Legacy Senior Care

Type of visit: POC

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a POC visit. LPA met with Jokaveti Tubuna during today's inspection. On 5/13/26, LPA conducted a case management visit and found 2 residents were missing prescribed medications. Today LPA reviewed 2 resident medications and found all medications ordered by physician is present and facility MAR indicates medications have been given as ordered. POC has been cleared. During today's inspection no deficiencies were cited. POC letter was provided. Exit interview conducted and copy of the report given.the state’s words, verbatim · CDSS document, Jun 10, 2026

Allegation investigated: Staff are not preventing a resident from wandering away from facility Staff are not adequately supervising resident in care

Licensed Program Analyst (LPA) Bethany Mirlohi arrived at the facility unannounced and met with Jokaveti Tubuna to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Substantiated Staff are not preventing a resident from wandering away from facility Records reviewed indicated that Resident R1 was unable to leave the facility unattended. R1 enjoyed taking walks outdoors and would be accompanied by a staff member. On 03/26/2026, R1 turned off the front door alarm, which staff were aware R1 was able to do, and walked out the front door to stand in the driveway. Staff were only alerted that R1 left the facility when a neighbor saw R1 standing in the driveway and brought R1 back inside. Interviews conducted indicated that staff were “on-call” and sleeping as facility does not require wake staff at night. Staff S1 was made aware of R1 leaving the premises when a neighbor brought R1 back inside the facility early morning on 3/26/2026. Therefore, the allegation staff are not preventing a resident from wandering away from facility is substantiated. Staff are not adequately supervising resident in care Interviews conducted with administrator and staff member S1 indicated that Resident R1 was a wandering risk. Staff would take R1 on walks around the neighborhood but sometimes R1 would try to leave the facility unassisted by turning off the front door alarm and walking outside. Staff were aware the R1 had wandering tendencies and knew that R1 had attempted to elope prior to the incident on 3/26/2026. Records reviewed indicated that R1 was unable to leave the facility unsupervised. Therefore, the allegation staff are not adequately supervising resident in care is substantiated. Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted with Executive Director and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, May 13, 2026 · control 59-AS-20260401135846

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a)(b) · Plan of correction due date: May 14, 2026

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident This requirement is not met as evidenced by: Based on interviews and record review the licensee did not meet the needs of resident which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: Administrator agrees to conduct a training for all staff concerning resident elopement. Administrator to send to LPA the date of training that will take place for the staff by 5/14/26. Once training takes place, administrator to send into CCL a copy of the training.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87461(a)(b) · Plan of correction due date: May 14, 2026

87461 Mental Condition (a) The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual: (1) tends to wander; (2) is confused or forgetful; This requirement is not met as evidenced by: Based on interviewed and record review the licensee did not provide sufficient supervision which poses an immediate health , safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: Administrator agrees to submit a plan into CCL on how staff will supervisor and redirect residents that are an elopement risk. Plan to be submitted into CCL by 5/14/26.

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

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with care staff during today's visit. Care staff reported administrator was at an appointment during LPA's visit. LPA toured the facility and observed outdoor area, kitchen, resident room, staff room, and common areas. LPA observed all exits were clear. LPA toured kitchen and observed 2-day perishable and 7-day non-perishable amount of food. LPA reviewed 6 of 6 resident records and all appeared to be up to date. LPA reviewed 6 resident medications and observed missing medications. LPA observed R1 has an order for senna once time daily, and medication is not available. LPA observed R2 had two over the counter medications, multivitamin and ferrous sulfate, marked given on MAR but there is no medication available in facility. Deficiencies cited during today's inspection. Citations on 809-D. Civil penalties assessed for repeat violation. Copy of report and appeal rights given.the state’s words, verbatim · CDSS document, May 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 14, 2026

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Based on interviews and record review, staff are not providing medications as ordered by physician which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: Administrator to obtain medications for R1 and R2, or receive updated medication orders from physician. Administrator to send into LPA a receipt of medications purchased or updated orders by 5/14/26.

Allegation investigated: The facility allowed excluded individuals to work in the facility. Staff are forging resident documents. The Administrator is not present at the facility for a sufficient amount of time.

