Lincoln Villa

Allegation investigated: Staff are not ensuring that residents are accorded privacy in their rooms

On 07/09/2026 at 12:35 PM, Licensing Program Analyst (LPA) P. Manalo conducted an initial 10-day complaint visit and delivered the findings on the above allegation. LPA met with Administrator, Divina Fernadez and explained the purpose of the visit. During the course of investigation, LPA interviewed 7 residents and 3 staff members. LPA reviewed and obtained the following documents including but not limited to Resident Roster, Personnel Report (LIC500), Client/ Resident Personal Property and Valuables (LIC621), Admission Agreement, House Rules, and Safeguard Personal Property Policy. Allegation: Staff are not ensuring that residents are accorded privacy in their rooms Continue to LIC9099-C... Substantiated Continued from LIC9099... It was alleged that staff are not ensuring that residents are accorded privacy in their rooms. Interview with R1 stated that on multiple occasions, other residents have walked in R1’s room and those residents are not R1’s roommate. Interview with 6 of 7 residents all indicated that they have observed other residents walk in their room and they were not their roommates. Interview with 2 of 3 staff members also stated that there are residents who wander in other residents’ rooms due to their medical diagnosis. Based on interviews conducted, 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), is being cited on the attached LIC 9099D. Exit interview was conducted with Administrator. A copy of this report and Appeal Rights was provided. Continued from LIC9099… Allegation: Staff do not safeguard resident's personal belongings. It was alleged that staff do not safeguard resident's personal belongings. Interview with R1 stated that there are some items in R1’s room that have been missing such as toiletries and food items. Interview with 5 other residents indicated that some of their personal belongings have been missing before. However, LPA conducted record review and it showed that residents' document of Client/ Resident Personal Property and Valuables (LIC621) indicated that they do not have items listed on it for the facility to safeguard. Based on interviews and record review conducted, the above allegation that staff do not safeguard resident’s personal belongings is unsubstantiated. 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 allegations are unsubstantiated. There is no deficiency noted. Exit interview was conducted with Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 15-AS-20260630120228

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Jul 23, 2026

87468.2(a)(1) Additional Personal Rights of Residents in Privately Operated Facilities (1)To have a reasonable level of personal privacy in accommodations, medical treatment, personal care... This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when 6 of 7 residents all stated that other residents aside from their roommate will wander in their room which poses a potential safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Administrator agrees to change residents' doors with a lock so that only the residents residing in that room and staff members have access. In addition, facility staff will coordinate with the resident and residents' responsible party of the new locking mechanism for their rooms. Proof of correction will be sent to CCLD.

Type of visit: POC

On 06/10/2026 at 2:15 PM, Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen conducted a POC case management visit. LPAs met with Administrator (ADM), Divina Fernandez, and explained the purpose of the visit. During the visit, LPAs observed the outside perimeter fence installed. LPAs are requesting for the official confirmation of the fence installation. ADM will submit the confirmation to CCLD once Licensees provide the documentation. No deficiencies cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jun 10, 2026

Type of visit: Case Management - Incident

On 06/10/2026 at 1:30 PM, Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen conducted a case management visit regarding an incident that occured with resident and staff. LPAs met with Administrator, Divina Fernandez, and explained the purpose of the visit. While LPAs were conducting a 1-year required visit, LPAs conducted interview with residents that revealed S1 was verbally abusing R1 and R2. Interview with S1 confirmed that S1 yelled at residents before. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 10, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 18, 2026

87468.1(a)(1) Personal Rights of Residents in All Facilities (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when S1 confirmed that S1 verbally abused residents which poses a potential safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 10, 2026

Plan of correction: By POC date, the Administrator will submit an action plan regarding S1 to CCLD addressing preventative measures to ensure S1 does not violate residents' rights.

