Opal Care

Type of visit: Case Management - Other

On 05/04/2026 at 2:40 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver an amended report for a complaint dated 02/03/2026. LPA met with Administrator Ferdinand Gutierrez and explained the purpose of the visit. Amended 9099 to correct missing information. LPA left Amended 9099 with Administrator Ferdinand Gutierrez. No deficiencies cited during the visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 4, 2026

Allegation investigated: Lack of supervision resulted in resident elopement

*THIS IS AN AMENDMENT OF REPORT DATED 04/23/2026* On 04/23/2026 at 10:30 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver findings in regards to the allegation above. LPA met with Administrator Ferdinand Gutierrez and explained the purpose of the visit. Allegation: Lack of supervision resulted in resident elopement Investigation Findings: It was reported to the department that there was an elopment of a resident due to the lack of coverage, as the resident was attempting to get to the hospital. This specific incident had already been reported to the department and addressed in a case management report dated 11/26/2025. The facility sent the department an Unusual Incident Report (LIC624) detailing that R1 left the facility. On 11/26/2025 at 11:45 AM, LPA A.Gharachorloo went to the facility. LPA interviewed staff. S2 reported to LPA that S2 followed R1 as R1 walked to Kaiser. S2 called 911 right after and filed a police report. It was determined by the department that the facility was observed to have followed protocol during this incident, therefore this allegation 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 allegation is UNSUBSTANTIATED. Nothe state’s words, verbatim · CDSS document, Apr 23, 2026 · control 15-AS-20260203163211

Type of visit: Case Management - Other

On 04/23/2025 at 12:15 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to gather documentation on residents currently in the facility. LPA met with Caregiver Vitelio Orellana and explained the purpose of the visit. Administrator Ferdinand Gutierrez had stepped out. Caregiver informed LPA there is only 6 residents in the facility. LPA obtained copies of the Identification and Emergency Information sheets for all 6 residents. LPA called Licensee/Administrator Victoria Puruganan to inform her of the visit. LPA also asked Licensee to have the Administrator email an LIC500 to the LPA as current staff did not have it available. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 23, 2026

Type of visit: Case Management - Incident

On 04/22/2025 at 09:45 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check regarding an elopement as reported to the department by the facility through an Unusual Incident Report (LIC624) received by the department on 04/16/2026. LPA met with Administrator Ferdinand Gutierrez and explained the purpose of the visit. Administrator Ferdinand Gutierrez called Licensee/Administrator Victoria Puruganan, for a three-way call. LPA spoke with the Administrator regarding the elopement of a resident (R1). R1 has a Physician’s Report (LIC602) stating that the residents cannot leave unattended. Licensee/Administrator Victoria Puruganan informed LPA that the resident had earlier in the day spoken to R1’s case manager and was upset by that conversation. R1 went to Licensee/Administrator Victoria Puruganan later that day to have a further discussion. After leaving the facility’s office, R1 walked out the front door. Staff did not notice R1 had left for about thirty (3) minutes. Staff then went to look for R1 and called the police. Licensee/Administrator Victoria Puruganan informed LPA that R1 was moved out of the facility by R1's case manager. 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. An immediate and repeat civil penalty of $1,000 is hereby assessed. Exit interview conducted. A copy of this report, LIC421IM and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 23, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 24, 2026

To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by Based on interview, the licensee did not comply with the section cited above by not having enough supervision which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: By POC date, Licensee will create and submit an elopement prvention plan to LPA. An Immediate and repeat Civil penalty assessed $1000.00

Type of visit: Case Management - Health Checks

On 04/13/2026 at 3:15 PM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to conduct a health and safety check. LPA met with Administrator Ferdinand Gutierrez and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, common area, kitchen, and outdoor area. Administrator informed LPA that 2 residents have moved out since the first of April. Administrator called Licensee Victoria Puruganan. Victoria informed LPA by phone that the new buyer is signing the application today by 4:30 PM. Licensee informed LPA that the LPA observed residents to be appropriately groomed and attired with no visible bruising or marks. LPA observed no trash piled, electricity and gas operational. Water was running. One week supply of nonperishable and 2-day supply of perishable foods were available. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 13, 2026

Type of visit: Case Management - Health Checks

On 03/13/2026 at 11:50 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check. LPA met with Administrator Victoria Puruganan and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, common area, kitchen, and outdoor area. There was sufficient supply of perishable and nonperishable foods. LPA also verified with Administrator Victoria Puruganan that on March sixth the notices to all responsible parties and residents was sent out. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 13, 2026

Type of visit: POC

On 02/17/2026 at 2:30 PM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to conduct a plan of correction visit. LPA met with Administrator Victoria Puruganan and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, common area, kitchen, and outdoor area. LPA observed residents to be appropriately groomed and attired with no visible bruising or marks. LPA observed no trash piled, electricity and gas operational. Water was running. One week supply of nonperishable and 2-day supply of perishable foods were available. LPA cleared all four deficiencies cited during the 02/11/2026 visit. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 17, 2026

Allegation investigated: Licensee does not ensure residents have their basic necessities Faclity is not meeting the resident's incontinence care needs Licensee does not ensure staff are present at all times Staff do not ensure that residents have adequate hygiene supplies

On 02/11/2026 at 09:00 AM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to conduct an initial 10-day complaint investigation and to deliver findings in regards to the allegations above. LPAs met with Administrator Ferdinand Gutierrez and explained the purpose of the visit. During the course of the investigation, LPAs obtained copies of the LIC 500, incontinence changing log for R1, and a copy of the facility's Admission Agreement. LPAs interviewed R1, R2, R3 R4, S1, S2 and S3. Allegations: Licensee does not ensure residents have their basic necessities. Continued on LIC9099-C Substantiated Continued from LIC9099 Investigation Findings: It was reported to the department that there was no toilet paper or paper towels in any of the residents’ bathrooms, and residents were using writing paper and newspapers as toilet paper. S2 reported that staff are instructed to put out only one roll of toilet paper per day. S2 has seen magazine and newspaper in toilets while cleaning, as did other staff members. LPAs observed only one roll of toilet paper in each bathroom and no paper towels in any bathroom. S3 informed LPAs that staff limit the amount of toilet paper and paper towels in each bathroom to prevent colgs as residents have been clogging toilets. Based on observation and interviews, the allegation is SUBSTANTIATED. Allegations: Facility is not meeting the resident’s incontinent care needs Investigation Findings: It was reported to the department that staff are not changing a resident with incontinence frequently. LPAs interviewed R1, who was not alert nor oriented enough to provide adequate information. The facility has a changing chart near the bed. Upon review, LPAs observed gaps between changing as long as 14 hours, and there is no log of staff checking R1’s diaper. Based on observation and record review, the allegation is SUBSTANTIATED. Allegations: Licensee does not ensure staff are present at all times Investigation Findings: It was reported to the department that the facility has no staff coverage on Monday through Sunday from 2:00 AM to 7:00 AM. LPAs reviewed the facility’s LIC 500 and confirmed there is no staff scheduled 2:00 Am to 7:00 AM Monday through Sunday, therefore this allegation is SUBSTANTIATED. Allegations: Staff do not ensure that residents have adequate hygiene supplies Continued on LIC9099-C Continued from LIC9099 Investigation Findings: it was reported to the department that there is a lack of basic necessities, such as soap and shampoo in the facility. LPAs observed one bottle of shampoo and 1 bar of soap in a supply cabinet, but none in any bathroom. The facility’s Admission Agreement specifies that basic needs, including soap and shampoo, are included in the rent. S2 informed LPAs that some residents will buy their own products based on personal preference, however the facility does not have an adequate supply to cover residents that do not buy their own or run out. Based on observation, the allegation is SUBSTANTIATED. Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of corrections by plan of correction due date and any repeat violation within 12 month period may result an additional civil penalty. An Immediate and repeat Civil penalty of $1000.00 is assessed. Deficiencies, plan and proof of corrections were discussed with Administrator Ferdinand Gutierrez Exit interview conducted, Appeal Rights, and copy this report provided. Continued from LIC9099 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. No deficiencies cited during the visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 15-AS-20260203163211

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Feb 18, 2026

Additional Personal Right…addition to the rights..residents…shall have all of the following personal rights…to have …accommodations…personal care…family groups. This requirement was not met as evidence by: Based on observation, the licensee did not comply with the section cited above by not having adequate amount of toilet paper and paper towels available which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: By POC date, licensee agrees to keep at least 4 rolls of toilet paper and one roll of paper towels in each bathroom at all times and submit proof to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Feb 18, 2026

In addition to Section 87611,…licensee shall…Ensuring...are kept clean and dry …remains free of odors from incontinence. This requirement was not met as evidence by Based on record review, the licensee did not comply with the section cited above by not tracking and recording incontinent checks which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: On POC date, Licensee will send a more detailed log that includes all incontinence checks every two to three hours in addition to all changing of briefs.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 18, 2026

To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by: Based on observation, the licensee did not comply with the section cited above by not having staff scheduled Monday to Sunday 2:00 Am to 7:00 AM which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: By POC date, Licensee agrees create and submit a new LIC 500/staff schedule that show 24 hour resident supervisor. An Immediate and repeat Civil penalty of $1000.00 is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(3)(D) · Plan of correction due date: Feb 18, 2026

Personal Accommodations and Services …supplies necessary…readily available to each resident…if the resident is…licensee shall assure provision of…Hygiene items…such as soap…. This requirement was not met as evidence by Based on observation, the licensee did not comply with the section cited above by not having an adequate supply to cover all residents which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: By POC date, Licensee agrees to buy more hygiene supplies and provide proof to LPA.