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Jokaveti Ulalea to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unfounded The facility allowed excluded individuals to work in the facility. Documents reviewed indicated that all staff present at the facility and currently listed on the staff roster are fingerprint cleared and associated to the facility. Interviews conducted with Administrator indicated that there are no uncleared staff at the facility and Administrator explained how she conducts hiring and fingerprinting staff prior to start date at the facility. Therefore, the allegation the facility allowed excluded individuals to work in the facility is unfounded. Staff are forging resident documents. Documents reviewed indicated that all physician signatures were from separate physicians and matched other signatures in each resident specific files. All resident files included all documents to meet regulatory requirements. In review of the staff files, signatures and printed names matched each staff file. Therefore, the allegation staff are forging resident documents is unfounded. The Administrator is not present at the facility for a sufficient amount of time. Observations made on unannounced visits by the Department made on 10/14/2025, 11/6/2025 and 2/19/2026 which indicated that the facility’s administrator was present at the facility. Documents reviewed indicated that a current staff schedule is being followed and is accurate to current staff working. Therefore, the allegation the administrator is not present at the facility for a sufficient amount of time is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 59-AS-20260212165627

Allegation investigated: Staff did not prevent resident from wandering from the facility Facility failed to meet reporting requirements

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Jokaveti Ulalea, to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unfounded Staff did not prevent resident from wandering from the facility Interviews conducted indicated that Resident R1 enjoys walking inside the facility and around the neighborhood. Staff accompany R1 on their walks due to R1 not being able to leave the facility unassisted. Staff S1 and Licensee both indicated that R1 has not eloped from the facility and is always accompanied during outside time and walks. Records reviewed indicated that R1 is unable to leave the facility unassisted which is why staff accompany R1 on their walks around the neighborhood. When R1 moved in to the facility, they were able to leave unassisted but now due to R1’s diagnosis, R1 must be accompanied by a staff member. Therefore, the allegation staff did not prevent resident from wandering from the facility is unfounded. Facility failed to meet reporting requirements Interviews conducted with Staff member S1 and Licensee indicated that incident reports are being completed and sent to the Department when an incident has occurred at the facility. S1 and Licensee indicated their knowledge of when and how incident reports are to be sent. Records reviewed indicated that incident reports are being completed and sent to the Department. Incident reports are kept at the facility for review as needed. Therefore, the allegation facility failed to meet reporting requirements is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 59-AS-20260305162555

Allegation investigated: Staff are mishandling a resident's medications Staff do not ensure a resident is attending scheduled medical appointments

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced to open and deliver findings for the allegations listed above. LPA met with Jokaveti Ulalea,during today’s visit. During today's inspection LPA conducted interviews, toured the facility and reviewed records pertinent to the investigation. At this time it is necessary to gather further information. Exit interview conducted and copy of this report given to facility. Unfounded Staff are mishandling a resident's medications Interviews conducted indicated that resident is taking their medications each day. Records reviewed indicated that resident is taking medications daily as prescribed. The quantity of medications at the facility indicate that medications are being given as prescribed. Medications on hand at the facility match the physician’s orders. Therefore, the allegation staff are mishandling a resident’s medications is unfounded. Staff do not ensure a resident is attending scheduled medical appointments Records reviewed indicated that facility is following and scheduling appointments for residents at the facility. Facility is also assisting with transportation to and from all appointments. Records indicated that facility staff made multiple attempts to encourage resident R1 to attend their scheduled appointments on 03/18/2026 and 03/23/2026. Resident R1 refused to attend both scheduled appointments. Facility staff documented refusals and let all appropriate agencies know of refusal. Interviews indicated that different staff made attempts to redirect and encourage resident R1 to attend scheduled appointments but resident R1 refused. Facility then assisted in rescheduling Resident R1's appointment for a later date. Therefore, the allegation staff do not ensure a resident is attending scheduled medical appointments is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 59-AS-20260322203954

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassandra Mikkelson and Licensing Program Manager (LPM) Laura Munoz arrived at facility to conduct an unannounced case management visit due to the Licensee's failure to pay licensing fees. LPA met with Administrator Adi Lina Tuiloma and explained the purpose of the visit. This facility has an outstanding balance for annual fees due. The current amount owed is $742.00 and was billed on 09/03/2025. As of this date, the fees are overdue. LPA explained to Licensee that proof of payment and/or proof of payment plan needs to be provided to CCL 03/19/2026. Per California Code of Regulations, Title 22, Type B deficiency is being cited today in violation of California Code of Regulations and follows on 809-D. Exit interview held with Caregiver and a copy of report provided.the state’s words, verbatim · CDSS document, Feb 19, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87156(b)(1)(F) · Plan of correction due date: Mar 19, 2026

Licensing Fees. (b) (1) In addition to fees set forth in subdivision (a), the department shall charge the following fees: A late fee that represents an additional 50 percent of the established annual fee when any licensee fails to pay the annual licensing fee on or before the due date as indicated by postmark on the payment. This was not met by evidenced by: Overdue licensing fees have not been paid for the 2025 year.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: Licensee will make payment in full for annual licensing fees due by POC due date of 03/19/2026.

