Family Home

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced Case Management/Health and Safety Check visit for the purpose of confirming that the facility is operating in accordance with licensing requirements. During the facility tour, LPA observed six (6) residents and two (2) caregivers present. Residents were observed eating an early lunch and appeared appropriately groomed. Due to cognitive limitations, residents were unable to answer LPA's questions during the visit. LPA observed cleaning supplies accessible to residents in bathroom drawers and in the backyard. LPA also observed that the facility did not have a sufficient two-day supply of perishable food available for the residents. Deficiencies will be issued as a result of the observations. During staff interviews, two (2) of three (3) staff reported that the facility administrator of record has not been present at the facility for the past few months. One (1) staff reported that it had been approximately one month since the administrator was last present at the facility. Exit interview was conducted with Medalyn Bandajo, Caregiver. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.the state’s words, verbatim · CDSS document, Aug 31, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 1, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions... and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met by evidence by: Here’s a polished deficiency statement: Based on observation during the facility walkthrough, LPA observed cleaning chemicals accessible to residents in the resident restroom cabinet, hallway restroom, and backyard which poses an immediate health, safety or personal rights risk to persons in care. .the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Licensee shall ensure all cleaning chemicals are stored in locked areas and inaccessible to residents at all times. Licensee shall submit proof of correction and a written plan detailing how the facility will ensure cleaning chemicals will remain secured and inaccessible to residents at all times. Proof of correction and the written plan shall be submitted by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(26) · Plan of correction due date: Sep 7, 2026

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met by evidence by: Based on observation during the facility walkthrough, the licensee did not comply with the section cited above, as the facility did not have a sufficient two-day supply of perishable food available for residents which poses/posed a potential health and safety or personal rights to residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Licensee shall ensure the facility maintains a sufficient supply of perishable food for a minimum of two (2) days at all times. Licensee shall submit proof of purchase, including receipts and photographs of the food supply by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Sep 11, 2026

(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by:Based on staff interviews, two (2) of three (3) staff reported that the facility administrator of record has not been present at the facility for the past few months. One (1) staff reported that it had been approximately one month since the administrator of record was last present at the facility which poses/posed a potential threat to the health and safety or personal right to residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Licensee shall ensure that a qualified administrator is present at the facility for a sufficient number of hours to effectively manage and oversee the day-to-day operations of the facility, as required. Licensee shall submit a written plan detailing how adequate administrator coverage will be maintained, including the administrator's proposed schedule and hours of presence at the facility. The written plan shall be submitted to CCL by the POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Blanca Gonzalez conducted a Case Management visit at the facility to collect documents requested during the annual conducted on 02/27/26. LPA was greeted by staff, and the purpose of the visit was explained. During today’s visit, LPA requested and obtained staff and client roster. LPA toured the physical plant and reviewed resident facility files, and staff facility files. During the physical plant tour, LPA observed a bottle of isopropyl alcohol on the counter top in the hallway and two (2) 1- gallon cans of paint under the bathroom sink in an unlocked cabinet, accessible to residents in care. Deficiency cited. Civil penalties issued for a repeat violation within 12 months. During file review, 1 staff did not have a facility file and was not associated to the facility. Interview with staff revealed it was their first day and documents had been submitted to the administrator prior to beginning. LPA was able to verify staff had background clearance on Guardian. Deficiency cited. Civil penalties issued for not obtaining a criminal background clearance transfer. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed today are indicated on the LIC809D page. Civil penalties in the amount of $350 ar Exit interview was conducted and a copy of this report, civil penalties and appeal rights were provided to Caregiver Eldie De La Rosa.the state’s words, verbatim · CDSS document, Jul 7, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 8, 2026

87309Storage Space and Access ...licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: LPA observed a bottle of isopropyl alcohol on the countertop in the hallway and two (2) 1-gallon cans of paint under the bathroom sink in an unlocked cabinet accessible to to residents, which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Corrected at the time of visit. Staff removed the items and secured them making them inaccessible to residents in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(a)(3) · Plan of correction due date: Jul 8, 2026

Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3)Request a transfer of a criminal record clearance… This requirement is not met as evidenced by: Based on interview and record review, 1 staff was not associated to the facility on Guardian prior to working at the facility which poses an immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Administrator is to ensure that all staff are associated to the facility prior to working at all times. Administrator is to submit a written plan explaining how the facility will ensure all staff are associated to the facility prior to beginning work and submit the proof staff has been associated to the licensing agency for review by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual visit. LPA was greeted by staff and the purpose of the visit was explained. Manager Rathany Suy arrived to assist with the tour. The facility is licensed to serve age range 60 and over, six (6) non-ambulatory residents of which one (1) may be bedridden. Approved hospice waiver for two (2) residents. The facility is a single story home located in a residential area of San Dimas. The home consists of five (5) bedrooms, two (2) bathrooms, kitchen, dining area, living room, backyard and an attached garage. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Facility has an Infection Control Policy in place and was observed to be posted. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded area located in the backyard with sufficient seating for residents in care. Passageways and exits are free of obstruction. The water temperature was tested in bathrooms and one bathroom measured 106.7°F which is within the required 105° F - 120° F. The second bathroom measured 103.6°F, technical violation was issued. LPA observed grab bars and non-skid mats in both the bathrooms. continued on LIC 809CResident Resident bedrooms were toured and were observed to be clean and contain required furniture. Bed linens were clean and in good repair. There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Disinfectants and cleaning supplies are kept away from the food preparation areas and inaccessible to residents. Kitchen is kept clean and free from rodents, vermin and insects. Plates, cups and utensils are kept clean and stored properly. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to residents. Dining area was clean and had sufficient seating. Smoke detectors were observed throughout the facility. The carbon monoxide detector is located in the living room, was tested and is operable. Fire extinguishers were observed located near the kitchen and in the hallway; last serviced January 2025. Emergency drills are conducted quarterly; last drill was conducted in 12/29/25. Medications are centrally stored in a locked cabinet. Medications are documented and administered as prescribed. Four (4) staff files were reviewed and were observed to contain required documentation. Five (5) resident files were reviewed. 3 out of 5 residents medical assessments reflected a dementia diagnosis but ambulatory status instead of non-ambulatory due to a mental condition. Deficiency cited. The facility has an updated Emergency Disaster Preparedness plan in place. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D. Exit interview conducted, copy of appeal rights and a copy of this report was provided to Manager Rathany Suy.the state’s words, verbatim · CDSS document, Feb 27, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Licensee did not comply with change of ownership requirements.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint investigation visit on 01/10/2026 regarding the above allegation. During today’s visit LPA Ramirez was greeted by Caregiver Agieh Dulay and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff#1 – 6 interviews (S1 – S6), Resident#1-3 (R1 - R3), Interview with R1 and R5’s family, copy of disclosure regarding Real Estate Agency Relationship dated 05/22/2025, copy of admission agreement, copies of physician’s report for residents#1-5 (R1- R5), copies of medication administration record (MAR) October 2025 for R1 & R4, copy of Unusual Incident/Injury Report (LIC 624) for R1 & R5, and physical plant tour. SEE 9099-C Substantiated The investigation revealed the following: regarding the allegation “Licensee did not comply with change of ownership requirements.” It is alleged that the licensee did not comply with change of ownership requirements. Six (6) out of the six (6) staff interviewed corroborated this allegation. Three (3) out of the three (3) residents interviewed corroborated this allegation. Interview with resident#1 (R1) and resident#5 (R5) family corroborated this allegation. Interview with S1 revealed on or around May 2025, S1 sold the facility business to S2, and a contract was signed and enforced. S1 revealed that they did not inform this licensing agency prior to the sale or after the sale, nor did they inform their residents or family in writing regarding the sale of the facility. Interview with S2 revealed that S1 sold the facility business to them in May of 2025. During record review, LPA Ramirez reviewed copy of disclosure regarding Real Estate Agency Relationship dated 05/22/2025, which documents the sale of Family Home LLC from S1 to S2 and a close of escrow date of 06/01/2025. Per Title 22, Division 6, Chapter 8, Article 02- Transferability of License 87109(b)- The licensee shall notify the licensing agency and all residents receiving services, or their representatives, in writing as soon as possible and in all cases at least thirty (30) days prior to the transfer of the property or business, or at the time that a bona fide offer is made, whichever period is longer, as specified in Health and Safety Code Section 1569.191. Based on interviews, and records reviewed the licensee did not comply with change of ownership requirements, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. One (1) deficiency was issued. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided. The investigation revealed the following: regarding the allegation “Staff did not seek timely medical attention for residents.” It is alleged that that staff did not seek timely medical attention for residents. Five (5) out of six (6) staff interviewed denied this allegation. Three (3) out of three (3) residents interviewed denied this allegation. Interview with resident#1 (R1) and resident#5 (R5) family did not corroborate this allegation. Review of Unusual Incident/Injury Report (LIC 624) for R1 - R5 did not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. “Staff did not dispense medication to residents as prescribed.” It is alleged that staff did not dispense medication to residents as prescribed. Five (5) out of six (6) staff interviewed denied this allegation. Three (3) out of three (3) residents interviewed denied this allegation. Interview with resident#1 (R1) and resident#5 (R5) family did not corroborate this allegation. On 10/24/25, LPA Ramirez reviewed medication administration record (MAR) October 2025 for R1 & R5 and compared physician medication orders to MAR and did not observe any discrepancies. Review of Unusual Incident/Injury Report (LIC 624) for R1 - R5 did not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff spoke to resident in an inappropriate manner. It is alleged that staff spoke to a resident in an inappropriate manner. Five (5) out of six (6) staff interviewed denied this allegation. Three (3) out of three (3) residents interviewed denied this allegation. Interview with R1’s family revealed that R1 told their family that staff#5 (S5) had spoken “harshly” to R1. On 10/24/25, LPA Ramirez interviewed R1 and R1 denied that S5 or any staff spoke to them in an inappropriate manner. R1 revealed that staff at the facility “do good job, I do not have anything bad to say about anyone.” Interview with R5’s family did not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff did not maintain adequate food supplies for residents. It is alleged that staff did not maintain adequate food supplies for residents. Five (5) out of six (6) staff interviewed denied this allegation. Three (3) out of three (3) residents interviewed denied this allegation. Interview with resident#1 (R1) and resident#5 (R5) family did not corroborate this allegation. During facility tour, LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. LPA Ramirez observed additional perishable foods in garage refrigerator. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 10, 2026 · control 28-AS-20251017122852

