Cortez Home

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds, including offices in the rear unit and detached storage shed. There are 3 client bedrooms--one with full private bathroom--two staff rooms--one for 2 staff with full private bathroom and the other for 4 staff--a common bathroom, living/dining area, family room, kitchen, and 2-car garage, where washer and dryer are located. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hot water temperature is tested at 109 degrees in front client bathroom. Food supply and first-aid kit are inspected. Client files are reviewed, including transaction records for clients' personal and incidental funds. A Disaster and Mass Casualty Plan is posted and emergency drills are documented quarterly. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records. Anaraar Manla is a certified RCFE administrator (x 1/27) that oversees facility operations. The following information/documents are requested to be sent to CCL by 7/3/26: • Proof of control of property (signed and dated lease agreement between landlord and licensee/tenant) • Proof of current liability insurance Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. See also Technical Advisory Notes--3 pages.the state’s words, verbatim · CDSS document, Jun 19, 2026

Type of visit: POC

In response to corrections submitted to CCLD as per annual inspection of 5/6/25, LPA Jeung met with new administrator to obtain additional information. Ms. Manla provided additional documents to support proof of corrections. LPA advised Ms. Ancheta of the following: - Annual licensing renewal fee of $495 plus late fee of $247 is due and payable - Revised lease agreement is between owner and a corporation, but licensee is an individual Per Ms. Ancheta, she has been added as co-owner and recorded document will be submitted - Submit correction of mailing address to San Bruno regional officethe state’s words, verbatim · CDSS document, May 27, 2025

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds, including offices in the rear unit and detached storage shed. There are 3 client bedrooms--one with full private bathroom--two staff rooms--one for 2 staff with full private bathroom and the other for 4 staff--a common bathroom, living/dining area, family room, kitchen, and 2-car garage, where washer and dryer are located. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hot water temperature is tested at 111 degrees in front client bathroom. Food supply and first-aid kit are inspected. Client files are reviewed, including Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records. Anaraar Manla is a certified RCFE administrator (x 1/27) that oversees facility operations. WRITTEN NOTIFICATION OF NEWLY DESIGNATED ADMINISTRATOR TO BE SENT TO CCLD, WITH QUALIFICATIONS. The following information/documents are requested to be sent to CCL by 5/20/25: • LIC 400 Affidavit Regarding Client/Resident Cash Resources • LIC 500 Personnel Report • Proof of control of property (signed and dated lease agreement between landlord and licensee/tenant) • Personnel Policies in facility's plan of operation Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. See also Technical Advisory Notes--6 pages.the state’s words, verbatim · CDSS document, May 6, 2025

Type of visit: Required - 1 Year

On 06/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with administrator Antolin Ucol and explained purpose of today's inspection. There are 3 staff present and no clients as they are out at day program. At 2:05pm one client returned from day program. LPA was allowed entry into the facility. This is a single level facility. Annual fees are not current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in a garage storage cabinet. Perishable and non-perishable food items are observed as in place. There are additional refrigerators and freezers in the garage areas which also carry additional food supplies. LPA observed the medications as in place and locked in a drawer in the living room. First aid kit is observed as complete with required items. LPA observed that there are multiple two extinguishers in place through out the facility last inspected on 05/03/2024, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. Facility is also equipped with fire pull alarm. PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational located in the garage area. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 107F in a resident bathroom. Bathtubs observed are equipped with non-skid mats. LPA observed all client rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place. Disaster drills take place monthly per records observed. Last taking place on 03/13/2024. Continued on next page... Page 2 LPA reviewed 2 client files and also reviewed 3 staff files on this day. All files are current per review made. P&I is handled by the facility and current per the records reviewed. Client medications are inspected and are current including facility medication administration records. Administrator certificate is observed as current expired on 11/18/2023 but has submitted the renewal has been sent and payment has been received. LPA informed the administrator that facility fees are not current. He says he will notify licensee that it needs to be paid. The following updated forms are requested to be submitted to CCLD by 06/19/2024: • Copy of updated Administrator Certificate • Updated surety bond with expiration date • LIC308 Designation of responsible staff person • LIC400 Affidavit Regarding Client/Resident Cash Resources • LIC402 Surety Bond • LIC610D Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property such as lease agreement with expiration date No citations issued. Report is reviewed with administrator Antolin. Copy is provided.the state’s words, verbatim · CDSS document, Jun 12, 2024