Br Care

Type of visit: Required - 1 Year

On 09/17/2025 at 12:20PM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Natividad Masiddo, Caregiver and explained the purpose of the visit. Administrator, Jamie Bernardino-Ruiz arrived at 12:42PM. The facility’s fire clearance was approved for five (5) non-ambulatory and one (1) bedridden resident. LPA toured facility with Jamie including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of ten (10) bedrooms, four (4) bathrooms with three (3) bedrooms occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 120.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of nonperishable and 2 days of perishable foods. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced 08/26/2025. First aid kit was observed to be complete. Fire drill last conducted on 07/28/2025. Emergency disaster plan last updated 09/25/2024. Continues on LIC809C Continued from LIC809. Five (5) staff records were reviewed; all five (5) staff were associate. LPA also reviewed all five (5) resident records, and they were complete. LPA requested the following documents to be submitted to CCLD by 09/24/2025. LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan (last page) Liability Insurance Updated Facility Sketch LPA observed no deficiencies during visit. Exit interview conducted a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 17, 2025

Type of visit: Post Licensing

On 10/23/2024 1:50PM, Licensing Program Analyst (LPA) T.Syess-Gibson conducted an unannounced Post Licensing inspection and met with Administrators (ADMs). LPA explained the purpose of the visit with ADMs. Administrator 1, holds a current certificate (#7035384740), which expires on 10/04/2025. Administrator 2, holds a current certificate (#6037285740), which expires on 10/04/2025. LPA observed one male resident with his wife in the living room watching TV and another male in his room watching TV. At 2:10PM, LPA inspected including, but not limited to, living room, kitchen, dining area, bathrooms, bedrooms, laundry area, activity room and outside areas. There were no bodies of water present at the facility. The facility has ten (10) bedrooms and four (4) bathrooms. Three bedrooms and one bathroom is designated for staff use only. Ample supply of toiletries and linens are available. Sufficient lighting and furniture throughout facility. 2 day perishable and 7 day non perishable food supply are available. Facility's inside temperature is maintained at 72 degrees, F. At 2:26PM, LPA observed Hot water temperature in resident's bathroom was measured at 111.7 degrees, F. Medications, toxins and sharps observed stored locked and inaccessible to residents in care. Fire extinguisher, smoke and carbon monoxide detectors were observed operational. Emergency Disaster Plan dated 09/25/2024 was near required posters and were centrally posted. Exits and passageways are free of obstruction. Disaster drills are conducted every three months. Continued on next page, LIC809-C Continue from LIC809 At 2:41 PM LPA reviewed two (2) residents and four (4) staff files, medication and medication logs. Staff were fingerprint cleared and associated to facility. Resident file contain Admission agreement, Pre-placement appraisal, ID/Emergency information, Personal Rights, Physician's report, Safeguard of property & valuables. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/25/2024: · LIC 500- Personnel Report · LIC 308- Designation of Facility Responsibility · LIC 610E- Emergency/Disaster Plan (9 pages) · Evidence of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided to Jamie Ruiz.the state’s words, verbatim · CDSS document, Oct 23, 2024

Type of visit: Prelicensing

On 09/26/2024 at 11:00am, Licensing Program Analyst (LPA) T.Syess-Gibson conducted an announced pre-licensing visit and met with applicant Jamie Bernardino-Ruiz, Administrator. LPA explained the purpose of the visit with Administrator. The facility has an approved fire safety clearance for total capacity of six (6) residents, five(5) non ambulatory and one (1) bedridden residents. LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage, back yard. The facility has ten (10) bedrooms and four (4) bathrooms. Four (4) bedrooms available for staff. There is sufficient lighting around the facility. LPA observed all six (6) residents' rooms equipped with hospital beds without bed rails, each bed had clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases and mattress pads. All rooms have proper lighting. LPA observed Bathrooms showers/tubs were equipped with grab bars, non-skid mats and hygiene supplies were observed inside cabinet. LPA observed television in the common area and board games for activities. Communal dining room is equipped with sufficient tables and chairs for the residents. All toxins and sharp objects were locked inside the laundry and kitchen areas. Passageways and hallways were free of obstruction. Fire extinguishers were last purchased on 05/15/2024. Smoke detectors and Carbon Monoxide detectors were operational. Medication cabinet was locked, and first aid kit was complete. All exit doors in the facility are equipped with auditory signals. Hot water temperature is measured at 116.8 degrees F. Emergency Disaster plans are complete and easily accessible to staff. Comfortable temperature was observed at 74 degrees F. Continue on LIC809C Continue from LIC809 No issues noted during this pre-licensing inspection. Component III was conducted with Jamie Bernardino-Ruiz on pre-licensing visit dated 09/26/2024. The applicant was reminded of the statute that requires CCL to be notified within 5 business days of admitting their first resident. This notification may be done by phone, by mail, or by fax. LPA observed the facility is ready to be licensed. This report will be submitted to the central application unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 26, 2024

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for the Elderly (RCFE) Application Type: Initial Capacity: 6 Census (if any clients in care): none COMP II Participants: Jamie Bernardino-Ruiz, Applicant/Administrator Mark Ruiz, Applicant Interview Method: Telephone interview On September 13, 2024 at 9:00 AM, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program. 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Applicants & Administrator. Report sent via email and informed to return sign copy to CAB by end of business day today.the state’s words, verbatim · CDSS document, Sep 13, 2024