Type of visit: Required - 1 Year

On 11/06/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a required 1 year annual inspection. LPA met with Administrator Adi Lina Tuiloma and explained the purpose of the visit. LPA and Administrator conducted a tour of the interior and exterior of facility. Areas toured include but not limited to two (2) shared bedrooms and two (2) private bedrooms, three (3) bathrooms, staff room, kitchen, common areas. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. In areas toured no immediate health and safety concerns. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins, cleaning supplies and knives are locked and inaccessible to residents in care. Fire extinguisher was last inspected on 10/16/2025. LPA observed required Licensing posters posted throughout the facility. LPA reviewed five (5) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. LPA reviewed three(3) staff files. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current training completed. LPA conducted a medication review of five (5) residents medications. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of the report and LIC809G was left at the facility.the state’s words, verbatim · CDSS document, Nov 6, 2025

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

On 10/14/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a case management visit. LPA met with staff, Mereisis Naisausau and explained the purpose of the visit. LPA notified Administrator, Adi Lina Tuiloma of LPA's presence at the facility. Administrator later arrived at the facility. During today's visit, LPA and Administrator conducted a tour of the facility to ensure the health and safety of residents in care. Storage space was inspected to confirm medications, toxins and sharps are locked and secured. LPA conducted a medication audit of three (3) residents. Resident #1 (R1) was prescribed Fluoxetine (40mg), Cyclobenzaprine (5mg) and Oxycodone (5mg) which were not present in the facility. Administrator said they will reach out to R1s doctor. Resident #2 (R2) was prescribed Clobetasol 0.05% ointment, Mupirocin 2% ointment and Terbinafine 250mg tablet which were not present in the facility. Administrator said they will reach out to R2s doctor. Resident #3 (R3) was prescribed Doxycycline 100 mg tablet and Levetriacetam 100 mg/ml solution which were not present in the facility. Administrator said they will reach out to R3s doctor. LPA conducted a file review of residents. All resident files contained required documents. Three (3) out of five (5) residents are non- ambulatory and require full or partial assistances with ADLs. One (1) resident is on hospice. One (1) resident requires a hoyer lift. Administrator stated that facility staff do not use the hoyer lift for R4. It is used for when transportation comes to take the resident to appointments. As a result of today's visit, deficiencies observed. Please see LIC 809-D. Copy of report and appeal rights provided during exit interview.the state’s words, verbatim · CDSS document, Oct 14, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 15, 2025

87465Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication audit the facility did not ensure that residents’ medications were reordered and present in the facility resulting in resident’s not being administered their prescribed medications. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: Licensee is to submit a plan on how the facility will ensure resident’s medications are ordered timely. Plan shall include procedures, staff responsibilities and training. Additionally, Licensee will reach out to R1, R2, R3 doctors for updated medication list. Due by POC due date

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(2) · Plan of correction due date: Oct 15, 2025

87405Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on medication audit and interviews facility did not comply to the section cited above as Administrator did not ensure medications are given as prescribed, which poses a immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: Licensee is to submit a plan on how they will ensure all Administrative duties are completed in a timely manner. By POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 1, 2025

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on records reviewed, the licensee did not comply with the section cited above as it has been identified that resident’s require additional staff during waking hours.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: Licensee is to have two (2) staff by 11/01/2025 and submit an updated LIC500 reflecting at least of two (2) caregivers minimum working at the facility during waking hours of 7 a.m - 7 p.m including the weekends and one (1) caregiver at night shift.