Type of visit: Required - 1 Year

On 06/10/2026 at 8:30 AM, Licensing Program Analysts (LPAs) P. Manalo and K.Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator Divina Fernandez and explained the purpose of the visit. Administrator certificate is current. The facility’s fire clearance was approved for capacity of 80 all may be bedridden. LPAs toured the facility inside and out including but not limited to 7 residents’ apartments, bathrooms, activity rooms, kitchen, common area and courtyard. LPAs observe lighting in all rooms is adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. The hot water temperature in a sample of residents shared bathroom was measured 113.5, 114.4, 115.8, 107.7, 108, and 112.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats and non-skid shower pan. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operation during visit. Fire extinguisher was last serviced on 08/20/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 04/15/2026. At 9:38 PM, LPAs reviewed 7 residents records. At 10:14 AM, LPAs reviewed 8 staff records and 8 of 8 have current first aid training and associated with the facility. At 1:30 PM, LPAs reviewed a sample of resident’s medications. Continued to LIC809-C... Continued from LIC809... THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT: At 11:22 AM, LPAs observed a water bubble forming on the ceiling wall in room #40 with black spots surrounding the bubble. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 10, 2026

Allegation investigated: Staff do not ensure that an appropriately skilled professional performs resident's glucose tests Staff did not assist resident with obtaining medication

On 04/30/2026 at 8:55 AM, Licensing Program Analyst (LPA) P. Manalo conducted an initial 10-day complaint visit and delivered the findings on the above allegations. LPA met with Administrator, Divina Fernadez and explained the purpose of the visit. During the course of investigation, LPA interviewed 7 residents, 5 staff members, and witness. LPA reviewed and obtained the following documents including but not limited to Resident Roster, Personnel Report (LIC500), staff schedule, List of Residents on Special Diets, Medication Administration Record (MAR), medication order, After Visit Summary, Physician Report, Appraisal Needs and Services Plan, Email Correspondence, Food Menu, and staff certifications. Continue to LIC9099-C… Substantiated Continued from LIC9099... Allegation: Staff do not ensure that an appropriately skilled professional performs resident's glucose tests. It was alleged that staff do not ensure that an appropriately skilled professional performs resident's glucose tests. Interview with 4 of 5 staff members stated that only skilled professionals are the ones performing the glucose test. Interview with ADM stated that there are nurses that work 7 days a week until 10:30 PM that can perform the glucose test and assist with other duties. However, interviews with 4 of 7 residents all stated that aside from the nurses, S2 or S4 will do the glucose tests for them. Based on record review, S2 and S4 are not skilled professionals and are not able to perform glucose monitoring tests. Based on interviews and record review conducted, 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), is being cited on the attached LIC 9099D. Allegation: Staff did not assist resident with obtaining medication. It was alleged that Staff did not assist resident with obtaining medication. A review of email correspondence showed that Family Member 1 (FM1) sent an email to the facility’s email address that R1’s medication was ready on 04/17/2026. FM1 sent a follow email on 04/21/2026 and 04/23/2026 to see if the medication was picked up. Interview with ADM revealed that a staff member picked up the medication on Thursday, 04/23/2026. Interview with S4 showed that S4 talked to FM1 regarding the medication ready to be picked up at the pharmacy, but S4 did not pick it up until the following day. During today’s visit, LPA observed the medication bottle with a note that it was started on 04/23/2026. Based on interviews and record review conducted, 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), is being cited on the attached LIC 9099D. Exit interview was conducted with Administrator. A copy of this report and Appeal Rights was provided. Continued from LIC9099-A... Allegation: Staff do not follow resident's dietary plan. It was alleged that staff do not follow resident's dietary plan. Interview with S3 revealed that S3 has a list in the kitchen of residents who are on special diets. During today’s visit, LPA observed that the kitchen has different plates for residents that is specified to their special diet. Interview with 4 of 7 residents all stated that they are receiving meals that are specific to their dietary plan that can include either low sugar, low sodium, or lactose free diets. Interview with 7 of 7 residents all indicated that they have no issues with the food that are being served to them. Based on interviews and observations conducted, the above allegation that staff do not follow resident’s dietary plan is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. There is no deficiency noted. Exit interview was conducted with Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 15-AS-20260424121354

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87628(a) · Plan of correction due date: May 15, 2026

87628(a)Diabetes(a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing...or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above by having staff who are not skilled professionals assisting residents with glucose testing which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: By POC date, the Administrator agrees to self certify the regulation with staff members and send proof to CCLD by POC date. Moving forward, only appropriate skilled professionals will be the ones assisting or administering with glucose monitoring.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: May 15, 2026

87465(a)(1) Incidental Medical and Dental Care(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not picking up the resident’s medication when it was ready for pick up which posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: By POC date, the Administrator will have an in-service meeting to ensure that the medications are picked up on time, make sure it's documented, and have a written order for all medications. Proof of correction will be sent to CCLD.

