Masonic Guest Home II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection and was greeted by administrator (admin) Leonida Lacap. Facility is an Adult Residential Care Facility for the Elderly with an approved fire clearance for capacity of 6 (six) residents. There are currently five (5) residents in care. LPA toured the building and grounds which was found to be clean and at a comfortable temperature. LPA observed all walkways and exits to be unobstructed. All required postings were in a highly visible area. Fire extinguishers were charged and last inspected 11/17/2025. Fire alarm and carbon monoxide alarms all tested and operational. Outdoor furniture accessible for resident use. Water temperature check measured within regulation at faucets accessible to residents within the allowable range of 105 to 120 degrees F. Resident bathrooms observed to have bath mat and grab bar. Disaster drills are being conducted quarterly. All bedrooms were equipped with required furnishing. Facility had an ample supply of linens, towels and extra hygiene products for residents. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable foods. Snacks accessible for residents. Emergency food was observed to meet the 72 hour emergency supply. Facility kitchen, refrigerators and freezers were clean, and food stored properly. Expiration dates were noted in food items found in refrigerator. Toxins are locked and inaccessible to residents. Sharps and knives were locked. Phone accessible for resident use. LPA conducted a file review for 5 of 5 residents. All required documentation found to be up to date. LPA conducted file review for 2 staff. All required documentation found to be up to date. Continued onto 809C.. continued from 809.... LPA and admin conducted a spot check of medication and medication records, all records up to date. Medication is centrally stored and locked. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance (Retrieved during visit) No deficiencies cited for today's visit. Exit interview conducted and report read with Administratorthe state’s words, verbatim · CDSS document, Apr 21, 2026

Allegation investigated: Facility did not seek timely medical care for resident in care Personal Rights

Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegations and met with facility Administrator Leonida Lacap. Complaint alleges the facility did not seek timely medical care for resident (R1) in care and that the facility violated R1’s Personal Rights. During the investigation, LPA reviewed R1’s file. LPA observed that R1 has attended multiple doctor’s visits. Additionally, LPA reviewed LIC 624s Unusual Incident/Injury reports filed with Community Care Licensing (CCL) for R1 for 2023, 2024 and 2025 which revealed that R1 was taken for medical treatment on multiple occasions as needed or recommended by medical professionals. Continued on 9099-C Unsubstantiated ...Continued from 9099 Information received during interview with R1, contradicted the allegation that they have been unable to get medical appointments when needed. The complaint further alleges that R1 is being over medicated. During record review of R1’s Centrally Stored Medication and Destruction Records LPA observed no indication or record of over administration of medication. The strength and quantity of the medications given to R1 were observed to match Doctors or psychiatrists’ orders. The complaint alleges that R1 is suddenly exhibiting a care need that was not previously known; however, during record review LPA observed that the care need was documented upon move-in on the Preadmission Appraisal. The complaint alleges that R1’s routines have changed and that they are unable to leave the facility. Through record review and interviews, LPA observed that R1 injured themselves, preventing them from leaving the facility as much as they have done before the injury. Interview revealed that R1 has had medical interventions allowing them to be able to go out of the facility on their own. Although the allegations 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.the state’s words, verbatim · CDSS document, Jul 25, 2025 · control 21-AS-20250410092323