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87109(b) · Plan of correction due date: Jan 16, 2026

The licensee shall notify the licensing agency and all residents receiving services, or their representatives, in writing as soon as possible and in all cases at least thirty (30) days prior to the transfer of the property or business, or at the time that a bona fide offer is made, whichever period is longer. This requirement was not met as evidenced by: intervews conducted and review of sale contract dated 5/22/25 which revealed the sale of Family LLC to S2 without notifying this agency first and it's residents prior to sale. This poses a potential risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Jan 10, 2026

Plan of correction: Licensee will submit a change of ownership application to central application bureau by 01/16/2026 and send proof to LPA via email.

Type of visit: Office

An informal office meeting was held at the Monterey Park Adult and Senior Care Licensing Office. Regional Manager (RM) Tony Vasallo, Licensing Program Manager (LPM) Adeline Ho, and Licensing Program Analyst (LPA) Blanca Gonzalez met with Licensee Joel Villalva and potential applicant Shelly Yamashiro. The purpose of this meeting is to determine plans for continued operations of the facility, updates on the change of ownership between Villalva and Yamashiro, licensee responsibilities and non-compliance with Title 22 regulations. On 10/17/25, the Department was made aware that the facility may have gone through a change of ownership. During today's meeting, the following Title 22 Regulation Sections were discussed and materials provided during the meeting. • Reporting Requirement 87211 (RCFE); Potential applicant who is an Administrator will submit administrator change for Family Home LLC per licensee’s request. Potential applicant and licensee understand the responsibility for being an Administrator for more than two facilities. • Transferability of License 87109 (RCFE); Licenses are not for sale, residents are not for sale. Licensee understands that he cannot let the potential applicant use his license. Licensee and potential applicant understand that an application for change of ownership is warranted. continued on LIC 809C continued from LIC 809 •Sale of Licensed Facility, Health and Safety Code 1569.191 Licensee agrees to comply with this Health and Safety Code. • Eviction Procedures 87224 (RCFE); Licensee agrees to notify licensing of any changes and notify residents in writing about the changes. • PIN 19-12 ASC Adding or Changing Management Company. Licensee and potential applicant understands that an application is needed for adding a management company. Licensee agreed to provide the following to Licensing: • Provide LPA via email a copy of 60-day Eviction Written notice by 01/09/2026 • Required documentation for change of Administrator, submit to licensing for approval by 01/16/2026 • Update LPA, in writing, with date for leaving the country and included contact information • Licensee was advised they are responsible until the applicant has been issued a license • Potential applicant agreed to provide the following: • Submit an application to central application bureau by 01/16/2026 • Advise LPA via email once the application is submitted • submit to LPA, via email, staffing schedule, LIC 500 An exit interview was conducted, and a copy of this LIC 809 report was provided to Licensee Joel Villalvathe state’s words, verbatim · CDSS document, Jan 7, 2026

Allegation investigated: Staff working do not have criminal record clearance.