Type of visit: Case Management - Other

On 04/30/2026, Licensing Program Analyst (LPA) P. Manalo conducted a case management visit. LPA met with Administrator (ADM), Divina Fernandez, and explained the purpose of the visit. While LPA was investigating a complaint (Complaint #15-AS-20260424121354), LPA observed the following: Staff are assisting R1 with medication without a doctor's order. Interview with ADM revealed that although the facility picked up R1's medication at the pharmacy, R1's medication was ordered by the family. ADM confirmed that they do not have R1's doctor order for the medication that was picked up. During the visit, LPA and Administrator discussed that the facility will have a doctor's order for all medications before assisting or administering it to the residents. ADM will send a copy of the doctor's order by 05/08/2026. A technical violation was issued. Exit interview was conducted with Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2026

Type of visit: Case Management - Other

On 04/03/2026 at 12:15 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported AWOL incidents that occurred on 03/28/2026. LPA met with Administrator (ADM), Divina Fernandez, and explained the purpose of the visit. On 04/01/2026, LPA P. Manalo received an incident report that indicated that on 03/28/2026, R1 and R2 AWOL’D from the facility at different times. R1 AWOL'D from the facility at approximately 11:00 AM and was found down the street using the GPS monitoring system. Incident report also indicated that during the time R1 AWOL'D, the alarm system was not working. Another incident dated 03/28/2026 revealed that R2 AWOL'D from the facility at approximately 2:15 PM during shift change and was also found outside near the street with the use of the GPS monitoring system. During the visit, LPA and ADM observed R3 test if the front door would set off while the resident attempted to leave. The front door alarm did not set off, and ADM stated that the door will not alarm if the resident's waunder guard bracelet is covered by the resident's clothing. However, when R1 tested the front door to see if it would alarm, the sound still did not set off and R1's waunder bracelet was observed to not be covered with anything. It was also observed that the facility installed a facial recognition. Interview with ADM revealed that the facial recognition recognizes the residents' who are known wanderers and will notify the facility via telephone if a resident attempts to leave through the front or side doors. It was observed that the facial recognition was working and it would call the facility's phone if a resident attempted to go out. Continue to LIC809-C... Continued from LIC809... LPA reviewed R1 and R2's physician report indicated that they are both not able to leave the facility unassisted. A review of the Medroom Communication Log indicated that for both residents it was noted that the resident was nowhere to be found and the facility staff were able to locate the residents with the GPS monitoring system. Interview with ADM and S1 confirmed that during the time of the residents' AWOL'D, the alarm system was not working. S1 also stated that the system was fixed the next day, but based on the observations done today, the alarm sound was still not working at the front door. The following deficiencies was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalty. Exit interview conducted. Appeal Rights, LIC421FC, and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 10, 2026

87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above when the alarm system for the facility door was in disrepair which posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: By POC date, the Administrator (ADM) agrees to contact the alarm system to see what the issue is with the alarm system not sounding. Then, based off that information, Administrator will notify LPA of what their plan is for the alarm system.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.2(a)(4) · Plan of correction due date: Apr 10, 2026

87468.2(a)(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 interview and record review, the licensee did not comply with the section cited above when R1 and R2 AWOL'D from the facility on the same day which posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: By POC date, the Administrator will request for R1 to have a 1:1 and do a two hour check in for R2. In addition, Administrator will create an activity schedule for the next two weeks and send proof to CCLD.