Type of visit: Office

A Non-Compliance Conference office meeting was held on 09/25/2025, at Sacramento Regional Office with the licensee Adi Lina Tuiloma and facility representative Una Phyllis to discuss the deficiencies found at the facility and the actions needed to bring the facility into compliance with Title 22 regulations. Present in the meeting were Community Care Licensing (CCL) staff, including Regional Manager Alycia Rayner, Licensing Program Manager Troy Ordonez, Licensing Program Manager, Laura Munoz, Licesning Program Manager, Stephen Richardson, Licensing Program Analyst Cassie Yang, Licensing Program Analyst Cheyenne Ratajczak and Licesning Program Analyst, Christina Valerio. During the meeting, CCL reviewed the facility’s history of citations, including several Type A and Type B violations since December 2024. The citations involved issues such as fire safety, resident rights, medication administration, staffing levels, administrator oversight, reporting requirements, and unsecured access to hazardous areas. CCL stressed the importance of taking immediate corrective action to ensure resident safety and meet licensing requirements. CCL expressed concern about limited administrator oversight, including the administrator’s low on-site hours, unresponsiveness to calls, and insufficient supervision of staff. Staffing levels were also noted as a concern, with coverage gaps that could put residents at risk. Delayed submission of Plans of Correction and incomplete documentation were identified as issues that need to be corrected right away. Please continue to LIC809C... The licensee agreed to take specific steps to fix these issues. These actions include making sure resident rooms meet licensed capacity, providing adequate staffing at all times, increasing administrator on-site hours or designating a qualified substitute, submitting personnel reports and supervision outlines, ensuring medications are available and administered on time, and conducting safety checks to secure chemicals and equipment. Licensee was provided a copy of Hospice Guide, Medication Guide, and Self-Assessment Guide. Additionally, CCL will submit a referral for technical support program. Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Sep 25, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility and met with Caregiver Dillon Williams, to conduct an unannounced case management visit on 08/28/2025. Caregiver and LPA Ratajczak attempted contact with Administrator. Administrator was unavailable during time of visit. The visit is to confirm Orders to Individual for Immediate Exclusion from All Facilities. LPA served order of immediate exclusion effective 08/28/2025 and explained the "Immediate Exclusion" notice indicating that staff member (S1) cannot be allowed to work, be present and/or live in a CCL licensed facility, or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Caregiver indicated they understood the notice. Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: POC

Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Cassandra Mikkelson arrived unannounced at the facility to conduct a Plan of Correction (POC) visit regarding the deficiencies LPA cited the facility on 08/06/2025 during a case management visit. LPAs met with Staff Dillon Williams and explained the purpose of the visit. Staff notified Administrator, Adi Lina Tuiloma of LPA's presence at the facility. Administrator was unable to meet at the facility and gave staff permission to assist and sign the report during today's visit. On 08/06/2025, LPA cited the facility on CCR 87405(a) and Licensee agreed upon a POC Due Date of 08/20/2025 Licensee will update LIC500 and have themselves on the schedule three days a week at the facility. Licensee did not ensure that the POC was corrected upon Due Date of 08/20/2025. LPA will be assessing a Civil Penalty of $100/day from 08/21/2025 to 08/26/2025 for this violation and will continue to accrue until POC is corrected. Additionally, during visit LPAs conducted a medication audit for four (4) residents. Civil Penalties were assessed during this visit for failure to correct the above violations by POC Due Date. Exit Interview was conducted. A copy of the report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Aug 26, 2025

Type of visit: Case Management - Other

On 08/06/2025 Regional Manager (RM) Alycia Rayner, Licensing Program Manger (LPM) Laura Munoz and Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit. RM, LPM and LPA met with Administrator and explained the purpose of the visit. RM, LPM and LPA Reviewed records and conducted a tour of the interior and exterior of the facility. During today visit, RM, LPM and LPA discussed the following with the Licensee: Staffing needs. The facility was cited on 02/19/2025 for staffing requirements. The Licensee was advised that the facility shall have (2) two staff working at the facility during all waking hours with an on call staff available. Administrator Qualification. The licensee was advised that the Administrator shall be at the facility a sufficient amount of hours. As a result of todays visit deficiencies cited and civil penalties assessed. Exit interview conducted and a copy of the report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Aug 6, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Aug 29, 2025

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interviews the licensee did not comply with the section cited above as it has been identified the facility has one (1) staff working at the facility 24 hours a day. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee is going to make job a posting on Indeed by 08/16/2025. Additionally, reaching out to people in church and contacting family and friends. Licensee plans to hire two people.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Aug 20, 2025

87405Administrator - Qualifications and Dutie(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 interviews the licensee did not comply with the section cited above as the Administrator is at the facility ten (10) hours a week. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee will update LIC500 and have themselves on the schedule three days a week at the facility.