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Health Checks

On 02/02/2026 at 12:00 PM, Licensing Program Analysts (LPA) David Doidge and Licensing Program Manager (LPM) Jeremy Fong arrived unannounced to conduct a health and safety check. LPA and LPM met with Administrator Victoria Puruganan and explained the purpose of the visit. LPA and LPM toured the facility including but not limited to bedrooms, bathrooms, common area, kitchen, and outdoor area. LPA and LPM inspected the kitchen and pantry as well as refrigerators and freezers. LPA and LPM observed residents to be appropriately groomed and attired with no visible bruising or marks. LPA and LPM observed no trash piled, electricity and gas operational. Water was running, and five staff observed. One week supply of nonperishable and 2-day supply of perishable foods were available. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 2, 2026

Type of visit: Case Management - Health Checks

On 01/09/2026 at 02:20 AM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to conduct a health and safety check. LPAs met with Administrator Victoria Puruganan and explained the purpose of the visit. Administrator informed LPAs that a new resident moved in on 12/23/2025. LPAs reviewed resident’s file; it was complete. LPAs toured the facility including but not limited to bedrooms, bathrooms, common area, kitchen, and outdoor area. LPAs inspected the kitchen and pantry as well as refrigerators and freezers. At: 2:15 PM, LPAs observed no toilet paper or paper towels in any of the four bathrooms. At 2:45 PM LPAs observed moldy cauliflower in the pantry. The following deficiencies were 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 and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Jan 10, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality. Based on observation, the licensee did not comply with the section cited above by having moldy food which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Administrator agrees to throw out all moldy food and provide proof to LPAs by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(a)(3)(D) · Plan of correction due date: Jan 16, 2026

(a) Living accommodations and grounds shall…lapply. 3)…supplies necessary for personal care...of adequate hygiene practice shall be readily available to each resident….the licensee shall assure provision of: (D) Hygiene items of general use such as…toilet paper. Based on observation, the Licensee did not comply with the section above by not having sufficient amount of hygiene supplies for the number of residents in the facility, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Administrator agreed to purchase hygiene supplies keep bathrooms supplied and provide pictures of supplies to the Department by the POC date. An Immediate and repeat Civil penalty assessed $250.00

Type of visit: Case Management - Health Checks

On 11/26/2025 at 11:45 AM, Licensing Program Analysts (LPA) Ardalan Gharachorloo arrived unannounced to conduct a health and safety check regarding an elopement as reported by the night staff (S2) on 11/24/2025 . LPA met with Administrator, Victoria Puruganan and explained the purpose of the visit. LPA spoke with the Licensee regarding the elopement of the resident (R1). R1, as previously reported, cannot leave unattended. LPA and Licensee/Administrator Victoria Puruganan spoke about the latest elopement. Licensee submitted the incident report to CCLD on 11/24/2025. On 11/24/25 at around 1:15 AM, R1 left the facility unattended. S2 stated that he attempted to prevent resident from leaving the facility but was not successful. S2 followed R1 as R1 went to Kaiser. S2 called 911 and filed the police report. LPA reviewed the facility’s LIC500 and obtained a copy of the resident roster. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 26, 2025

Type of visit: Case Management - Health Checks

On 11/19/2025 at 09:10 AM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to conduct a health and safety check. LPAs met with Administrator Ferdinand Gutierrez and explained the purpose of the visit. LPAs toured the facility including but not limited to bedrooms, bathrooms, common area, kitchen, and outdoor area. LPAs inspected the kitchen and pantry as well as refrigerators and freezers. LPA reviewed the facility’s LIC500 to confirm there is enough staff on duty to provide coverage for residents. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 19, 2025

Type of visit: Case Management - Health Checks

On 11/14/2025 at 10:20 AM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to conduct a health and safety check. LPAs met with Administrator Ferdinand Gutierrez and explained the purpose of the visit. LPAs toured the facility including but not limited to bedrooms, bathrooms, common area, and outdoor area. LPAs inspected the kitchen and pantry as well as refrigerators and freezers. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 14, 2025

Type of visit: Case Management - Health Checks

On 11/07/2025 at 12:50 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check. LPA met with Licensee/Administrator Victoria Puruganan and explained the purpose of the visit. LPA toured the facility LPA toured the facility including but not limited to bedrooms, bathrooms, common area, and outdoor area. LPA inspected the kitchen and pantry as well as refrigerators and freezers. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 7, 2025

Type of visit: Case Management - Health Checks

On 10/31/2025 at 02:06 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check regarding an elopement. LPA met with Licensee/Administrator Victoria Puruganan and explained the purpose of the visit. While LPA was speaking with staff regarding an elopement, S2 informed LPA that R2 walked up the street to a nearby café. LPA spoke with staff, W1, at the café who confirmed R2 had walked, unassisted, to the corner of the street, in front of the café. R2 sat on a nearby fire hydrant, was there for less than a half hour, then walked back down the street. S2 confirm R2 walked to the café as S2 watched, but S2 did not redirect nor follow R@ as S2 was the only one on shift and di not want to leave the other residents unattended in facility. LPA and Licensee/Administrator Victoria Puruganan spoke about the elopements and what steps are to be taken to prevent future elopements. 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. An immediate and repeat civil penalty of $1,000 is hereby assessed. Exit interview conducted. A copy of this report, LIC421IM and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 31, 2025

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

To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by Based on interview, the licensee did not comply with the section cited above by not having the supervision which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2025

Plan of correction: By POC date, Licensee will create and submit an elopement prevention plan to LPA. An Immediate and repeat Civil penalty assessed $1000.00

Type of visit: Case Management - Health Checks

On 10/31/2025 at 01:25 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check regarding an elopement. LPA met with Licensee/Administrator Victoria Puruganan and explained the purpose of the visit. While LPA was at the Center for Elders' Independence (CEI) PACE Temescal, investigating a previous elopement, LPA observed a resident (R1) from the facility walk unassisted into the driveway. R1, seemed upset, and informed LPA that R1 asked for a ride, but was not offered one. R1 decided to walk to CEI and was not assisted by the facility. LPA and Licensee/Administrator Victoria Puruganan spoke about the elopements and what steps are to be taken to prevent future elopements. 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. An immediate and repeat civil penalty of $1,000 is hereby assessed. Exit interview conducted. A copy of this report, LIC421IM and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 31, 2025

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

To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by Based on observation, the licensee did not comply with the section cited above by not having the supervision which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2025

Plan of correction: By POC date, Licensee will create and submit an elopement prevention plan to LPA. An Immediate and repeat Civil penalty assessed $1000.00

Type of visit: Case Management - Health Checks

On 10/31/2025 at 12:50 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check regarding an elopement as reported by Center for Elders' Independence (CEI) PACE Temescal to CCLD. LPA met with Licensee/Administrator Victoria Puruganan and explained the purpose of the visit. LPA spoke with the Licensee regarding the elopement of a resident (R1). R1, as previously reported, cannot leave unattended. LPA and Licensee/Administrator Victoria Puruganan spoke about the elopements and what steps are to be taken to prevent future elopements. 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. An immediate and repeat civil penalty of $1,000 is hereby assessed. Exit interview conducted. A copy of this report, LIC421IM and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 31, 2025

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

To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by Based on interview, the licensee did not comply with the section cited above by not having the supervision which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2025

Plan of correction: By POC date, Licensee will create and submit an elopement prvention plan to LPA. An Immediate and repeat Civil penalty assessed $1000.00

Type of visit: Case Management - Health Checks

On 10/28/2025 at 12:00 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check. LPA met with Licensee/Administrator Victoria Puruganan and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, common area, kitchen, and outdoor area. LPA obtained copy of facility’s menu for the last month. LPA inspected the kitchen and pantry as well as refrigerators and freezers. The following deficiency was observed: · At 12:30 PM, LPA observed Inadequate food supply. Vegetables in the refrigerator were moldy. There was not enough cereal nor snacks for 9 residents. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. An immediate and repeat civil penalty of $1,000 is hereby assessed. Exit interview was conducted, a copy of this report and Appeal Rights provided.the state’s words, verbatim · CDSS document, Oct 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(3)(26) · Plan of correction due date: Oct 29, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply:(3) Between-meal nourishment or snacks shall be made available for all residents...(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in not having snacks, nonperishable foods for a minimum of one week and perishable foods for a minimum of two days which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Administrator agreed to get snacks/fresh fruits/vegetables and other foods for residents. Will submit photos of purchase and send a copy of receipt. An Immediate and repeat Civil penalty assessed $1000.00

Allegation investigated: Staff moved resident's room into a common area. Staff leave residents unattended.

On 09/29/2025 at 10:30 AM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to open a 10-day initial visit and to deliver findings for the allegations above. LPAs met with Licensee/Administrator Victoria Puruganan and explained the reason for the visit. During the course of the investigation, LPAs toured the facility, inspected all residents’ rooms, obtained and reviewed copies of the staff schedules for August and September. Allegations: Staff moved resident's room into a common area. Investigation Finding: It was reported to the department that the licensee is moving a resident to a converted room which is not up to code The licensee has converted living room space into a bedroom, and other residents have access to this common area. Continued on LIC9099-C Substantiated Continued from LIC9099 During investigation, LPAs toured the facility and observed a resident, R1, occupying a space in the living room that has been converted into a bedroom that is not fire cleared nor on the original facility sketch. Therefore, this allegation is SUBSTANTIATED. Allegations: Staff leave residents unattended. Investigation Findings: It was reported to the department that there are no night staff on the premises. LPAs reviewed the staff schedule for August and September, and found there were no specific times listed for staff shifts. LPAs spoke with S1 and discovered that there are no listed times for the shifts due to inconsistent number of staff on shift S1 also reported that there are no staff scheduled 10:00 PM to 6:00 AM. Therefore, this allegation is SUBSTANTIATED. The preponderance of evidence is met; therefore, the allegations are substantiated. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809-D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalties. Deficiency plan and proof of correction were discussed with Licensee/Administrator Victoria Puruganan. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 29, 2025 · control 15-AS-20250925114054

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a)(2)(B) · Plan of correction due date: Sep 30, 2025

87307 Personal Accommodations and Service (a) Living accommodations…facility shall…provide…accommodations and privacy for… residents…shall apply: (2) Resident bedrooms shall…(B) No…used for other purposes shall be used as a sleeping room for any resident. Based on observation, the licensee did not comply with the section cited above by having a resident's sleeping quarters in commmon area which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2025

Plan of correction: By POC date, Licensee will move resident into a private room. Licensee will submitt photos to LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 30, 2025

To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by: Based on interview, the licensee did not comply with the section cited above by not having staff scheduled 10:00 PM to ^:00 AM which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2025

Plan of correction: By POC date, Licensee will schedule sufficient staff to cover 10:00 PM to 6:00 AM and submitt staff schedule to LPA. An Immediate and repeat Civil penalty assessed $1000.00

Type of visit: Case Management - Other

On 9/26/2025 at 12:15 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver a 10-day letter to correct. LPA met with Licensee/Administrator Victoria Puruganan and explained the purpose of the visit. LPA printed the letter and left it with the Licensee/Administrator. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 26, 2025

Allegation investigated: Staff did not prevent residents room from being hazardous.