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Caregiver Arlene Dulay and explained the reason for today’s visit. House Manager Shelly Yamashiro was notified by telephone. The investigation consisted of the following: During the initial visit conducted on 11/04/2025 LPA Gutierrez interviewed S1. LPA obtained copies of the following documents: staff roster, resident roster and toured the garage. On today’s visit LPA Gutierrez interviewed staff 2-staff 3 (S2-S3) in person, staff 4 (S4) over telephone, residents 1-residents 4 (R1-R4), and delivered findings. See 9099C Substantiated In regard to the allegation “Staff working do not have criminal record clearance”, it is alleged that S5 was not fingerprint cleared. During interviews with staff one (1) out of four (4) S1 stated that they thought S5 was cleared and was unaware they were pending background clearance. During interviews with residents four (4) out of four (4) residents couldn’t remember S5. During record review LPA discovered that S5 was pending background check clearance and not cleared. Immediate Civil Penalties assessed during this visit. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was given to Caregiver Arlene Dulay. In regard to the allegation “Staff were drinking alcohol in the facility”, it is alleged that staff were drinking alcohol in the garage. During interviews with staff four (4) out of four (4) stated that they have never witnessed any staff drinking alcohol at the facility. During interviews with residents four (4) out of four (4) residents stated that they have never seen staff drink alcohol at the facility. During pre investigation LPA obtained a picture of alcohol in a drawer, however LPA cannot confirm where and when picture was taken. LPA toured garage at time of visit and did not observe any alcohol. In regard to the allegation” Staff were using drugs in the facility”, it is alleged that staff is smoking marijuana in the garage. During interviews with staff four (4) out of four (4) staff stated that they never witnessed staff doing drugs at facility. S1 stated that it was reported to him/her about possible drug use but S5 left facility and never returned. During interviews with residents four (4) out of four (4) residents stated they have not witnessed staff doing drugs at the facility. LPA obtained a picture of a pipe in a drawer however LPA cannot confirm where and when picture was taken. LPA toured garage at time of visit and did not observe any drugs. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Caregiver Arlene Dulay.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 28-AS-20251027133520

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Dec 12, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department This requirement was not met as evidenced by: S5 did not have record of criminal clearance transfer. This poses an immediate risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: Licensee will insure al staff is finger print cleared prior to working with residents. S5 no longer works at the facility.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christian Gutierrez generated this Case Management - Deficiencies report in conjunction with complaint control 28-AS-2025102733520 pertaining to observations during tour of facility. The purpose of the report was explained to staff. During complaint investigation, LPA Gutierrez entered unlocked attached garage and observed several pill boxes with prefilled medication for several residents in unlocked drawer accessible to residents. During the visit S4 stated that he/she knew that they were not supposed to have medication in pill boxes and hid them once they saw LPA. Based on observation, citations are being issued. See LIC 809D. An exit interview was conducted, and a copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Dec 11, 2025

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

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: LPA observed medication in an unlocked drawer in attached garage accessible to residents. This poses an immediate risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: Facility will conduct training with all staff on section 87465(h)(2) and submit to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(5) · Plan of correction due date: Dec 12, 2025