Allegation investigated: Staff mishandled a resident's medication while in care

On 08/05/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings to a complaint Community Care Licensing (CCL) received on 03/24/2025. LPA met with Staff Dillon Williams and explained the purpose of the visit. Staff notified Administrator, Adi Lina Tuiloma of LPA's presence at the facility. Administrator was unable to meet at the facility and gave staff permission to assist LPA during today's visit. During the course of the investigation, the Department conducted interviews and record reviewed. Please continue to LIC9099C... Substantiated Allegation: Staff mishandled a resident's medication while in care The department conducted a medication audit of six (6) resident’s medications. The results are as follows: Resident #1 (R1) was prescribed Ascorbic acid and Zinc Sulfate which were not present in the facility. LPA interviewed the Administrator, Adi Lina Tuiloma who indicated it may need to be reordered. Resident #2 (R2) was prescribed ChlordiazePOXIDE, nitrofurantoin, and thiamine which were not present in the facility. Additionally, based on the facility Medication Administration Record (MAR) for R2, facility staff administered R2 Naltrexone 50MG however there were no orders for the Naltrexone on R2’s recent medication list. Resident #3 (R3) was prescribed Ascorbic Acid, Lidocaine, Melatonin, Multivitamins & minerals, NovoLOG FlexPen and Zinc Oxide, which were not present in the facility. LPA interviewed the Administrator, Adi Lina Tuiloma and asked where R3’s medications were. The Administrator stated they were unsure. Resident #4 (R4) was prescribed Acetaminophen-rectal suppository and Morphine Sulfate, both of which were not present in the facility. Resident #5 (R5) was prescribed Cephalexin 500mg, clobetasol 0.05%, ergocalciferol 1,250 mcg, FeroSul 325mg, mupirocin 2%, nystatin 100,00 unit/gram ointment, nystatin 100,000 unit/gram powder, risperidone 0.5 mg, sennosides-docusate sodium 8.6, thiamine 100 mg, vitamin D3- vitamin K2 (MK4) which were not present in the facility. Additionally, Hibiclens 4% Liquid was with R5s medications but not list on R5s medication list. LPA reviewed facility Medication Administration Record (MAR) and did not observe the medication as being given to R5. LPA asked Staff who stated it came with R5 from the skilled nursing facility. The facility has not used the Hibiclens 4% Liquid on R5. Resident #6 (R6) was prescribed Fluoxetine 40mg which was not present in the facility. Based on LPAs medication audit and interviews, the facility did not ensure that staff did not give residents their medication as prescribed. Therefore, 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 LIC 9099D As a result of today's visit deficiencies are cited. Exit interview conducted a copy of the report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 59-AS-20250324140656

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 6, 2025

87465Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication audit the facility did not ensure that residents’ medications were reordered and present in the facility resulting in resident’s not being administered their prescribed medications. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: The Licensee shall conduct the following: 1. Obtain updated medications orders for all resident’s in care 2. Compare medications present in the facility with resident’s medication orders 3. Order any medications prescribed to residents that are not present in the facility 4. If there are any medications in the facility that have been discontinued, the licensee shall obtain discontinue orders from physician and follow medication destruction regulations 5. Submit a plan on how the facility will ensure resident’s medications are ordered timely. Plan shall include procedures, staff responsibilities and training The licensee shall submit all resident current medication orders and discontinued orders by POC date (24 hours). The licensee shall submit plan by (2 weeks).

Type of visit: Case Management - Health Checks

On 05/01/2025 Licensing Program Manager (LPM) Laura Munoz and Licensing Program (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit. LPM and LPA met with staff Dillon Williams and explained the purpose of the visit. LPM and LPA conducted a tour of the facility. In the areas toured no immediate health, safety, or personal rights violations were observed. Additionally, LPM and LPA interviewed residents and staff No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, May 1, 2025

Type of visit: POC

On 03/11/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak and Cassandra Mikkelson arrived unannounced at the facility to conduct a Plan of Correction (POC) visit regarding the deficiencies LPA cited the facility on 02/19/2025 during a case management visit. LPAs met with Staff Mosese Delai and explained the purpose of the visit. LPA notified Administrator, Adi Lina Tuiloma of LPA's presence at the facility. Administrator was unable to meet at the facility and gave staff permission to assist and sign the report during today's visit. While on the phone with the Administrator LPA explained that failure to correct plan of correction by the given due date could and will result to $100 per day civil penalty until corrected. On 02/19/2025, LPA cited the facility on CCR 87211(2) and Licensee agreed upon a POC Due Date of 03/05/2025 Licensee is to submit a statement of understanding of this regulation. Additionally, the licensee shall submit a plan to the department on how the licensee will ensure the facility will meet reporting requirements timely. Licensee did not ensure that the POC was corrected upon Due Date of 03/05/2025. LPA will be assessing a Civil Penalty of $100/day from 03/06/2025 to 03/11/2025 for this violation and will continue to accrue until POC is corrected. On 02/19/2025, LPA cited the facility on CCR 87411(a) and Licensee agreed upon a POC Due Date of 03/05/2025 License is to have two (2) staff on the floor during waking hours. Licensee is to hire additional staff and send LPA updated LIC500 as well as the new staff facility file. Licensee did not ensure that the POC was corrected upon Due Date of 03/05/2025. LPA will be assessing a Civil Penalty of $100/day from 03/06/2025 to 03/11/2025 for this violation and will continue to accrue until POC is corrected. Please continue to LIC809C.... On 02/19/2025, LPA cited the facility on CCR 87411(a) and Licensee agreed upon a POC Due Date of 03/05/2025. Licensee is to have R1s responsible party sign admission agreement. Licensee is to obtain an updated Physician's Report/ LIC602 for R2 and ensure it is signed by physician. Once completed send a copy of both to LPA. The licensee shall submit a plan to the department on how the Licensee did not ensure that the licensee will ensure resident's records are complete and maintained. POC due 03/05/2025. POC was corrected upon Due Date of 03/05/2025. LPA will be assessing a Civil Penalty of $100/day from 03/06/2025 to 03/11/2025 for this violation and will continue to accrue until POC is corrected. Civil Penalties were assessed during this visit for failure to correct the above violations by POC Due Date. Exit Interview was conducted. A copy of the report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Mar 11, 2025