On 09/24/2025 at 12:30 PM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to open a 10-day initial visit and to deliver findings for the allegation above. LPAs met with Licensee/Administrator Victoria Puruganan and explained the reason for the visit. During the course of the investigation, LPAs conducted interviews with S1 and S2. LPAs toured the facility and inspected all residents’ rooms. Allegations: Staff did not prevent residents room from being hazardous. Investigation Finding: It was reported to the department that there is a room currently under construction being painted while a resident, R1, was in the room. S1 and S2 informed LPAs that R1 was in room 13 and that staff painted the room while R1 was in it. Room 13, according to the facility sketch, was originally a staff room not meant for residents. Room 13 is not fire cleared for residents. Continied on LIC9099-C Substantiated Continued fro LIC9099 R1 has since moved out of the facility. LPAs observed exposed wires hanging in the corner of the room next to door, and room 13 smells of paint. The preponderance of evidence is met; therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 809-D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalties. Deficiency plan and proof of correction were discussed with Licensee/Administrator Victoria Puruganan. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 24, 2025 · control 15-AS-20250917130441

From the deficiency page — Deficiency type: Type A · Section cited: CCR 97204)b) · Plan of correction due date: Sep 25, 2025

87204 Limitations - Capacity and Ambulatory Status (b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. . Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents Based on observation, the licensee did not comply with the section cited above by having a bedridden resident in a non-cleared room.the state’s words, verbatim · CDSS document, Sep 24, 2025

Plan of correction: R1 has already moved out of the facility.

Type of visit: Case Management - Health Checks

On 09/24/2025 at 4:001 PM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to open a 10-day initial visit for complaint number 15-AS-20250917130441. LPAs met with Licensee/Administrator Victoria Puruganan and explained the reason for the visit. During the complaint investigation, LPAs noted and cited for the following deficiencies: At 12:45PM, LPAs observed a resident (R1) in a room that is not fire cleared. LPAs evaluated the resident and came to the conclusion that the resident is bedridden. At 1:00PM, LPAs reviewed R1's file. The Appraisal Needs And Services Plan (ANS) had not been updated March 2023 while needs have clearly changed. At 1:15 PM, LPAs observed in the closet of bedroom 5 a blanket that had been soiled with urine, emitting a urine smell throughout the second floor of the facility. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Sep 25, 2025

87202 Fire Clearance All facilities shall maintain a fire clearance…Prior to accepting or retaining any of the following types of persons…State Fire Marshal. (2) Bedridden persons Based on observation, the licensee did not comply with the section cited above by having a bedridden resident in a non-cleared room.the state’s words, verbatim · CDSS document, Sep 24, 2025

Plan of correction: By POC date, Licensee will move resident out of current room, and into a cleared room. Licensee will submit photos to LPA. An Immediate and repeat Civil penalty of $1000 is hereby assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(b) · Plan of correction due date: Oct 1, 2025

87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's ...mental, cognitive...condition, including those required to be documented as specified in Section 87466, Observation of the Resident. Based on record review, the licensee did not comply with the section cited above by not performing a reappraisal since March 2023.the state’s words, verbatim · CDSS document, Sep 24, 2025

Plan of correction: By POC date, Licensee will complete a reappraisal for R1 and submit a copy to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 1, 2025

87303 Maintenance and Operation (a) The facility shall be clean...sanitary...at all times. Maintenance shall include provision of maintenance services...residents, employees and visitors. Based on observation, the licensee did not comply with the section cited above by not removing soiled linens in bedroom.the state’s words, verbatim · CDSS document, Sep 24, 2025

Plan of correction: POC clear during visit. An Immediate Civil penalty of $250 is hereby assessed.

Type of visit: Case Management - Health Checks

On 09/15/2025 at 12:00 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check regarding an elopement that occurred 08/24/2025 as reported by Oakland Police to CCLD. LPA met with Victoria Puruganan, Licensee/Administrator and explained the purpose of the visit. LPA interviewed staff and Licensee regarding the elopement of a resident (R1). R1 is back, was gone for three (3) to four (4) hours. Staff and Licensee/Administrator know R1 cannot leave unassisted. R1 left the facility for a walk after breakfast. 911 was called around 10:30 AM and R1 walked back to the facility while staff were on the phone with 911. While interviewing, LPA learned a new resident (R2) moved in on 09/09/2025. R2 is bedridden roomed in a non-fire cleared room. Licensee/Administrator did not submit the Unusual Incident Report (LIC624) to CCLD for the 08/24/2025 elopement. The following deficiencies were 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. An immediate and repeat civil penalty of $1,500 is hereby assessed for elopement, not reporting elopement to CCLD, and having a bedridden resident in a non-cleared room. Exit interview conducted. A copy of this report, LIC421IM and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 16, 2025

To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by: Based on interview, the licensee did not comply with the section cited above by not having the supervision which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: By POC date, Licensee will submit to CCLD a detailed written plan on how they will address incidents of elopement and safety and also how they plan to mitigate this type of situation. An Immediate and repeat Civil penalty assessed $1000.00

From the deficiency page — Deficiency type: Type A · Section cited: CCR87202(a)(2) · Plan of correction due date: Sep 16, 2025

87202 Fire Clearance All facilities shall maintain a fire clearance…Prior to accepting or retaining any of the following types of persons…State Fire Marshal. (2) Bedridden persons Based on observation, the licensee did not comply with the section cited above by having a bedridden resident in a non-cleared room.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: By POC date, Licensee will move resident out of curret room, and into a cleared room. Licensee will submitt photos to LPA. An Immediate and repeat Civil penalty assessed $500.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Sep 22, 2025

(2) Occurrences...which threaten the welfare, safety or health of residents,...shall be reported within 24 hours... Based on interview and record review the licensee did not comply with the section cited above by not reporting to CCL within 24hrs R1's elopement which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Facility has agreed to conduct an in-service training with staff that writes incident reports/SIRs and submit staff sign in sheet with training materials to CCLD by POC date. An Immediate and repeat Civil penalty assessed $1000.00

Type of visit: Case Management - Health Checks

On 09/04/2025 at 11:15 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check of the facility. LPA met with Victoria Puruganan, Licensee/Administrator and explained the purpose of the visit. Three (3) staff and the Licensee/Administrator were present. LPA spoke with the Licensee/Administrator about staffing. Facility now has 7 staff total. Administrator/Licensee informed LPA that potential new hire, and potential new administrator, may not start after all. LPA obtained copy of new LIC500. No citations issued during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 4, 2025

Type of visit: Case Management - Health Checks

On 08/21/2025 at 2:30 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check regarding an elopement that occurred 08/19/2025. LPA met with Victoria Puruganan, Licensee/Administrator and explained the purpose of the visit. LPA interviewed staff and Licensee regarding the elopement of a resident (R1). R1 is not back and may not return. LPA obtained R1’s Physician’s report (602). Physician’s Report shows resident able to leave unassisted. Staff and Licensee/Administrator know resident cannot leave unassisted. Licensee/Administrator had the Unusual Incident Report (UIR LIC624) created, but had not yet sent in the report due to a computer issue. LPA obtained a copy. The following deficiencies were 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. An immediate and repeat civil penalty of $1000 is hereby assessed. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 28, 2025

To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by: Based on interview, the licensee did not comply with the section cited above by not having the supervision which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: By POC date, Administrator will speak to staff and retrain in resident supervisons for elopement prevention. And come up with a plan to prevent future elopments. An Immediate and repeat Civil penalty assessed $1000.00t.

Type of visit: Case Management - Health Checks

On 08/19/2025 at 11:15 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check of the facility. LPA met with Victoria Puruganan, Licensee/Administrator and explained the purpose of the visit. Three (3) staff and the Licensee/Administrator were present. LPA spoke with the Licensee/Administrator about staffing. New hire, S1, started 08/18/2025. Licensee/Administrator is going to make S1 the new administrator. S1 will be joined by S2, once cleared. One staff, S5, has put in a resignation letter with a last day of August sixteenth. No citations issued during visit. Exit interview conducted and a copy of this report provided Scan_20250821 (2).pdfthe state’s words, verbatim · CDSS document, Aug 19, 2025

Type of visit: Case Management - Health Checks

On 08/19/2025 at 11:15 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check of the facility. LPA met with Victoria Puruganan, Licensee/Administrator and explained the purpose of the visit. Three (3) staff and the Licensee/Administrator were present. LPA spoke with the Licensee/Administrator about staffing. New hire, S1, started 08/18/2025. Licensee/Administrator is going to make S1 the new administrator. S1 will be joined by S2, once cleared. One staff, S5, has put in a resignation letter with a last day of August sixteenth. No citations issued during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 19, 2025