Type of visit: Case Management - Other

On 03/24/2026 at 1:45 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced case management visit to follow up on the case management visit conducted on 12/30/2025. LPA met with Administrator, Divina Fernandez, and explained the purpose of the visit. On 12/30/2025, LPA conducted a case management in which a deficiency was cited for the hallways near R1's room with a strong urine odor. During today's visit, LPA verified that the deficiency has been corrected. No deficiencies cited during the visit. Exit interview was conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Case Management - Other

On 03/24/2025 at 2:20 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct a Case Management visit for a follow up. LPA met with Administrator Divina Fernandez, and explained the purpose of the visit. While LPA was conducting investigation for complaint #15-AS-20250924164021, LPA observed the following: During the complaint interview, S1 revealed that R1 was one of the residents that has scabies. On 12/26/2025, LPA received a SOC341 cross-reported from Adult Protective Services (APS) of R1's scabies. During today’s visit, LPA reviewed the following documents including but not limited to Medroom Daily Communication Log, physician fax report, Unusual Incident Report (LIC624), and shower logs. A review of the Medroom Daily Communication Log and physician fax report showed that the facility notified R1's physician that R1 was suspected to have scabies. Interview with ADM and a review of LIC624 showed that the facility reported to the department of R1’s scabies. However, LPA did not receive LIC624. A technical violation was issued. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Case Management - Other

On 03/24/2025 at PM, 3:10 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct a Case Management visit. LPA met with Administrator (ADM) Divina Fernandez, and explained the purpose of the visit. While LPA was at the facility for another visit, LPA observed the following: LPA observed R1 down the street from the facility and R1 entering the facility couple minutes later. During the visit, LPA reviewed R1's physician report dated 05/29/2025 that indicated that R1 is able to leave the facility unsupervised. LPA observed incident report that indicated R2 had a unwitnessed fall on 10/12/2025. During the visit, LPA reviewed documents including but not limited to Medroom Daily Communication Log, After-Visit Summary, Email Correspondence, and facility's care plan. Documents revealed that R2 had multiple falls. During the visit, LPA verified that the facility was following their care plan which was to provide 1:1 care to R2. LPA observed a portable safety barrier blocking the front, side, and back exit doors. Interview with ADM revealed that the barriers are there temporarily while the facility is working on their gates outside. LPA observed the facility is currently repainting the walls all around the facility and LPA was not notified. LPA and ADM discussed that any construction being done needs to be reported to the Department. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Mar 27, 2026

87307(d)(6) Personal Accommodations and Services (6)All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above by having the front, side and back exit doors blocked with a portable safety barrier which posed a potential safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: By POC date, the Administrator will remove the barriers and send proof to CCLD.

Allegation investigated: Staff did not prevent a resident from developing scabies while in care.

On 12/30/2025 at 1:50 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct more interviews and deliver findings on the above allegation. LPA met with Administrator, Divina Fernandez, and explained the purpose of the visit. During the course of investigation, LPA interviewed staff, witnesses, and residents. LPA obtained the following documents including but not limited to LIC500, Resident Roster, Fax Documentation to Physicians, Doctor’s Order for Medication, Local Public Health (LPH) documentation of the outbreak, After Visit Summaries, SOC341, Staff Contact Information and Shower and Sheet Log. Continue to LIC9099-C… Substantiated Continue from LIC9099… It was alleged that Staff did not prevent a resident from developing scabies while in care. On 09/29/2025, the Administrator contacted LPA P. Manalo that the facility has an outbreak of scabies and the first case occurred on 09/24/2025. A review of the Unusual Incident/ Injury Report (LIC624) dated from 09/24/2025 to 09/27/2025 showed that 5 residents had symptoms of itching and discomfort. On 10/02/2025, LPAs P.Manalo and K. Nguyen conducted a visit and observed staff members wearing Personal Protective Equipment (PPE) before going inside a resident's room. On 11/03/2025, LPA received an incident report indicated that another resident was also confirmed with scabies. Interview with S5, S8, S9, and S10 verified that there were multiple residents that had rashes. Interview with S5 revealed that the rashes began in October, but management dismissed the reports from S5. Furthermore, S5 stated there were staff members also experiencing rashes. Based on interviews conducted, 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), is being cited on the attached LIC 9099D. Exit interview conducted with Fernandez. Appeal rights and a copy of this report provided. Continue from LIC9099… It was alleged that staff did not ensure that resident’s room is cleaned. Interview with S3, S5, S8, and S9 confirmed that the residents’ rooms are cleaned every day. S3 stated that S3 will clean and mop around the facility including the residents’ room. Interview with S3 and S5 revealed the two housekeepers are responsible for cleaning the resident’s room on their designated side during their shift. S5 stated that every day, the housekeeper will have a list of rooms to clean. If a room becomes soiled during the day, the housekeeper will add that room to their list to clean. S8 confirmed that there are two staff members that are assigned to clean the rooms every day. S8 stated that if the residents request to have their room cleaned, the assigned staff will clean the room. Interview with 3 of 4 residents all stated that their rooms will get cleaned every day. Interview with R1, R3, and R4 indicated that there are no issues with their room not being cleaned. Staff did not clean resident's bedding. S5 and S8 confirmed that each resident have shower days twice a week. During scheduled shower days, residents beddings will be changed. S8 stated that there are some residents that might need their bedding changed more often and staff will change it according to the residents’ needs. S8 included that if a resident notifies staff that their bedding needs to be changed, staff will change it per resident’s request. Both interviews with S8 and S9 added that if a resident refuses a shower during their shower days, staff will still change the resident’s beddings. S9 indicated that if S9 notices a residents’ bedding has been soiled, S9 will change or clean the bedding right away during their shift. On 12/30/2025, LPA observed that residents' room and beddings were clean and unsoiled. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Dec 30, 2025 · control 15-AS-20250924164021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(a)(2) · Plan of correction due date: Jan 9, 2026