Type of visit: Case Management - Incident

On 03/03/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit to follow up on the incident report the department received on 02/28/2025. LPA met with Administrator, Adi Lina Tuiloma, and explained the purpose of the visit. LPA and Administrator discussed the incident which occurred on 02/21/2025 regarding an electrical fire which happened in the hallway bathroom. The fire happened in the evening on 02/21/2025 around 7:30 p.m. There was six (6) residents and one (1) staff present. Staff #1(S1) stated the facility smoke alarms went off. S1 assessed rooms and residents and saw the smoke coming out of the bathroom. S1 was able to put the fire out. Once fire was out S1 called emergency services to come out and assess the area. Local emergency services told the facility to not use the bathroom until the wires were fixed. On 02/22/2025 the facility did have an electrician come out to assess all the wires in the facility. Administrator stated it was just that one wire and it was fixed the same day as the visit from the electrician. The bathroom is in working condition and residents are able to use it again. LPA and Administrator discussed that incidents need to be reported to Community Care Licensing (CCL) within 24 hours of occurrence. As a result of todays visit deficiencies cited. Exit interview conducted and a copy of the report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Mar 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(2) · Plan of correction due date: Mar 5, 2025

87211 Reporting Requirements (2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above due to Administrator not reporting to Community Care Licensing (CCL) winthin 24 hours of the facility having a firethe state’s words, verbatim · CDSS document, Mar 3, 2025

Plan of correction: LPA went over with Licensee the reporting timeframe. Licensee is to submit a statement of understanding of this regulation. Additionally, the licensee shall submit a plan to the department on how the licensee will ensure the facility will meet reporting requirements timely. POC due 03/05/2025

Allegation investigated: Staff left residents unattended at the facility

On 02/19/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak and Licesning Program Manager (LPM) Laura Munoz arrived at the facility unannounced to deliver final findings for a complaint Community Care Licensing (CCL) received on 11/20/2024. LPA and LPM met with Administrator Lina Tuiloma and explained the purpose of the visit. During the course of the investigation, the Department conducted interviews and obtained pertinent documents relevant to the complaint investigation. Please continue to LIC9099C.. Substantiated Allegation: Staff left residents unattended at the facility Interviews conducted revealed that on 11/18/2024, S1 left the facility leaving no staff on the premises to care for the residents. S1 had left the facility sometime throughout the night. During interview, R1 stated that S1 had come into their room sometime throughout the night and stated that they will be leaving. R1 stated they went back to sleep and thought it was just a dream. When R1 and the other residents woke up in the morning of 11/18/2024, they found no staff present in the facility and attempted to make their own breakfast noting they were hungry. Interviews indicated R1 called their family in the morning of 11/18/2024 to notify that there were no staff present in the facility. Administrator stated they were unaware residents were left unattended until a R1's family member called and stated that there was no care staff at the facility. Administrator stated that they were notified around 9:30 a.m. and showed up to the facility at 10 a.m. An interview with S1 confirmed that S1 did leave the facility stating they were not feeling well and needed medical attention. When asked if S1 contacted Administrator, S1 stated they called and left a voicemail message. Administrator additionally stated that the staff has not been back at the facility since the incident. Based on interviews conducted by the department, the preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is cited on the attached 9099-D page. As a result of resident's being left without supervision, civil penalties are assessed in the amount of $500. Exit interview conducted and a copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 59-AS-20241120120334