Type of visit: POC

On 08/15/2025 at 3:00 PM Licensing Program Analysts (LPAs) L. Alexander arrived unannounced to conduct a Plan of Correction (POC) visit. LPA met with Licensee/Administrator, Victoria Puruganan and explained the purpose of the visit. Deficiencies not cleared: CCR 87405(a)(b) Administrator - Qualifications and Duties $100.00 x 107 days = $10,700.00 (05/01/2025 thru 08/15/2025) CCR 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities = $100.00 x 128 days = $13,050.00 (Includes $250.00 repeat violation on 06/17/25) ) (04/10/2025 thru 08/15/2025) CCR 87621(2)(b) Colostomy/Ileostomy $100.00 x 10 days = $1,000.00 (08/06/2025 thru 08/15/2025) HSC §1569.605 Liability insurance; coverage requirements $100.00 x 10 days = $1000.00 (08/06/2025 thru 08/15/2025) LIC809-C Continued... LIC809-C (Page 2) CCR 87608(a)(3) Postural Supports $100.00 x 10 days = $1,000.00 (08/06/2025 thru 08/15/2025) CCR 87628(a) Diabetes $100.00 x 17 days = $1700.00 (07/29/2025 thru 08/15/2025) CCR 80086(a)(c) Alterations to Existing Building or New Facilities $100.00 x 17 days = $1,700.00 (07/29/2025 thru 08/15/2025) Continuing Civil Penalties in the total amount of $6,900.00 is assessed today for failure to meet POC date for deficiencies. Civil penalties total as of today is $30,150.00. Facility is subject to ongoing civil penalties until deficiencies is corrected. Exit interview conducted, LIC421FC, appeal rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 15, 2025

Type of visit: Case Management - Health Checks

On 08/15/2025 at 1:15 PM, Licensing Program Analyst (LPA) L. Alexander conducted a Health & Safety inspection as a result continuing Non-Compliance Conference meeting which was held 03/26/2025. LPA met with Licensee/Administrator, Victoria Puruganan and explained the purpose of the visit. Upon entry LPA observed three (3) residents and two (2) staff. The three (3) residents were sitting and walking in the front common area. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperatures was measured at 105.8 and 108.3 degrees F in the upstairs shared bathroom. LPA observed 7-day of non-perishable and 2-day of perishable food supplies were sufficient. LPA obtained a copy of current LIC 500 and Progress Report for Resident (R) R5. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 15, 2025

Type of visit: Case Management - Health Checks

On 08/11/2025 at 1:30 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check of the facility. LPA met with Victoria Puruganan, Licensee/Administrator and explained the purpose of the visit. During this visit, the LPA interviewed the Licensee/Administrator Victoria Puruganan regarding R1’a return from the hospital. R1 returned on 08/08/2025 in the evening with no new condition. Two staff and the Licensee/Administrator were present. LPA spoke with the Licensee/Administrator about staffing. New staff to join 08/19/2025, and another on 08/14/2025. S1 has left as of 08/10/2026. No citations issued during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 11, 2025

Type of visit: Case Management - Health Checks

On 08/08/2025 at 2:30 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a health and safety check regarding an elopement from an Unusual Incident Report (UIR) dated 08/04/2025. LPA met with Victoria Puruganan, Licensee/Administrator and explained the purpose of the visit. LPA interviewed staff and Licensee regarding the elopement and return of resident (R1). R1 is back with no injuries. LPA obtained R1’s after care report and spoke to R1. The following deficiencies were 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. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(1) · Plan of correction due date: Aug 15, 2025

Administrator - Qualifications and Duties.The administrator shall have the qualifications..all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. Based on Interviews and document review, Administrator did not update the Appraisal Needs and Services Plan for R1 nor train staff on new conditions from 602.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: Administrator agreed to create an Appraisal Needs and Services Plan for R1 and train staff on ANS Plans. Administrator to submit ANS to CCLD with self-certifying letter saying staff have been trained by POC date.

Type of visit: Case Management - Incident

On 08/06/2025 at 9:25 AM, Licensing Program Analysts (LPAs) David Doidge and L. Alexander arrived unannounced to conduct case management inspection regarding an elopement from an Unusual Incident Report dated 08/04/2025. LPAs met with Victoria Puruganan, Licensee/Administrator and explained the purpose of the visit. LPAs obtained a copy of R1’s Physician’s report (602) and Appraisal Needs and Services Plan (ANS). LPAs interviewed Administrator about incident. Around 1PM, R1 was seen walking out the front door by S2. Previous Physician’s Report shows resident able to leave unassisted. Administrator said that R1 would walk to the local store on own, and per previous 602, R1 was able to do that. Upon learning of elopement staff walked the block to look for resident. Most recent 602, dated 05/02/2025 confirms resident is unable to leave the facility unassisted. A new Appraisal Needs and Services Plan was not created, and staff were going off of previous information. An immediate and repeat civil penalty of $1000 is hereby assessed. Exit interview was conducted with Licensee/Administrator, Victoria Puruganan, copy of this report and Appeal Rights provided.the state’s words, verbatim · CDSS document, Aug 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 13, 2025

To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by: Based on interview, the licensee did not comply with the section cited above by not having the supervision which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: By POC date, Administrator to have all staff trained by an authorized CCLD approved vendor on resident elopement prevention. An Immediate and repeat Civil penalty assessed $1000.00t.

Type of visit: POC

On 08/06/2025 at 9:25 am, Licensing Program Analysts (LPAs) L. Alexander and D. Doidge arrived unannounced to conduct a Plan of Correction (POC) visit. LPAs met with Licensee/Administrator, Victoria Puruganan and explained the purpose of the visit. Deficiencies cleared: 87355(e)(3) 87555(b)(3)(26) 87307(a)(3)(D) 80075(k)(1) 87303(a) Deficiencies not cleared: 87621(2)(b) $100 x 1 day = $100.00 HSC 1569.605 $100 x 1 day = $100.00 87608(a)(3) $100 x 1 day = $100.00 87628(a) $100 x 8 days = $800.00 80086 (a)(c) $100 x 8 days = $800.00 Civil Penalties in the total amount of $1,900.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiency is corrected. Exit interview conducted. Appeal Rights, Deficiency cleared letters, LIC421FC, and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 6, 2025

Type of visit: Required - 1 Year

On 08/06/2025 at 12:45 PM, Licensing Program Analyst (LPA) David Doidge unannounced to conduct 1-Year Annual Required Inspection. LPA met with Licensee/Administrator Victoria Puruganan, and explained the purpose of the visit. LPA toured the facility including but not limited to residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75 degrees Fahrenheit. The hot water temperature was measured at 105.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. 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 operating condition during visit. Fire extinguisher was last serviced on 10/02/2024. Emergency Disaster Plan was last posted on 02/27/2025. Emergency disaster and fire drill are conducted quarterly; last conducted on 04/12/2025. First aid kit was observed to be complete. LPA reviewed five (5) residents records and five (5) staff records; all were complete. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 6, 2025

Type of visit: Case Management - Other

On 08/06/2025 at 02:00 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct case management to obtain documents on residents. LPA met with Victoria Puruganan, Licensee/Administrator and explained the purpose of the visit. LPA obtained records for all 10 residents. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 6, 2025

Type of visit: Case Management - Deficiencies

On 07/29/2025 at 10:00 AM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct case management inspection as part of on-going monitoring plan from Non-Compliance Conference (NCC) held on March 26, 2025. LPA met with House Manager, Jezrael Pascual, and explained the purpose of the visit. Jezrael phoned Licensee/Administrator, Victoria Puruganan to inform. Victoria arrived approximately an hour later. On 06/17/2025 LPA's L. Alexander and D. Doidge conducted a Case Management visit in which deficiencies were cited with a Plan of Correction (POC) due date of 06/24/2025. LPAs were unable to return before 10 days POC visit. Deficiencies will be re-cited. LPA L. Alexander obtained copies of Residents (R) R1-R11 Medication Administration Records (MARs) for July 2025, Resident Registry List, Medical Assessment (LIC602-A) for R11, Emergency Disaster Plan (signed 02/27/2025) and screenshot print of building permit (filed 03/18/2024). THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 10:09 am LPA observed R4 in a hospital bed without a doctor's order At 10:09 am LPA observed unfinished wall constructions in bedrooms #9-12 including upstairs bedrooms. At 10:14 am LPA observed unlocked medications in refrigerator located in sun porch At 10:15 am LPA observed foods in containers, food bags/freezer bags unlabeled without dates located in refrigerators on sun porch that was expired and spoiled LIC809-C Continued... LIC809-C Continued... (Page 2) At 10:20am LPA observed meats in rear refrigerator not contained in proper storage and freezer was not cleaned At 10:21 am LPA observed expired opened boxed Cherrios Cereal, salad dressing bottles, eggplants that was spoiled located in rear sunroom porch At 10:23 am LPA observed bottle Awesome Window Clean At 10:27 am LPA observed 1/2 bed rails on R5's bed without doctor's orders At 10:38 am LPA observed three (3) ladders, window screens, crutches, yard shovels, hoes, lawn mower, dolly, rakes, wood, sink, cooking pot in rear backyard At 10:39 am LPA observed laundry room door unlocked where Fabuloso Multi Cleaner, bleach, toxic chemicals were located At 10:39 am LPA observed screens, wheelchair in rear side backyard At 10:40 am LPA observed spoiled vegetables, expired gallons of milk, bottles of milk, unlabeled foods in refrigerator and freezers located on side back yards At 10:48am LPA observed four (4) boxes of laminate flooring upstairs, in which laminate flooring was unwrapped laying on hallway floor At 10:52 am LPA observed missing shower mats and no toilet paper in two (2) shared bathrooms located upstairs At 11:02 am LPA observed Lysol Disinfectant Spray located in locked closet with dried foods At 11:03 am LPA observed expired Velveeta Shells & Cheese, opened waffle cones and bagged brown rice At 11:05 am LPA observed toilet paper, bag of fruits, boxes of hot dog buns, Brownie Bars located in locked closet with fans, tool boxes, lotions, sprays, antiseptic rinse The following deficiencies were 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. Appeal Rights, LI421BG, LIC421FC, LIC421IM and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jul 30, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review (b) shall prior to working...in a licensed facility: (3) Request a transfe...of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in not having S3 associated with Guardian systems which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator submitted LIC9182 and US Issued ID for S3. S3 associated during visit. Deficiency cleared. Civil Penalty $500.00 assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(3)(26) · Plan of correction due date: Jul 30, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply:(3) Between-meal nourishment or snacks shall be made available for all residents...(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in not having snacks, nonperishable foods for a minimum of one week and perishable foods for a minimum of two days which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator agreed to get snacks/fresh fruits/vegetables/tuna..other canned foods for residents other than carbs. Will submit photos of purchase and send a copy of receipts to CCLD by POC due date. Immediate Civl Penalty $500.00 assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87621(2)(b) · Plan of correction due date: Aug 5, 2025