87470(a)(2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: This requirement is not met as evidenced by: The licensee did not comply with the section cited above by not preventing a scabies outbreak at the facility which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 30, 2025

Plan of correction: The Administrator agrees to have an in-service with staff regarding infection control plan and how to mitigate the infection. Proof of correction will be sent to CCLD by POC date.

Type of visit: Case Management - Other

On 12/30/2025 at 3:30 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct a Case Management visit. LPA met with Administrator, Divina Fernandez, and explained the purpose of the visit. While LPA was conducting another visit in regards to a complaint (15-AS-20250924164021), LPA observed the following deficiency: LPA observed the hallway area near Room #10 to to Room #14 have a strong odor of urine. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Jan 7, 2026

87625(b)(3) Managed Incontinence (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above by having a strong urine odor in the hallways which poses health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2025

Plan of correction: Administrator agrees to come up with the plan to reduce the odor smell and clean the hallway. LPA will come back to verify the correction.

Type of visit: Case Management - Incident

On 12/08/2025 at 1:35 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported AWOL incident that occurred on 12/08/2025. LPA met with Administrator (ADM), Divina Fernandez, and explained the purpose of the visit. On 12/09/2025, LPA P. Manalo received an incident report that indicated that on 12/08/2025, R1 AWOL’D from the facility. Staff used the R1's GPS tracking device to locate R1, and it showed that R1 was transported to the Emergency Room. Interview with Administrator revealed R1 returned back to the facility later that day. During today's visit, LPA reviewed and obtained the following documents such as R1's physician report, Appraisal Needs and Services Plan, After-Visit Summary, and facility's communication log. LPA interviewed and observed ADM with the Wander Guard Bracelet walk out of the facility's side door and the alarm in operational condition. A review of R1's physician report dated 07/04/2025 showed that R1 is unable to leave the facility unassisted. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted. Appeal Rights, LIC421FC, and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 5, 2026

87468.2(a)(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: Based on record review, the licensee did not comply with the section above when R1 AWOL'D from the facility which posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Administrator will 1) review all physicians report and identify which residents are not able to leave the facility unassisted, 2) update Appraisal Needs and Services Plan to address wandering behaviors, 3) submit the facility's activity calendar, 4) LPA will schedule an office visit to address AWOL incidents.

Allegation investigated: Resident developed pressure injury due to lack of care and supervision. Staff are not meeting the needs of the resident in care. Staff do not answer resident's call button in a timely manner. Staff do not provide adequate food service to resident in care.