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by: LPA observed medication in prefilled pill boxes in an unlocked drawer in attached garage. This poses an immediate risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: Facility will conduct training on section 87465(h)(5) with staff and submit to LPA by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christian Gutierrez generated this Case Management - Deficiencies report in conjunction with complaint control 28-AS-2025102733520 pertaining to observations during facility tour. The purpose of the report was explained to staff. During complaint investigation, LPA Gutierrez was touring garage and observed an drawer with residents’ medication pre filled in pill boxes for the month. LPA spoke to S2, and it was revealed that he/she put them in the drawer because they knew that they were not supposed to have medication pre filled in pill boxes and did not want LPA to see them. Based on observation, a citation is being issued. See LIC 809D. An exit interview was conducted, and a copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Nov 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Nov 10, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by: Four residents’ medication were not stored in original container. S2 pre- filled medication for month and hid pill boxes in garage drawer because LPA made an unannounced visit and S2 knew they shouldn’t have had resident’s pills in boxes.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: Facility will conduct training to all staff on section 87465(h)(5) and send completed log to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit-Deficiencies on 10/24/2025. LPA was greeted by Caregiver- Shirely Espinoza and explained the purpose of the visit. Case Management findings: On 10/24/2025, LPA Ramirez was conducting a staff records review, and it revealed that staff#1 (S1) and staff#2 (S2) did not complete a criminal clearance transfer prior to working at the facility. Interviews with S1 and S2 revealed they began their employment at the facility 2 weeks ago. Per title 22, Division 6, Chapter 8- Criminal Record Clearance 87355(e)(1)(3): (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Submit a valid mailing address at which the individual shall receive communications from the Department. (3) Request a transfer of a criminal record clearance as specified in Section 87355(c). Based upon records reviewed and interviews conducted, LPA Ramirez will issue one (1) Type A deficiency and one (1) civil penalty in the amount of $1000.00. During tour of physical plant, LPA Ramirez observed refrigerated medication for Resident#1 (R1) on the side door of the kitchen refrigerator which was observed to be unlocked. Per title 22, Division 8, Chapter 8- Incidental Medical and Dental Care 87465(h)(2): (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 supervision of the centrally stored medication. Based upon observation, LPA Ramirez will issue one (1) Type A deficiency. Two (2) deficiencies were cited for this visit, and one (1) civil penalty was issued. Exit interview was conducted via telephone with Administrator Joel Villalva. A copy of this report, 809-D, LIC 421BG, and appeals rights were provided.the state’s words, verbatim · CDSS document, Oct 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1)(3) · Plan of correction due date: Oct 27, 2025

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Submit a valid mailing address at which the individual shall receive communications from the Department. (3) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by: S1 and S2 did not have record of criminal clearance transfer. This poses an immediate risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Licensee will develop a plan on when S1 and S2's criminal clearance transfer will be completed and how the facility will comply with this regulation until this is completed.

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

(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 supervision of the centrally stored medication. This requirement was not met as evidenced by: R1's refrigerated medication was not in a locked place and was accessible to other persons besides staff. This poses an immediate risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: Licensee will draft plan on how the facility will comply with regulation.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Elizabeth Irra conducted an annual inspection visit. LPA met with Joel Villalva/S-1 and discussed the purpose of today’s visit. This home is a single-story home with (5) bedrooms, (3) bathrooms, kitchen, dining area, living room and an attached garage. The fire clearance is approved for (6) non-ambulatory residents, of which (1) may be bedridden. This home also has an approved Dementia Care Plan and a Hospice Waiver approved for (2) residents. There are currently no residents receiving hospice care nor any residents are bedridden. Mr. Villalva showed LPA proof of the required liability insurance and will be e-mailing a copy of the insurance coverage to LPA. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility has an Infection Control Policy in place and was observed to be posted. Operational Requirements: Facility is adhering to the operational requirements. Physical Plant & Environment Safety: LPA toured facility grounds. Fire smoke alarms and carbon monoxide detectors observed. The fire extinguisher is located in the kitchen, hallway and garage and were last serviced on 01/08/25. Bathrooms have non-skid surfaces and grab bars. Refer to LIC 809C for the continuation of this report. Staffing: Facility is adhering to staffing requirements. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for S-1 and Staff #2. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Resident Rights-Information: Resident rights are posted and are included in Resident files. Planned Activities: Activity provides planned activities. This facility also provides internet access to the clients. Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining areas have adequate seating. Resident Records-Incident Reports: LPA reviewed Resident file for Resident #1 (R-1). Resident files are maintained at the facility. Resident file has the required documents. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment and Preplacement Appraisal Information, Resident Pre-Appraisal. Resident Rights were observed. Disaster Preparedness: The facility has a Disaster Preparedness plan in place. Health Related Services/Incidental Medical Services: The medications are stored and locked. Medications are administered as prescribed. Exit interview conducted, copy of appeal rights and a copy of this report was provided to Joel Villalva/S-1.the state’s words, verbatim · CDSS document, Feb 28, 2025

Allegation investigated: Administrator engaged in an altercation with a staff in the presence of the residents.