87621 Colostomy/Ileostomy In addition to Section 87611(b), the licensees shall be responsible for the following: (1) Ensuring that ostomy care is provided by an appropriately skilled professional. This requirement is not met as evidenced by: Based on observation, record review and interview, the licensee did not comply with the section cited above in not having exception request for R5's ostomy bag with documents that an appropriately skilled professional is caring for ostomy bag which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator agreed to submit an exception request with all supporting documents including but not limited signed documents by appropriately skilled professionals and submit to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Aug 5, 2025

87303 Maintenance and Operation (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 observation the licensee did not comply with the section cited above in not having backyards clean, refrigerators/freezers clean which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator will submit photos of entire back yards cleans to CCLD by POC due date. Repeat Violation $250.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Aug 1, 2025

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above in not having toilet paper in shared bathrooms for residents which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator agreed to purchase toilet paper and submit receipts to CCLD by POC due dates. Send photos of having toilet paper available for residents.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.605 · Plan of correction due date: Aug 5, 2025

§1569.605 Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Based on record review and interview the licensee did not comply with the section cited above in not having liability insurance which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator will submit copy of liability insurance to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Aug 5, 2025

87608 Postural Supports (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Based on observation, record review and interview the licensee did not comply with the section cited above in not having doctor's orders for hospital bed and bed rails for R4 and R5 respectively which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator will submit doctor's order for 1/2 rail bed and/or hospital bed for R4 and R5 to CCLD by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Aug 5, 2025

87628 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 with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on record review and interview conducted, R7 is diabetic and per dr's medication orders requires insulin injections daily at night. However, R5 and R6 is unable to check own blood sugar and administer own injections per current physician's report, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator will submit request for exception for R5's and R6's restricted condition - diabetes management and submit to CCLD by POC date. Repeat Violation $250.00

From the deficiency page — Deficiency type: Type A · Section cited: CCR80075(k)(1) · Plan of correction due date: Jul 30, 2025

80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation there was unlocked insulin located in the refrigerator which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator to place the insulin in a lock box and send a photo to CCLD by POC due date. Repeat Violation $250.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80086(a)(c) · Plan of correction due date: Aug 5, 2025

80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.(c) Prior to construction or alterations, state or local law requires that all facilities secure a building permit. Based on observation, the licensee did not comply with the section cited above in by not notifying Licensing of the renovations, providing a copy of building permit and ensuring that residents will be safe during renovation which poses an health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator agrees to submit a proposed plan with a timeline, updated facility sketch and copy of building permit to CCLD by POC due date. Repeat Violation $250.00

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

On 07/29/2025 at 10:00 AM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct case management inspection as part of on-going monitoring plan from Non-Compliance Conference (NCC) held on March 26, 2025. LPA met with House Manager, Jezrael Pascual, and explained the purpose of the visit. Jezrael phoned Licensee/Administrator, Victoria Puruganan to inform. Victoria arrived approximately an hour later. Upon entry to the facility, LPA observed three (3) residents (R), which R1 was sitting outside front patio, and R2 and R3 were sitting inside the front living room area watching television. Deficiencies not cleared: 87405(a)(b) Administrator - Qualifications and Duties $100.00 x 77 days = $7,700.00 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities $100.00 x 77 days = $7,700.00 Civil Penalties in the total amount of $15,400.00 is a continuation of a daily penalty that was first assessed on 04/10/2025 for failure to meet Plan of Correction (POC) dates for deficiencies. Facility is subject to ongoing civil penalties until deficiency is corrected. Exit interview conducted. Appeal Rights, LIC421FC, and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 29, 2025

Type of visit: Case Management - Incident

On 07/11/2025 at 10:45 AM Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to conduct a Case Management Incident due to an Unusual Incident Report submitted to CCLD on 07/08/2025 regarding a resident that eloped. LPAs met with Jezrael Pascual, House Manager and explained the purpose of the visit. Licensee/Administrator, Victoria Puruganan was called and informed of the visit, and arrived at 12:00 PM. LPAs interviewed Jezrael and another staff about incident. Neither saw R1 elope. Licensee/Administrator Victoria was present, but did not see R1 walk away. Staff reported that R1 had an appointment with Center for Elders Independence (CEDI) and was last seen waiting for the van in front of the house. Upon learning of elopement staff walked the block to look for resident. R1 was later found by the police. LPAs obtained a copy of R1’s Physician’s report (602) and a staff schedule for that day. The 602 confirms resident is unable to leave the facility unassisted. An immediate civil penalty of $250 is hereby assessed for a repeat violation Exit interview was conducted with Licensee/Administrator, Victoria Puruganan, copy of this report and Appeal Rights provided.the state’s words, verbatim · CDSS document, Jul 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 11, 2025

To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by: Based on interview, the licensee did not comply with the section cited above by not having the supervision which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 11, 2025

Plan of correction: By POC date, Administrator will rerain staff on supervision procedures for residents and will ensure a staff member accompanies residents to CEI van. Civil penalty assessed $250.00 for repeat.

Type of visit: Case Management - Deficiencies

On 06/17/2025 at 3:30 PM Licensing Program Analysts (LPAs) L. Alexander and D. Doidge arrived unannounced to conduct a Case Management inspection as part of monitoring plan from Non-Compliance Conference (NCC) held on March 26, 2025. LPAs met with Licensee/Administrator, Victoria Puruganan, and explained the purpose of the visit. LPAs received and reviewed updated medical assessments for 5 (five) residents (R). During the review, LPAs observed R1 tested positive with Tuberculosis, and is currently taking a course of antibiotics for 4 months. Licensee did not have confirmation from R1's primary care physician if they were contagious or not. LPAs observed that R2's physician's report indicated that they can not administer their own insulin nor check their own blood glucose. LPAs observed that R4 had a recent Emergency Room visit of 06/07/2025 in which the After Visit Summary indicated that R4 was seen for a fall. During interview with S1, S1 stated that R4 had eloped and that the hospital called. S1 stated that they had notified CCLD but they did not have a copy of the Incident Report (LIC624). LPAs observed that R5 is diabetic on insulin and also has a ostomy bag. S1 stated that there is a nurse from Kaiser that comes to monitor R5 for the osotmy bag but S1 did not have care plan to address R5's insulin use for diabetes and ostomy. LPAs obtained copies of medical assessments for R1-R5, MAR for R3, Admission Agreement and Emergency Identification Form for R5. Civil penalties were assessed today of $500.00 for repeat violations. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report, LIC421FC and appeal rights provided.the state’s words, verbatim · CDSS document, Jun 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 24, 2025

To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by: Based on interview, the licensee did not comply with the section cited above by not having the supervision which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: By POC date, Licensee will submit to CCLD a detailed written plan on how they will address incidents of elopement and safety and also how they plan to mitigate this type of situation. Civil penalty assessed $250.00 for repeat.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(2) · Plan of correction due date: Jun 24, 2025

(2) Occurrences...which threaten the welfare, safety or health of residents,...shall be reported within 24 hours... This requirement was not met as evidence by: Based on interview and record review the licensee did not comply with the section cited above by not reporting to CCL within 24hrs R4's elopement which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: By POC due date, Licensee will submit an Incident Report (LIC 624) for R4's elopement on 06/07/25. Civil penalty assessed $250.00 for repeat.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87621(a)(2) · Plan of correction due date: Jun 24, 2025

87621 Colostomy/Ileostomy (a) Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a colostomy or ileostomy under the following circumstances Based on interview, and record review the licensee did not comply with the section cited above by not having appropriate documentation and care plan on file for R5's ostomy bag which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Administrator agreed to submit documentation care plan for R5's ostomy provided by an appropriately skilled professional by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87629(a) · Plan of correction due date: Jun 24, 2025

(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. Based on interview, and record review the licensee did not comply with the section cited above by not having on file for R5 if the injections are administered by an appropriately skilled professional which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Administrator agreed to submit an exception request, appriasal needs and services and doctor's orders for R5's diabetes and insulin injection by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87455(c)(1) · Plan of correction due date: Jun 24, 2025

87455 Acceptance and Retention Limitations (c) No resident shall be accepted or retained if any of the following apply: (1) The resident has active communicable tuberculosis. Based on interview, record review the licensee did not comply with the section cited above by not having written doctor's order indicating if R1 has active TB which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Administrator agreed to submit written doctor's documentation indicating if R1 is non-contagious. If R1 is contagious Administrator will update care plan and submit an exception request for R1 by POC due date to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(a)(6) · Plan of correction due date: Jun 24, 2025

87465 Incidental Medical and Dental Care (6) When requested by... the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. Based on interview and record review the licensee did not comply with the section cited above by not having a record (MAR) for R1-R5 on file which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Administrator agreed to submit prescription doctor's orders for R1-R5 including but not limited to diabetes management. Administrator will conduct an In-Service training with all staff with an skilled professional from an licensed health agency. Administrator will submit sign-in sheet and a copy of training synopsis to CCLD by POC due date.