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 20, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews the licensee did not comply with the section cited above as staff had left the facility and residents were left unattended.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Licensee is to conduct a training with staff regarding supervision as well as submit a LIC500 with back up staff. POC due by 02/20/2025

Type of visit: Case Management - Other

A case management visit was conducted at this facility today. Licesning Program Analyst (LPA) Cheyenne Ratajcak and Licesning Program Manager (LPM) Laura Munoz met with Licensee/Administrator Lina Tuiloma. During today's case management visit, LPM conducted an informal conference with the licensee at the facility. During this meeting, the licensee was made aware that this Informal conference is a part of the Administrative Action process. Issues discussed during this meeting were: Staffing concerns Administrator qualifications Recent deficiencies Facility records Reporting requirements To support the facility maintaining substantial compliance with Health and Safety Statute and Title 22 regulations, the department has issued citations. The licensee has been notified the department will provide additional case management visits as well as complete a referral to TSP (Technical Support Program) for the licensee. . An exit interview was conducted with administrator.the state’s words, verbatim · CDSS document, Feb 19, 2025

Type of visit: Case Management - Deficiencies

On 02/19/2025 Licensing Program Analyst (LPA) Cheyenne Ratajcak and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced. LPA and LPM met with Administrator Adi Lina Tuiloma and explained the purpose of the visit. LPA and LPM conducted a case management visit to issue citations in relation to complaint control#: 59-AS-20241120120334 During the complaint investigation, it was found that S1 was not criminally record cleared or associated to this facility at the time the incident occurred. The Administrator admitted that the facility failed to request a criminal clearance association for S1. Additionally, the Licensee failed to report the incident related to the complaint investigation. During today's case management visit, LPA and LPM toured the facility, conducted interviews and records review. The following deficiencies were found: 1) S2 is a live in staff at this facility. S2 has worked 24 hours a day for the past 14 days without any additional staff assistance. There are currently six (6) resident's residing in the facility. Two (2) are receiving Hospice services and bedridden, one (1) of six (6) residents is diagnosed with Dementia and four (4) of six (6) resident's are non-ambulatory. Based on resident's needs and documentation, the department has determined that this facility does not have sufficient staffing. Based on Title 22, Section 87411(a), the facility shall ensure there are two (2) care staff on duty during all waking hours. 2) During a facility walk through, LPA and LPM found chemicals and toxins in the laundry room unlocked and accessible to resident's in care. Continued on 809-C 3) A review of resident records found the following R1) Admission agreement is not signed by resident and/or responsible party R2) Physician's Report/ LIC602 is not signed by physician 4) The department learned that the facility thermostat was inoperable for several days during November 2024 resulting in the facility not having heat. The licensee failed to report this incident to the department as required. As a result of todays visit deficiencies cited and civil penalties assessed. Exit interview conducted and a copy of the report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Feb 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Feb 20, 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) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above due to caregiver not being associated with the facility which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Licensee will submit a statement of understanding to LPA Ratajczak that all staff must be fingerprint cleared and/or transferred prior to working in the facility. POC due 02/20/2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Feb 20, 2025

87309 Storage Space and Access (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above due facility laundry room door being unlocked and open making chemicals assessable to residents in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Licensee is to lock laundry room door immediately. Licensee is to conduct a staff training regarding this regulation and submit a copy of who attended the training to LPA. POC due 02/20/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(2) · Plan of correction due date: Mar 5, 2025

87211 Reporting Requirements (2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above due to Administrator not reporting to Community Care Licensing (CCL) when the facility heater was out for two (2) days.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: LPM and LPA went over with Licensee what needs to be reported. Licensee is to submit a statement of understanding of this regulation. Additionally, the licensee shall submit a plan to the department on how the licensee will ensure the facility will meet reporting requirements timely. POC due 03/05/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(a) · Plan of correction due date: Mar 5, 2025

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interviews and records, the licensee did not comply with the section cited above as it has been identified that resident’s require additional staff during waking hours.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: License is to have two (2) staff on the floor during waking hours. Licensee is to hire additional staff and send LPA updated LIC500 as well as the new staff facility file. POC due by 03/05/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Mar 5, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above due two (2) out of six (6) residents files being incomplete with signatures.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Licensee is to have R1s responsible party sign admission agreement. Licensee is to obtain an updated Physician's Report/ LIC602 for R2 and ensure it is signed by physician. Once completed send a copy of both to LPA. Additionally, the licensee shall submit a plan to the department on how the the licensee will ensure resident's records are complete and maintained. POC due 03/05/2025.