Licensing Program Analyst (LPA) Alberto Lopez made initial unannounced visit to investigate the above allegation. LPA met with Latai Tuihalamak (Tai) DSP and Administrator Joel Villalva showed up a short time later. The investigation consisted of LPA interviewing three (3) staff (S#1-S#3) and three (3) residents (R#1-R#3). LPA took tour of facility. Allegation: Administrator engaged in an altercation with a staff in the presence of the residents. It is alleged that Administrator engaged in altercation with staff in resident’s presence. The investigation revealed that on 01/01/2025 around 1-2pm, S#3 arrived at facility and observed the Christmas tree on the ground in the living room and told S1 that he will go get a box to store it. Not to put in the garage. S1 was concerned that the tree was causing an obstruction and hazard to residents and took the tree to the garage. (Continued on 9099C) Substantiated (Continued to from 9099) Around 20 minutes later, S3 returned to facility and slammed the table (S#3 demonstrated how S3 slammed the table and stated it sounds loud because it is a loud table) in the dinning/living room because S3 stated he was having a bad day. Three (3) of three (3) staff were able to corroborate the allegation. One (1) of three (3) residents were able to corroborate the allegation. One resident could not recall anything happening on 01/01/2025 and one (1) resident was unable to answer questions. One resident stated it was not appropriate and was able to hear the slamming from resident's room. One (1) resident stated that S3 was yelling at S1 and apologized after saying I’m sorry, I’m sorry. Based on interviews with staff and residents, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, and Chapter 8 are cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Jan 7, 2025 · control 28-AS-20250102091448

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1)(3) · Plan of correction due date: Jan 10, 2025

87468.1(a)(1)(3) Personal Rights of Residents in All Facilities. (a)Residents in all residential care facilities for the elderly shall have all the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidence by: S3 slammed table inappropriately, and yelled at S1 in presence of residents. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 7, 2025

Plan of correction: Administrator will read section 87468.1 (a)(1)(3) and send a written statement to LPA certifying that he has read the section and understands it by POC date which is 01/10/2025. Administrator will also attend training on section 87468.1 for himself and staff and send copies of rosters with signatures for those in attendance.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alberto Lopez made initial unannounced visit to investigate a complaint allegation. LPA met with Latai Tuihalamak (Tai) DSP and Administrator Joel Villalva showed up a short time later. The investigation consisted of LPA interviewing three (3) staff (S#1-S#3) and three (3) residents (R#1-R#3). LPA took tour of facility. During the course of the investigation, LPA learned that the two staff currently working at facility have not been cleared or associated to facility. Deficiency cited on 809D, Civil penalties issued. $500 each staff.the state’s words, verbatim · CDSS document, Jan 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jan 8, 2025

Criminal Record Clearance Prior to working ... in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. This requirement is not met as evidence by: S1 and S4 are employed by facility for at least 5 days and have not been cleared and/or associated to facility which poses a health a safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 7, 2025

Plan of correction: Administrator will make sure staff are finger printed and associated to facility prior to working at facility, Due to supervision of resident's concerns, LPA did not ask Administrator to remove the staff from premises immediately. Administrator will associated and clear staff by POC date which 01/08/2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Administrator, Joel Villalva, and explained the purpose for the visit. During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (4) resident medications, (4) resident files, (3) staff files, and conducted interviews with (2) staff, and attempted interviews with (4) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (6) non-ambulatory residents, of which (1) may be bedridden. It has an approved Dementia Care Plan and a Hospice Waiver approved for (2) residents. There are currently no residents receiving hospice care. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file, as required. LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are (2) full bathrooms in the home- both equipped with required grab bars and non-skid mats. The hot water was tested and measured at 111*F, which is in compliance. Food supplies was observed and was sufficient as required. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. The last fire drill was conducted on 01/14/2024. Auditory devices were observed at all entrances/exits of the home and were operational. (4) resident files and (3) staff files were reviewed and observed to be complete with all required documentation. (4) resident medications were reviewed and were observed to be documented properly and given as prescribed. No deficiencies were observed or cited, during today's visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 13, 2024