Type of visit: POC

On 05/13/2025 at 1:30 pm, Licensing Program Analysts (LPAs) L. Alexander and D. Doidge arrived unannounced to conduct a Plan of Correction (POC) visit. LPAs met with House Manager, Jezrael Pascual, and explained the purpose of the visit. Jezrael called Licensee/Administrator, Victoria Puruganan, to inform. On 03/26/2025, the Department held a Non-Compliance Conference (NCC) meeting with the Licensee, Victoria Puruganan. The Plan of Corrections (POC) was discussed with Licensee to get the facility in compliance. The due dates were 04/09/25, 04/30/25 and an extension was granted per the Licensee's request for 05/02/25. Deficiencies not cleared: 87405(a)(b) Administrator - Qualifications and Duties $100.00 x 13 days = $1,300.00 87788(h)(1)(A) Continuing Education Training Program Vendor Requirements $100.00 x 13 days = $1,300.00 87458(c) Medical Assessments $100.00 x 11 days = $1,100.00 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities $100.00 x 34 days = $3,400.00 Civil Penalties in the total amount of $7,100.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiency is corrected. Exit interview conducted. Appeal Rights, LIC421FC, and a copy of this report provided.the state’s words, verbatim · CDSS document, May 13, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a)(b) · Plan of correction due date: Apr 30, 2025

(a) All facilities shall have a qualified...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 observation, record review and interview the licensee did not comply with the section cited above in by hiring a qualified administrator that will be present at the facility for 40 hours a week which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 13, 2025

Plan of correction: Licensee to hire a qualified Administrator that will be present 40 hours a week by April 30, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87788(h)(1)(A) · Plan of correction due date: Apr 30, 2025

87788(h)(1)(A) Continuing Education Training Program Vendor Requirements This requirement is not met as evidenced by: Based on observation, record review and interview the licensee did not comply with the section cited above in by completing staff training with a approved CCLD approved vendor which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 13, 2025

Plan of correction: Training for all staff by CCLD approved vendors, including Licensee, completed by April 30, 2025: 4 Hours Training for proper eviction procedure 4 Hours training for dementia care and responding to elopements 4 Hours training for observing for changes in condition 4 Hours training for reporting requirements 4 Hours training for appraisals and re-appraisals 4 Hours training for records keeping

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(c) · Plan of correction due date: May 2, 2025

87458(c) Medical Assessments (c) The licensee shall obtain an updated medical assessment when required by the Department This requirement is not met as evidenced by: Based on observation, record review and interview the licensee did not comply with the section cited above in by not submitting updated physician's reports for all eleven (11) residents which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 13, 2025

Plan of correction: Provide Physician's Reports for all residents, fully completed within the past 12 months, by April 30, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.2(a)(4) · Plan of correction due date: Apr 9, 2025

87468.2(a)(4) 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 observation, record review and interview the licensee did not comply with the section cited above in by not submitting a comprehensive plan for adequate staffing and to identify, document and mitigate elopements which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 13, 2025

Plan of correction: Develop a comprehensive plan for adequate staffing that addresses the ability to monitor all areas of the facility, provide for all required needs of residents, by April 9, 2025. Develop a comprehensive plan to identify, document, and mitigate the potential for elopements, by April 9, 2025.

Type of visit: Case Management - Deficiencies

On 05/09/2025 at 10:30 AM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct case management inspection as part of monitoring plan from Non-Compliance Conference (NCC) held on March 26, 2025. LPA met with Licensee/Administrator, Victoria Puruganan, and explained the purpose of the visit. LPA left the facility to complete the report and returned back for Licensee to sign documented report. Upon entry to the facility, LPA observed four (4) residents (R) sitting in the common area watching television. LPA was greeted by House Manager, Jezrael Pascual. LPA entered the office where Licensee/Administrator, Victoria Puruganan, was sitting at her desk. During the visit LPA reviewed six (6) current physician's reports out of eleven (11) residents. During the review, LPA observed two (2) of the residents are diabetic and need to take insulin daily. The physician's reports for both residents indicated that they are not able to administer their own injections nor take their own glucose readings. LPA left the facility to complete the report and returned back for Licensee to sign LPA observed the following deficiencies: At 12:36 pm a large bottle of bleach and a spray bottle labeled "Clorox" was unlocked under kitchen sink LIC809-C At 12:38 pm prescription insulin unlocked in refrigerator located on back sun porch At 12:40 pm wood planks laying out side in the side/back yards, buckets, ladder propped up against the outside exterior on the eastern side of house At 12:41 pm box mattress, top mattress and pillows stacked up against stairs in back yard At 12:42 pm doors, ladder, more wood, lawn mower, lawn rake, paint cans, buckets, dresser chest drawer with a missing top drawer At 12:44 pm glass window frame, buckets, boxes, bottle of bleach and spray bottles located on the western side of the house At 12:45 pm construction in Room #12 where there was a ladder, bottles of DAP repair, the floor was taped and wires were loose hanging out from the ceiling. At 12:50 pm R1 laying in a full hospital bed located in a bedroom not fire cleared for residents. Licensee stated that the room was for staff. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, May 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202 (a) · Plan of correction due date: May 10, 2025

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Based on observation, the licensee did not comply with the section cited above in by having R1 located in a staff room without a fire clearance which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 9, 2025

Plan of correction: Administrator to contatc local fire department to advise R1 is located in another room that doesn't have a fire clearance. Immediate Assessed Civil Penalty $500.00 for today.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: May 16, 2025

(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 in by having bleach and Clorox spray unlocked under kitchen cabinet which poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, May 9, 2025

Plan of correction: Administrator to remove bottle of Bleach and conduct a training with all staff about unlocked chemicals and conduct a In-Service Training with all staff. Submit training sign-in sheet to CCLD by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: May 16, 2025

87628 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 with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Based on record review and interview conducted, R4 is diabetic and per dr's medication orders requires insulin injections daily at night. However, R2 and R3 is unable to check own blood sugar and administer own injections per current physician's report, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 9, 2025

Plan of correction: Administrator will submit request for exception for R2's and R3's restricted condition - diabetes management and submit to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR80075(k)(1) · Plan of correction due date: May 10, 2025

80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation there was unlocked insulin located in the refrigerator which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 9, 2025

Plan of correction: Administrator to place the insulin in a lock box and send a photo to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 16, 2025

87303 Maintenance and Operations (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. Based on observation, the licensee did not comply with the section cited above in by not having the back yards cleaned up with ladders, mattresses, paint cans, doors removed and inaccessible to residents which poses an health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 9, 2025

Plan of correction: Administrator to clean up the back yard and send a photo to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR80086(a)(c) · Plan of correction due date: May 16, 2025

80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.(c) Prior to construction or alterations, state or local law requires that all facilities secure a building permit. Based on observation, the licensee did not comply with the section cited above in by not notifying Licensing of the renovations, providing a copy of building permit and ensuring that residents will be safe during renovation which poses an health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 9, 2025

Plan of correction: Administrator agrees to submit a proposed plan with a timeline, updated facility sketch and copy of building permit to CCLD by POC due date.

Allegation investigated: Staff do not accord dignity to resident in care. Licensee leaves resident(s) unsupervised while in care. Staff are not seeking medical attention for resident in care as necessary.

On 04/02/2025 at 09:30 am, Licensing Program Analysts (LPAs), D. Doidge and L. Fontanilla arrived unannounced to conduct the 10-day initial visit and to deliver complaint findings for the allegations above. LPAs met with Jezrael Pascual, House Manager and explained the purpose of the visit. The Administrator was informed about the visit. During the investigation the LPAs interviewed staff and resident 1 (R1) and obtained copies of R1's physician's report (LIC602), identification and emergency contact, and appraisal needs and services plan. Allegation: Staff do not accord dignity to resident in care Findings: S1 had taken pictures of R1's soiled underwear and bedsheet and texted them to R1's friend with R1 included in text thread without R1's permission. Continued on LIC9099C. Substantiated Continued from LIC9099 Allegation: Staff do not ensure that resident's hygiene needs are being met while in care. Findings: Per Physician's report and interviews, R1 is able to bathe self. R1 has preference to frequency of taking showers, and is able to take care of self. Allegation: Staff do not ensure that resident is provided with clean bedding while in care. Findings: Per interviews with resident and staff, bed are changed at least once a week, and more frequently as needed. Beds were observed by LPA to be clean and good repair. Facility has more than adequate linens for all beds. Allegation: Staff do not safeguard resident's personal possessions while in care. Findings: Facility maintains Client/Resident Personal Property and Valuables, LIC 621. R1 has reported missing an ATM card, however R1 admitted to placing ATM card in a book and not being able to remember which book it was placed in. R1 reported missing noise canceling headphones. LIC621 has headphones, but house manager mentioned that headphones was written by mistake, package that arrived had ear buds. Staff have not seen R1 with noise canceling headphones. R1 reported missing an Iphone. Staff found Iphone in R1's bed and was handed to R1 during visit. Allegation: Staff member harasses resident in care. Findings: During the visit, LPAs interviewed 3 residents. There was no disclosure of harassment made by staff against any resident. Resident denied harassment by staff. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED. No deficiencies were issued. Exit interview conducted and a copy of this report was provided. Continued from LIC9099 Allegation: Licensee leaves resident(s) unsupervised while in care. Findings: Based on interview conducted with staff, when Licensee is on site, Licensee will monitor residents in the security cameras located in the office but will not interact with residents directly. Allegation: Staff are not seeking medical attention for resident in care as necessary. Findings: Based on interviews and record reviews conducted, R1 was admitted to the facility on January 12, 2025. LPAs were informed that R1 has not had any visit with a doctor because R1 does not have a primary doctor assigned yet. S1 states there is a medication that needs refill but has not been filled yet. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted. A copy of the appeal rights and , and this report provided.the state’s words, verbatim · CDSS document, Apr 2, 2025 · control 15-AS-20250324113724

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 30, 2025

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... Additional staff shall be employed as necessary... The licensing agency may require any facility to provide additional staff... Based on interview conducted with staff, when Licensee is on site, Licensee will monitor residents in the security cameras located in the office but will not interact with residents directly.the state’s words, verbatim · CDSS document, Apr 2, 2025

Plan of correction: This deficiency has been discussed in the NCC conducted on 03/226/2025.Hire a qualified Administrator that will be present 40 hours a week, April 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 9, 2025

(a) Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights. (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: S1 had taken pictures of R1's soiled underwear and bedsheet and texted them to R1's friend with R1 included in text thread without R1's permission.the state’s words, verbatim · CDSS document, Apr 2, 2025

Plan of correction: Have staff review Personal Rights and provide a self certifying letter to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Apr 14, 2025

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical...care and provide...obtaining such care, by compliance with the following:The licensee shall arrange...for medical...care appropriate to the conditions and needs of residents. R1 has not had any visit with a doctor because R1 does not have a primary doctor assigned yet. S1 states there is a medication that needs refill but has not been filled yet.the state’s words, verbatim · CDSS document, Apr 2, 2025

Plan of correction: Assist R1 with contacting Kaiser and set up PCP. Email LPA with PCP information.

