observed a 64 ounce jug of bleach accessible in the hallway shower and there was approximately 4 ounces remaining in the jug. Unlocked hallway closet had toxins accessible including acetone and disinfectants. Per Title 22 regulation 87705(f)(2) Care of Persons with Dementia (f) 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.(deficiency cited, see 809). Fire extinguishers were last inspected 7/14/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have an auditory alert system that was functional at time of inspection. Per LPA and Licensee observation and record review, facility has not conducted quarterly disaster drill since 2020, as documented in disaster drill paperwork. Licensee began to fill out fire drill paperwork dating it with a date in the future (2/10/2024) and signing the names of the attendees with date of attendance. LPA advised facility can not do the paperwork prior to conducting the actual drill as it may appear that the drill was not actually completed. Per Health and Safety Code HSC 1569.695(c) - Other Provisions (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenario... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill (deficiency cited, see 809D). Facility has a backup generator for use during a power outage. Upon LPA arrival to facility at approximately 8:45am, LPA observed medication cart in living room to be unlocked. All medication stored in cart was accessible to residents. Per Title 22 regulation 87465(h)(2) 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 responsible for...the centrally stored medication (deficiency cited, see 809D). Continued on 809C... Continued from 809C... At approximately 9:15am LPA and Licensee observed unlocked drawer in kitchen to contain prescription Tramadol, unwrapped insulin syringe, and pre-poured medication in dishes. Per Title 22 regulation 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 (deficiency cited, see 809D). Syringe for insulin found accessible in unlocked kitchen drawer. Syringe was unwrapped from packaging and possibly was used. Per Title 22 regulation 87303(f)(2) Maintenance and Operation (f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens (deficiency cited, see 809D). At approximately 10:00am LPA observed resident's bathroom shower (R3) in room #1 to have the drywall/sheet rock missing from around shower spigot and pipe(s) exposed. Per Title 22 regulation 87307(d)(2) 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 (deficiency cited, see 809D). At approximately 1:00pm LPA conducted a review of three resident records. Facility has one resident (R1) that is bedridden but does not have bedridden fire clearance and could not produce proof of notification to fire department. Per Title 22 regulation 87606 Care of Bedridden Residents (b) A facility shall notify the local fire jurisdiction within 48 hours of accepting or retaining any bedridden person, as specified in Health and Safety Code Section 1569.72(f).(deficiency cited, see 809D). Resident (R1) did not have a current LIC602 Physician's Report, last report dated 2022. Per Title 22 regualtion 87705(c) Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually... (deficiency cited, see 809). R1 did not have a current Appraisal Needs and Services plan (Care plan) on file. Per Title 22 regulation 87705(c) Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals (deficiency cited, see 809D). Continued on 809C... Continued from 809C... At approximately 2:00pm LPA conducted a review of two staff records. Both staff (S1 and S2) were missing required training. Per Health and Safety Code HSC 1569.695(b)(2)87458(b)(1) (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 (deficiency cited, see 809D). Staff (S1) did not have Health Screen on file. Per Title 22 regulation 87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:(11) A health screening as specified in Section 87411, Personnel Requirements - General (deficiency cited, see 809D). Luningning Alicdan, Administrator Certificate 6010428740 expired October 2023; however, certificate is currently in Renewal-Pending status. All fees are current as of this time. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Evidence of Liability Insurance 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 Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Feb 8, 2024