On 12/03/2025 at 2:05 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to deliver findings on the above allegations. LPA met with Administrator, Divine Fernandez, and explained the purpose of the visit. During the course of investigation, LPAs interviewed 7 residents, Administrator, and Staff. LPAs obtained copies including but not limited to of the Resident Roster, Staff Schedule, Employee Contact Numbers, Admission Agreement, Identification and Emergency Information, Physician’s Report, Appraisal Needs and Services Plan, Physician’s Fax Reports, After Visit Summaries, Unusual Incident Reports, Agency Visit Report Form, Shower Logs, Shower Shift Cluster Schedule, Call Button Policy, Resident Call Button List, In-House Physician's Notes, Facility Menu, Skin Assessment, Email Correspondence with all responsible parties, and Incontinent Care Log Sheet dated 08/15/2025 to 09/10/2025. Continue to LIC9099-C... Unsubstantiated Continue from LIC9099… It was alleged that Resident developed pressure injury due to lack of care and supervision. Interview with the Administrator on 09/11/2025, revealed that R1’s pressure injury has been on and off, and the latest pressure injury was caused by anti-fungal cream. A review of the facility’s Skin Monitoring Daily Skin Check dated 05/23/2025 showed that R1 was developing a pressure ulcer and was noted that on 05/29/2025, R1 had a big tear on left buttocks area. Skin Monitoring Daily Skin Check dated 07/07/2025 showed R1’s pressure injury was staged 1, however, it was noted that it was healing. Skin Monitoring Daily Skin Check dated 08/02/2025, showed that there was a pressure ulcer and staff were applying cream. After Visit Summary dated 08/26/2025 showed that R1 developed a stage 1 pressure sore and was referred to home health to follow up with a wound specialist. A review of the Agency Visit Report Form dated 08/26/2025 noted that R1 does not have an open wound and a review dated 09/08/2025 advised R1 to continue applying anti-fungal cream and encouraged education to R1. It was alleged that Staff are not meeting the needs of resident in care and Staff do not answer resident’s call button in a timely manner. On 09/11/2025, LPA P. Manalo and K. Nguyen observed residents’ call button pendant working and staff radio’s being called if a resident needs assistance. According to the facility’s Call Button Policy, staff will respond to immediate safety or medical concerns within 1-2 minutes and non-urgent needs within 5 minutes. Interview with 4 out of 7 residents revealed that there have been no issues with staff assisting with their needs and attending to their calls when needed assistance. Record review of email correspondence between Resident 1 (R1), the facility, and multiple other people showed that R1 would document how long R1 would wait for diaper change or assistance. However, interview with R1 stated that there have been no issues with staff coming for assistance when R1 would call for help. A review of the facility’s Incontinent Care Log Sheet dated 08/20/2025 to 09/11/2025 and Resident Communication Log dated 8/22/2025 to 09/09/2025 showed the date, time, and notes of when R1 would get checked or changed in every shift. Continue to LIC9099-C... Continue from LIC9099-C... It was alleged that Staff do not provide adequate food service to resident in care. On 08/14/2025, LPA P. Manalo observed a sufficient supply of perishable and non-perishable food during the visit. LPA observed the fridge, freezer, and pantry filled with various meat products, bread, milk, snacks, etc., Interview with 4 out of 7 residents revealed that the facility provides food for residents 3 times a day and offers snacks. Interview with Resident 7 (R7) disclosed that if there is a food item that they don’t eat, facility staff will accommodate to the type of food they want. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Dec 3, 2025 · control 15-AS-20250813172258

Type of visit: Case Management - Incident

On 12/03/2025 at 2:30 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported AWOL incident that occurred on 10/19/2025 and 11/22/2025. LPA met with Administrator, Divine Fernandez, and explained the purpose of the visit. On 10/20/2025, LPA P. Manalo received an incident report that indicated that on 10/19/2025, R1 AWOL’D from the facility. Staff was able to locate R1's location with the GPS monitor system. On 11/25/2025, LPA P. Manalo received an incident report that indicated that on 11/22/2025, staff noticed that R1 was not present in the dining area. R1 was then found using R1’s GPS monitor. Both incidents, R1 was found sitting on the pavement being assessed by Emergency Medical Services (EMS) and was sent to the hospital for further evaluation. During the visit, a review of the facility’s communication log indicated that the facility’s alarm was not working during R1’s AWOL’d on 11/22/2025. Interview with S1 and S2 revealed that all the staff were busy assisting residents during that time and did not hear the alarm. LPA verified that both alarms on the side and front of the facility are in operational. A record review of R1’s physician report dated 10/05/2025 revealed that R1 is unable to leave the facility unassisted. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 12, 2025