Type of visit: Case Management - Other

On this day while at the facility conducting investigation in connection with complaint 15-AS-20250324113724, LPAs observed the following: R1 did not have completed preplacement and Appraisal Needs and Services Plan R2 eloped from the facility on January 14, 2025 and ended up at Kaiser Hospital for pneumonia and hypothermia the facility did not report incident to CCL Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D). Exit interview was conducted with Pascual and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Apr 2, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 874111(a) · Plan of correction due date: Apr 9, 2025

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... Additional staff shall be employed as necessary... The licensing agency may require any facility to provide additional staff.. R2 eloped from the facility on January 14, 2025 and ended up at Kaiser Hospital for pneumonia and hypothermiathe state’s words, verbatim · CDSS document, Apr 2, 2025

Plan of correction: This deficiency has been discussed in the NCC conducted on 03/226/2025.Hire a qualified Administrator that will be present 40 hours a week, April 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC87506(a) · Plan of correction due date: Apr 2, 2025

. 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. Based on observation Licensee did not have any records completed for R1.the state’s words, verbatim · CDSS document, Apr 2, 2025

Plan of correction: Complete records for R1 and provide copies to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87211(a)(D) · Plan of correction due date: Apr 2, 2025

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:Any incident which threatens the welfare...of any resident, such as...abuse of a resident...or ...unexplained absence of any resident. the facility did not report incident to CCLthe state’s words, verbatim · CDSS document, Apr 2, 2025

Plan of correction: Licensee to review Reporting Requierments and provide a self certifying letter to LPA by POC date.

Allegation investigated: Staff do not ensure adequate supervision is provided resulting in residents eloping from the facility.

On 12/30/2024 at 10:25am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit and to deliver complaint findings for the allegation above. LPA met with Jazrael Pascual, House Manager and explained the purpose of the visit. During the investigation the LPA interviewed staff, obtained a copy of the personnel record (LIC500), resident roster, a copy of December calendar, R1's physician's report (LIC602), identification and emergency contact, and appraisal needs and services plan. Allegation: Staff do not ensure adequate supervision is provided resulting in residents eloping from the facility. Continued on LIC9099C. Substantiated Continued from LIC9099. Based on interviews with S2 and S3 there were three (3) staff during the day. Staff noticed that R1 was missing before dinner, which is around 4pm, because R1 didn't come to eat. S2 also stated staff thought R1 was outside in the front area. S2 stated R1 goes outside into the front area without supervision. S1 stated she was not working on 12/15/2024, the day of the incident; however, S1 received a call from R1's responsible party stating R1 was missing from the facility. Based on interviews the deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. *An immediate Civil Penalty of $1,000 is being assessed on today's date for a repeat violation* Exit interview conducted. A copy of the appeal rights, LIC421M, and this report provided.the state’s words, verbatim · CDSS document, Dec 30, 2024 · control 15-AS-20241221181547

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 31, 2024

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... Additional staff shall be employed as necessary... The licensing agency may require any facility to provide additional staff... This requirement was not met as evidence by: Based on interviews the Licensee did not comply with the section cited above in having sufficient supervision for residents, which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: Administrator agreed to implement a plan to assist with staffing and submit plan to CCLD by POC date. *An immediate Civil Penalty of $1,000 is being assessed on today's date for a repeat violation*

Type of visit: Case Management - Other

On 12/30/2024 at 1:15pm Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Jazrael Pascual, House Manager and explained the purpose of the visit. While LPA L. Hall was conducting a complaint investigation 15-AS-20241221181547 on 12/30/2024, it was stated R1 had eloped from the facility. LPA toured the first level of the facility, obtained R1's physician's report (LIC602), appraisal needs and services plan, and identification and emergency information. LPA observed the following deficiencies during the visit. LPA observed during interview R1 had eloped. LPA observed during record review the elopement incident that occurred on 12/152024, had not been reported. LPA observed R1 did not have an current annual physician's report or appraisal needs and services plan. LPA observed during record review facility did not have a permit for the alterations of the facility. LPA observed plan the area called the solarium is blocked with a couch, 2 refrigerators, clothing, and other items. Continued on LIC809C. Continued from LIC809. LPA observed facility did not have a supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. LPA observed the facility had four (4) refrigerator/freezer and all were unsanitary. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Dec 30, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Dec 31, 2024

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs... This requirement was not met as evidence by: Based on interviews the Licensee did not comply with the section cited above in having a sufficient number of staff which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: Administrator agreed to implement a plan to prevent elopement of residents and submit plan to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Jan 8, 2025

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in report an elopement to CCLD, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: Administrator agreed to submit the incident report for the incident that occurred on 12/15/2024 to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(26) · Plan of correction due date: Jan 2, 2025

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of 1 week and perishable foods for a minimum of 2 days shall be maintained on the premises. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having a minimum of 1 week perishable and 2 day non perishable foods on premises, which poses a potential health and safety risk to person in care.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: Administrator agreed to purchase food and submit photo of food and copy of receipts to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(21) · Plan of correction due date: Jan 8, 2025

(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F, and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F. They shall be kept clean... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above with having all four (4) refrigerator/freezers sanitary, which poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: Administrator agreed to have all refrigerator/freezers cleaned and submit photos to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Jan 8, 2025

87307 Personal Accommodations and Services (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section above in have solarium area blocked with 2 refrigerators, a couch, clothing and other items, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: Administrator agreed to remove clothing, couch and other items from solarium and submit photos to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87305(a) · Plan of correction due date: Jan 8, 2025

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having a permit for alterations in facility, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: Administrator agreed to submit permit to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jan 8, 2025

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having R1 an annual medical assessment and reappraisal done, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: Administrator agreed to have R1 a medical assessment and reappraisal and submit copies to CCLD by POC date.

Type of visit: Case Management - Other

On 12/20/2024 at 2:45 PM, Licensing Program Analyst (LPA) D. Doidge conducted an unannounced Case Management visit based on information received by the agency on (the date of visit). LPA met with Jezrael Pascual, House Manager, and explained the purpose of the visit. LPA D. Doidge tried to obtain the following documents for R1. 1. Admissions Agreement (Opal) 2. Medical Assessments 3. Appraisal Needs and Services 4. Emergency & Identification 5. Any copies of Doctor’s Orders 6. Incident Reports if any The facility did not have any of the records available. One citation issued.. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 20, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(c) · Plan of correction due date: Dec 24, 2024

The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). Based on record review, the licensee did not comply with the section cited above by not having the resident's records available at the facility for LPA to inspect during regular business hours. LPA was informed that resident’s records was moved to another facility in which resident was transferred to which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: Administrator to provide copies of resident's records to LPA by POC date by email. 1. Admissions Agreement (Opal) 2. Medical Assessments 3. Appraisal Needs and Services 4. Emergency & Identification 5. Any copies of Doctor’s Orders 6. Incident Reports if any

Allegation investigated: Staff did not provide adequate supervision resulting in resident eloping from facility

On 12/11/2024 at 4:00 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with House Manager, Jezrael Pascual, to deliver the findings of above allegation. LPA explained the purpose of the visit with Jezrael Pascual. Jezrael called Administrator, Victoria Puruganan, to inform. During the investigation, the LPA obtained the following documents from the facility – copy of R1’s admission agreement, physician’s report, Pre-Placement Appraisal, Resident Appraisal, Appraisal Needs and Services, medication list, resident registry list, staff roster (LIC 500), MAR (October and November), Unusual Incident Report (07/18/2023, Oakland Police Department (OPD) Report #23-036660, Washington Hospital After-Visit Summary (02/03/2024) and Regional Medical Center of San Jose Patient Discharge. LIC9099-C Continued... Substantiated LIC9099-C (Page 2) Allegation: Staff did not provide adequate supervision resulting in resident eloping from facility Finding: Substantiated During the investigation, the LPA conducted interviews of facility staff (S), and witnesses (W). On 11/18/2024 LPA interviewed W1. W1 stated that R1 arrived at Regional Medical Center of San Jose (RMC) on 11/13/2024 at around 3:00 AM. W1 stated that R1 was found in San Jose and that the Emergency Medical Services (EMS) transported R1 to the Emergency Department (RMC) for evaluation. W1 stated that R1 was disoriented and presented with an altered mental status. W1 stated that R1 was hospitalized and was receiving treatment for an infection before they would get discharged. W1 stated that they found out that Opal Care LLC (facility) have gave notice of 30-Day eviction to R1 and that they were not going to accept R1 back after being discharged. W1 stated that they spoke with the Administrator and advised that they have to accept R1 back to the facility. W1 stated that a Missing Persons Report was filed by the family and not the facility. On 11/20/2024 LPA interviewed S2. S2 stated that on 11/12/2024 the staff did a “roll call” for dinner at around 4:15 PM to 4:30 PM. S2 stated that S2, S4, S5 and S6 noticed that R1 was not in the facility. S2 stated that S2, S4, S5 and S6 searched all the rooms, the neighborhood and S3 drove to MacArthur Bart Station to look for R1. S2 stated that on 11/17/2024, another resident, R2, was admitted to Kaiser Permanente Oakland Emergency Department (ED) after being found. S2 stated that the ED Physician called them and said that they attempted a call to the administrator at the facility but there was no answer. S2 stated that they received the call and that they called the facility to confirm if R2's was missing and staff confirmed that R2 was not at the facility. LIC9099-C Continued LIC9099-C (Page 3) On 12/02/2024 LPA interviewed W2. W2 stated that this was the 3rd time that R1 has left the facility. W2 stated that they don’t know how R1 traveled to San Jose. W2 stated that the facility did call them to notify that R1 was missing and that they filed a Missing Person’s Report with OPD. W2 stated that they are trying to find another placement facility for R1. W2 stated that they received notice of 30-Day Eviction for R1. On 12/02/2024 LPA interviewed S1. S1 stated that R1 was at the facility at around 4:00 PM, but the staff were calling R1 for dinner at 5:00 PM and that is when the staff discovered that R1 was missing from the facility. S1 stated that two (2) groups went out to search for R1. Which was S3 that drove to MacArthur Bart Station to look for R1. S1 stated that R1 “knows what he’s doing”. S1 stated that R1 goes out, then the staff will call the police, call the bus line and the family was informed. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 11, 2024 · control 15-AS-20241113155956

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 8, 2025

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on observation, interviews and record review, the licensee did not comply with the section cited above in by not performing re-evaluations of R1 who was diagnosed with dementia on 02/03/24 and later AWOLd a total of 3 times in which this last AWOL R1 traveled over 50+ miles and found disoriented and confused by EMS which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Administrator agreed to install an alarm at outside front gate and will send a photo/video to CCLD. Also, LIC 500 with night shift staff scheduled. In addition, Administrator will send R1's updated physician's report and Appraisal, Needs and Services to CCLD by POC date. Immediate Civil Penalty of $1,000 is being assessed today for repeat violation.