Type of visit: Required - 1 Year

At approximately 9:10 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and was greeted by Administrator Leonida Lacap. Masonic Guest Home II is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a single story ranch house. The facility has an approved fire clearance for six (6) non-ambulatory residents. The facility has a Hospice Waiver for two (2) residents. Upon arrival, LPA was informed that there were six (6) residents in care and two (2) staff members on-site. At approximately 9:25 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:30 AM, LPA toured the facility with Administrator Lacap. All exits were clear and unobstructed. The facility's two (2) fire extinguishers were last serviced and tagged on 9/10/2024. Fire Department inspected and cleared the facility in March, 2024. The facility was sufficiently lighted. LPA inspected three (3) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. Regulations' stipulate that the facility should be conducting fire and emergency drills quarterly. LPA observed that the last disaster drill was conducted on 12/1/2024. This deficiency will be cited. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Continued on 809-C ...Continued from 809 Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. At approximately 10:10 AM, LPA reviewed five (5) resident files. Four (4) of five (5) resident files were found to be missing various documentation. Resident one's (R1) file was observed to be missing signed personal rights and preplacement appraisal documents. Resident two's (R2) file was observed to be missing personal rights and an annual medical assessment. Resident three's (R3) file was observed to be missing an annual medical assessment. Resident 4's (R4) file was observed to not have reappraisals completed from 2021 to 2023. These deficiencies will be sighted. LPA reviewed three (3) staff files. Two (2) of three (3) staff files were found with all required documentation including First Aid and CPR certification and proper training documentation. Staff member S1's file was observed to be missing the LIC 503 Medical assessment and Tuberculosis (TB) test and current 1st Aid and CPR certification. These deficiencies will be cited. LPA spot checked Medication for three (3) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. The facility does not handle resident’s monies for personal and incidental items. Leonida Lacap’s Administrator Certification 7033434740 is current with an expiration date of 10/14/2025. LPA requested the following documents be submitted to Community Care Licensing by 5/15/2025: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Proof of Liability Insurance Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Administrator Lacap. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator, Leonida Lacap. This facility is licensed for a total of 6 non-ambulatory residents and no approval for bedridden. There are currently 5 residents living in the home and the facility has a Hospice waiver approved for 2 of the residents. Currently there are no residents receiving hospice services. LPA toured facility and grounds and observed facility was found to be clean at a comfortable temperature, with all exits free from obstruction. Facility has at least two days of perishable and one week of non-perishable foods. Fire Extinguisher was found to be charged, and serviced 8/25/2023. Smoke alarms and carbon monoxide detector were operational during the inspection. Water temperature in bathrooms measured at 108 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Resident bedrooms are furnished per regulation. LPA went over daily activities for residents. LPA reviewed resident files, and some staff files. Medication is centrally stored and locked in closet/cabinet. Facility uses the centrally store log and residents medication is organized in a container, labeled with individuals name. Administrator Certificate for Administrator,Leonida Lacap #6006612735 expires 10/14/2025. Staff training was reviewed and CPR/1st Aid for staff, expires 1/17/2026. Continue report see LIC809-C LPA discussed the Emergency Disaster Plan and Infection Control Plan. Licensee/Administrator to submit the current following documents by 7/05/2024: · LIC 308 Designation of Facility Responsibility · LIC 500 Personnel Report · LIC 400 Affidavit Regarding Client/Resident Cash Resources · LIC 610E Emergency Disaster Plan · LIC 9020 Register of Facility Residents Infection Control Plan of Operation (If changes) Copy of Liability Insurance Copy of current Lease Agreement No citations issued during todays inspection.the state’s words, verbatim · CDSS document, Jun 7, 2024

Allegation investigated: Facility staff did not ensure resident was provided proper nutrition. Personal Rights

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. During the course of this investigation, statements were taken, documents reviewed, and site visits were made to the facility. The following determinations are made: Complainant alleges R1 does not receive proper nutrition and has lost weight as a result; Complainant alleges R1 states the Administrator yells at R1; Complainant has no direct knowledge of R1's personal rights status; R1 refuses food prepared by facility staff and chooses to eat a restricted diet of mostly organic fruit; Other residents interviewed by this Department have not confirmed R1's allegations regarding personal rights violations; Site visits to facility show a well stocked kitchen with plenty of fresh and non perishable food meeting or exceeding regulations; Professional case worker familiar with R1 and the facility indicates R1 makes contradictory statements about R1's care and has observed the staff to make every effort to accommodate the needs of R1. Although the allegations may be true, or valid, based upon the statements; documents and site visits, there is not a preponderance of evidence to prove or, disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 21, 2024 · control 21-AS-20240112133609

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced and met with Licensee, Leonida Lacap. During a complaint investigation LPA discovered resident R1 recently walked out of the facility, went to a neighbors home and requested the police was called. Facility also stated they called the police regarding R1 not wanting to return to the facility and being upset and yelling. LPA will review and get additional information regarding the incident. The facility failed to report incident to Community Care Licensing and to R1's physician as required. LPA will review incident and return to issue any citations warranted. LPA went over hallway bathroom that had no toilet paper and licensee explained they were told they can provided each resident with two rolls of toilet paper per month and each resident has their own. Per statements received, facility expects residents to purchase their own toilet paper if they go over two rolls. LPA went over facility requirements to supply residents with the required toilet paper. An advisory note was issued to facility, failure to correct may result in facility being cited under regulation: 87307(a)(3)(D) Personal Accommodations and Services. LPA also once again went over master bedroom bathroom and that resident R2 and R3 can use their bedroom bathroom and this is not for staff to use. A previous Advisory note was issued to this facility regarding this matter. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Jan 19, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(D) · Plan of correction due date: Jan 24, 2024

87211(a)(D)Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirment was not met as evidenced by: during todays inspection, it was disclosed resident R1 walked out of the facility to a neighbor, was upset and yelling and asked they call the police. Facility failed to report to CCL and notify R1s physician. This is a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jan 19, 2024

Plan of correction: Facility to send in written plan of correction on how they will ensure they stay in compliance and submit incident report to LPA Canela POC due date 1/24/2024