87468.2(a)(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 record review and interview, the licensee did not comply with the section cited above when R1 AWOL’D from the facility which posed a potential safety risk to person in care.the state’s words, verbatim · CDSS document, Dec 3, 2025

Plan of correction: The Administrator agrees to implement a plan to meet R1's needs, have in-service training with staff regarding awol and regulation, and have the LIC500 updated. Proof of correction will be sent to CCLD by POC date.

Type of visit: Case Management - Incident

On 09/11/2025 at 9:00 AM, Licensing Program Analysts (LPAs) P.Manalo and K.Nguyen conducted an unannounced Case Management visit regarding a self-reported incident that occured on 08/04/2025. Administrator self-reported the incident on 08/04/2025. LPA met with Administrator, Divine Fernandez, and explained the purpose of the visit. LPAs received a self-reported incident report from the facility that indicated that Resident 1 (R1) and Resident 2 (R2) had an altercation where R1 was attempting to grab R2's food. Interview with Administrator revealed that an internal investigation was conducted regarding the incident and facility has been in contact with R1's responsible party regarding R1's care. LPAs interviewed Staff 1 (1) in which S1 stated that there has been no other altercation with R1 since then and R1 has a 1:1 private caregiver for two hours a day. LPAs is requesting for the facility to submit an updated appraisal needs and services plan and care plan for R1 by 09/25/2025 for review. No deficiency noted. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2025

Type of visit: Case Management - Health Checks

On 08/14/2025 at 1:10 PM, Licensing Program Analyst (LPA) P. Manalo conducted a Health & Safety inspection as a result of a priority 2 complaint. LPA met with Administrator Divina Fernandez and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and courtyard area. Hot water temperature was measured at 117, 107.9, 112, and 112.2 degrees Fahrenheit in residents’ bathroom. Residents’ bathrooms are equipped with grab bars and non-skid shower pans. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. Smoke detectors and carbon monoxide detectors were observed in operating condition. First-aid kit was complete. LPA observed the following deficiencies: Fire extinguisher was last serviced on 08/09/2024. Food was not properly labeled and stored. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87203 · Plan of correction due date: Aug 22, 2025

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic This requirement is not met as evidenced by: The licensee did not comply with the section cited above by having expired fire extinguisher tags that poses an immediate health and safety risk to person in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: The Administrator agrees to service the fire extinguishers and send proof to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(8) · Plan of correction due date: Aug 28, 2025

87555(b)(8) General Food Service Requirements(8) All food shall be of good quality...Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by The licensee did not comply with the section cited above by not properly labeling and storing food in the kitchen which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: The Administrator agrees to have an in-service on properly storing and labelling food items with staff and send proof to CCLD by POC date.

Type of visit: Case Management - Incident

On 06/20/2025 at 1:45 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident that occured on 06/14/2025. Administrator self-reported the incident on 06/17/2025. LPA met with Administrator, Divine Fernandez, and explained the purpose of the visit. LPA received a self-reported incident report from the facility that indicated that Resident 1 (R1) was allowed to leave the facility by the facility staff. When R1 did not return to the facility, R1's responsible party was informed. R1 returned to the facility couple hours later with a hematoma on the forehead. R1 was sent to the hospital after. During the visit, LPA reviewed R1's physician's report dated 06/05/2025 that revealed that R1 is unable to leave the facility unassisted. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 1, 2025

87468.2(a)(4)Additional Personal Rights of Residents in Privately Operated Facilities (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 evidence by: The licensee did not comply with the section cited above by not allowing R1 to leave the facility unassisted which posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jun 20, 2025

Plan of correction: Moving forward, the Administrator will have staff review physician's report before allowing residents to leave the facility unassisted. In addition, Administrator will review the regulation and self certify. Proof of correction will be sent to CCLD by POC date.