Type of visit: Required - 1 Year

On 12/18/24 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to conduct a Required 1 year annual inspection utilizing the care tool. LPAs met with Administrator, Adi Lina Tuiloma and explained the purpose of the visit. LPAs and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to: resident bedrooms, bathrooms, laundry room, kitchen and the common areas. While on tour LPAs observed two (2) residents residing in a room that is cleared for only one (1) non- ambulatory resident. LPA conducted a file review of four (4) resident files. Residents files contain signed admission agreements, physician reports, Identification sheets, releases, preplacement appraisals, and resident rights. LPA also conducted a file review of two (2) staff files. Staff have training in dementia, first aid and CPR, and other various areas of care provision. CARE inspection tool completed and deficiencies was observed. Please see LIC 809-D. Today's visit, civil penalties assessed. LPA requested a copy of facility's liability insurance, LIC 500 and LIC 308 by 12/20/24. Exit interview conducted and a copy of the report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Dec 18, 2024

Type of visit: Post Licensing

On 05/15/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a post- licensing visit utilizing the care tool. LPA met with Administrator, Lina Tuiloma and explained the purpose of the visit. The facility was licensed on/around 12/29/23 for six (6) non-ambulatory residents and has an approved hospice waiver for one (1). Currently, there are five (5) residents and no one receiving hospice services. LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to: two (2) private resident bedrooms, two (2) shared residents bedrooms, two (2) bathrooms, laundry room, kitchen, backyard and the common areas. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins, knives and medications are locked and inaccessible to residents in care. Hot water temperature was measured at 116 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 72 degrees. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed required Licensing posters posted throughout the facility. LPA conducted a file review of two (2) resident files. Residents files contain signed admission agreements, physician reports, Identification sheets, releases, preplacement appraisals, and resident rights. LPA also conducted a file review of two (2) staff files. Staff have training in dementia, first aid and CPR, and other various areas of care provision. As a result of today's inspection, no deficiencies cited. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, May 15, 2024

Type of visit: Prelicensing

On 12/21/2023, Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Cassie Yang arrived at the facility announced to conduct a Pre- Licensing inspection utilizing the pre-inspection tool. LPAs met with Licensee, Lina (Nina) Tuiloma. LPAs and Licensee conducted a tour of the facility. Areas toured include but are not limited to, two (2) private resident bedrooms, two (2) shared residents bedrooms, two (2) bathrooms, laundry room, caregiver bedroom, kitchen, backyard and the common areas. All bedrooms had furnishings which include, a bed for each resident, night-stand, lamp, and storage space. Each exit door has a chime that rings whenever door is opened. All sharps and toxins will be stored and locked in the laundry room. Medications will be locked in the kitchen area. Facility has 7+ day of non-perishables. LPAs observed the facility to have the needed signs posted in the common areas. The facility is at 73 degrees. Two (2) carbon monoxide detectors and six (6) smoke alarms were present in the facility. Fire extinguisher was last checked on 09/06/23. It was advised Licensee should fix the small hole in the wall in bedroom #5. In bedroom #3 to lower the bed frame as it is too tall for a resident to slide into the bed. As well as to store the knives in the kitchen in a locked cabinet so it will be easily accessible to a caregiver when they are cooking. LPA advised if residents records are centrally stored in the common area, it is to be safeguard to maintain confidentiality. Comp III completed. No deficiencies observed. LPA Ratajczak will notify CAB of inspection completion. Exit interview conducted and a copy of the report was provided..the state’s words, verbatim · CDSS document, Dec 21, 2023

Type of visit: Prelicensing

On 12/13/23, Licensing Program Analyst (LPA) Cheyenne Ratajczak and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced to conduct a Prelicensing inspection. LPA and LPM met with Licensee, Nina Tuiloma and explained the purpose of this visit. This facility is currently under change of ownership and there are zero (0) resident residing. LPA and LPM observed the facility to be in the process of being cleaned out and organized. Licensee stated they are still in the process of getting the facility ready for residents. Licensee stated that they need more time to get the facility ready, but should be ready by end of this week. LPA and Licensee are going to schedule a pre licensing visit for next week. On 12/21/2023, exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 13, 2023

Type of visit: Office

Facility Type: CHOFT Application Type: RCFE Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Adi Lina Tuiloma (Licensee/Administrator) Interview Method: Virtual interview via Microsoft Teams On December 01, 2023, applicant/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. Signed LIC 809 with copy of photo ID have been obtained. 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 readinessthe state’s words, verbatim · CDSS document, Dec 1, 2023