Type of visit: Prelicensing

At around 9:45 am, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to verify corrections made with the facility sketch as required from the 5/7/2025 pre licensing inspection. LPAs met with Licensees/Applicants Wendy Wong and Olive Manalastas. . During the visit, LPAs were provided with the updated facility sketch identifying all the rooms. LPA P. Manalo also verified all the rooms during the visit. LPAs observed that the facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required. A copy of this report was provided to Licensees/applicants.the state’s words, verbatim · CDSS document, May 30, 2025

Type of visit: Case Management - Other

On 05/30/2025 at AM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct Component lll with Licensees/applicants. LPAs went over with Licensee/ applicant Component lll Power point presentation. LPAs provided applicant with CCLD and LPA contact information. A copy of this report was provided to applicants.the state’s words, verbatim · CDSS document, May 30, 2025

Type of visit: Prelicensing

On 05/07/2025 at 11:45 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct pre-licensing inspection. LPA met with Licensee/ Applicant, Wendy Wong, Olive Manalasta, and Administrator, Divina Fernadez, and explained the purpose of the visit. This is pre-license for a change of ownership. Applicants gave authorization for Administrator to sign the report. LPA toured facility with Administrator and Applicants including but not limited to a sample of 4 residents' bedrooms, 3 bathrooms, kitchen, dining hall, resident lounge, and courtyard. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. The hot water temperature in residents’ bathroom were measured at 107,116.2, 109.8 degrees Fahrenheit. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguishers were last serviced on 08/09/2024. LPA was informed by the fire department that the facility needs a permit for the exterior and interior construction that happened after the fire inspection was conducted. Continue to LIC809-C... Continue from LIC809... Prior to licensure, the following shall be corrected and faxed to CCLD by 05/16/2025: The facility sketch has to identify all the rooms and the purpose such as storage rooms, central supply, kitchen storage, electrical room, etc. The licensee/applicant will then verify with the fire department of the facility sketch. At 1:30 PM, LPA observed TUMS unlocked in a drawer in room #43. At 3:00 PM, LPA observed Lysol wipes in the front office and resident's has access to the office. This facility is not ready to be licensed. The facility will notify LPA after all the corrections have been corrected. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 7, 2025

Type of visit: Prelicensing

On 03/20/2025 at 9:30 AM, Licensing Program Analysts (LPAs) P. Manalo and K.Nguyen arrived announced to conduct pre licensing inspection. LPAs met with Licensee/ Applicant, Wendy Wong, Olive Manalasta, and Administrator, Divina Fernadez, and explained the purpose of the visit. This is pre-license for a change of ownership. LPAs toured facility with Administrator and Licensees/ Applicants including but not limited to a sample of 4 residents' bedrooms, 3 bathrooms, kitchen, dining hall, resident lounge, and courtyard. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. The hot water temperature in a sample of residents’ shared bathroom were measured at 110.3 and 109.8 degrees Fahrenheit. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguishers were last serviced on 08/09/2024. The facility has a working telephone that was verified during the visit. Prior to licensure, the following shall be corrected and faxed to CCL by 04/10/2025: At 10:50 AM, LPA observed the Med cart unlocked, and medications were found in Room #3, Room #15, and Room #31. At 11:00 AM, LPAs observed that the freezer did not have a thermostat inside. At 11:05 AM, LPAs observed food not properly stored in containers. At 11:15 AM, LPAs observed that there is not enough emergency food. At 11:26 AM, LPAs observed window screens with holes and clutter outside in the courtyard that needs to be removed. Continue to LIC809-C... Continue from LIC809... At 11:45 AM, LPAs observed that staff did not have emergency flashlights available. At 12:00 PM, LPAs observed Lysol Cleaning wipes in Room #26 and shower grease spray, deep cleaning spray in Room #15. At 12:15 PM, LPAs observed the residents' records were found to be incomplete. This facility is not ready to be licensed. The facility will notify LPA after all the corrections have been corrected. Exit interview was conducted and a copy of this report was provided to Licensee/applicant.the state’s words, verbatim · CDSS document, Mar 20, 2025

The state marks this report as 11 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.