Type of visit: Case Management - Other

On 12/11/2024 at 6:00 PM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with House Manager, Jezrael Pascual, and explained the purpose of the visit. While LPA L. Alexander was conducting a complaint investigation(15-AS-20241113155956) on 12/11/2024. During interview and record review LPA observed that R1 was issued a 30-Day Eviction notice dated 11/21/2024. The reason for the eviction was due to "High Level of Care and Change of Medical Condition." LPA interviewed Administrator, Victoria Puruganan, and confirmed that no new re-assessments have been performed on R1. LPA observed that Licensee has a Plan of Operation that indicates Care of Dementia. Further, the eviction notice lacked all appropriate requirements. The following deficiencies were 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. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.683 · Plan of correction due date: Jan 8, 2025

§1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. In addition, the notice to quit shall include all of the following: (1) The effective date of the eviction. (2) Resources available to assist in identifying alternative housing and care options, including public and private referral services and case management organizations. (3) Information about the resident's right to file a complaint with the department regarding the eviction, with the name, address, and telephone number of the nearest office of community care licensing and the State Ombudsman. (4) The following statement: "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." (b) The licensee, in addition to either serving a 30-day notice, or seeking approval from the department and serving three days notice, on the resident, shall notify, or mail a copy of the notice to quit to, the resident's responsible person. This requirement is not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above in serving R1 with an appropriate eviction notice that contained all items required under regulation, which poses a potential health and safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: The Administrator will read the regulation and submit self-certification that it has been read, understood and they will comply going forward to CCLD by POC due date. In addition, the licensee shall rescind the eviction, notify resident, and responsible parties.

Type of visit: Case Management - Other

On 11/20/2024 at 10:45AM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit. LPA met with House Manager, Jezrael Pascual, and explained the purpose of the visit. Jezrael phoned, Administrator, Victoria Puruganan to inform. While LPA was conducting a complaint investigation, #15-AS-20241113155956, on 11/20/2024, LPA observed during record review and interview that Licensee had not reported an incident where R1 eloped on 11/12/2024. The following deficiencies were 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. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 20, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Nov 27, 2024

87211 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(2)Occurrences,...shall be reported within 24 hours This requirement was not met as evidence by: Based on interview and record review the licensee did not comply with the section cited above by not reporting to CCL within 24hrs that resident eloped which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 20, 2024

Plan of correction: By POC date, Licensee will submit self-certification that they read and understand the regulation and will comply moving forward. In addition submit to CCLD a detailed written plan on how they will address reporting incidents, including but not limited to elopements.

Type of visit: Required - 1 Year

On 10/24/2024 at 10:00 AM, Licensing Program Analysts (LPAs) D. Doidge and A. Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Jezrael Pascual Office Manager and explained the purpose of the visit. LPAs toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 69 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 107 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 10/01/2024. Emergency Disaster Plan was last posted on 06/06/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 08/07/2024. LPAs reviewed 5 residents records and 5 staff records, and all were complete. LPAs also reviewed a sample of resident’s medications. The following reports were reviewed: LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, Liability Insurance, and Current Administrator’s Certificate. At 10:38 AM, LPAs inspected the shared bathroom and observed no lids on trash cans. The above deficiency was observed (see LIC809D) and cited from the California Code of Regulations, Title 22and/or health safety Code failure to correct deficiency by POC date may result in additional civil penalties. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 24, 2024

Type of visit: Case Management - Other

On 9/24/2024 at approximately 8:45 am, LPAs James Sampair and David Doidge conducted an Unannounced Case Management visit to deliver an amended civil penalty originally issued on 9/12/24, in the amount of $1,400. The LPAs met with Office Manager Jezrael Pascual and explained the purpose of the visit. The amended civil penalty issued today is in the amount of $400 and supersedes the previous civil penalty of 9/12/24. This report and the amended civil penalty were reviewed with the facility, and Appeal Rights were provided..the state’s words, verbatim · CDSS document, Sep 24, 2024

Allegation investigated: Staff speaks to residents in an inappropriate manner. Staff threatens the residents in care.

On 09/12/2024 at 8:45 AM, Licensing Program Analysts (LPAs) James Sampair and David Doidge arrived at the facility unannounced to complete the investigation of the allegations above. The LPA stated the purpose of the visit to Office Manager Jezrael Pascual. The complaint alleges that staff speaks to residents in an inappropriate manner. LPAs interviewed the Reporting Party (RP), Office Manager, and Residents R1, R2, and R3. The statements from the 3 residents were that staff does not speak to residents in an inappropriate manner. Staff threatens the residents in care. LPAs interviewed the Reporting Party (RP), Office Manager, and Residents R1, R2, and R3. The statements from the 3 residents were that staff does not threaten them. Continued on LIC 9099-C... Unsubstantiated ...Continued from LIC 9099 Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 15-AS-20240910150006

Type of visit: POC

On 09/12/2024 at 8:45 AM, Licensing Program Analysts (LPAs) D. Doidge and J. Sampair arrived to conduct an unannounced Plan of Correction (POC) inspection. Upon entry into the facility, the LPAs identified themselves and the purpose of the visit to Office Manager Jezrael Pascual. At facility Administrator Victoria Puruganan was called and asked if proof of correction had been sent. It had not.. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 421F.. A $1,400 civil penalty is assessed today; Exit interview conducted and a copy of this report was provided..the state’s words, verbatim · CDSS document, Sep 12, 2024

Allegation investigated: Facility staff did not provide itemized billing statement to responsible person

On this day at around 9:50 am, LPAs Luisa Fontanilla and David Doidge arrived at the facility to conduct investigation on the above allegations and met with House Manager Jezrael Pascual. LPAs explained to Pascual the purpose of the visit. Administrator Victoria Puruganan arrived at a later time. During the course of investigation, LPAs reviewed 4 resident records including but not limited to admission agreement, Physician's Report, Emergency Information, Register of Residents, Lic 500 and interviewed the Administrator and House Manager. LPAs interviewed R1, R3 and R4. Facility staff did not provide itemized billing statement to responsible person During the visit, LPAs obtained and reviewed a copy of the facility's admission agreement. LPAs observed the facility is using a revised admission agreement that does not meet the requirements. It does not ***continuation on lic 9099C*** Substantiated indicate itemized charges as required in the admission agreement that was approved by the Department. Based on record review conducted, the above allegation is substantiated. Based on LPAs observations and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, is being cited on the attached LIC 9099D. Exit interview was conducted with the Administrator and Appeal Rights was provided. Facility staff did not dispense medications as prescribed During interview, the House Manager explained to the LPAs procedure when giving medications to the residents. House Manager also states that staff giving medications make sure that the residents take their medications. Residents interviewed state they get all their medications on time. Facility staff did not properly supervise resident resulting in resident wandering away from facility During interview conducted, the Administrator and House Manager state the facility has an auditory device that gets turned off during the day and turned on at night. During the day when the alarm is off, staff monitor the residents. The Administrator will install additional auditory device (Ring) by tomorrow, 8/29/2024. While at the facility, LPAs observed a staff watching over the residents in the front yard. The facility's last AWOL was recorded on 7/21/2023. Facility staff did not provide written copy of admissions agreement to responsible person. Based on interviews conducted, the Administrator states after admissions agreement are signed, a copy has always been given to the resident's responsible person. During the visit, LPAs interviewed Housing Authority of the County of Alameda (HACA) Supervisor (W1) who states that the office has a copy of all the clients' admission agreements. Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was conducted with the Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2024 · control 15-AS-20240820101350

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(a) · Plan of correction due date: Sep 6, 2024

87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidenced by: Based on record review conducted, the facility did not have an admission agreement that is compliant to the section cited. The facility is using a revised form that is not approved by the department and is missing required itemized charges which poses a potential risk to the health and safety of clients under care.the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: By POC date, the Administrator will review section 87507 Admission Agreement and will submit to CCL the following: 1) understanding of the section 2) self-certification stating that effective immediately, the approved admission agreement will implemented.

Type of visit: Case Management - Other

On this day at around 3:45 pm, LPAs Luisa Fontanilla and David Doidge conducted a case management visit and met with the Administrator. While conducting file reviews related to complaint #15-AS-20240820101350, LPAs observed the following: facility has an approved fire clearance for 3 non ambulatory but actual count of non ambulatory residents is 6 (one resident in a skilled nursing facility) facility converted the formal living room to a non ambulatory room with one non ambulatory resident occupant without an approved fire clearance staff does not have sufficient medication training Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D). Civil penalties are assessed for this visit. Exit interview was conducted with the Administrator and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Aug 28, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: Aug 29, 2024

87204 Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. Based on interview conducted, the facility is approved for 3 nonamb residents. However, the actual number of nonamb residents is 6 which poses an immediate risk to the health and safety of clients under care.the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Within 24 hours, the Administrator will notify the local fire department about the 3 nonamb residents and submit proof of communication to CCL. Administrator states families will be offered to move to the Union City, if agreeable. If not, 30-day eviction will be issued. $500 civil penalty is asessed

From the deficiency page — Deficiency type: Type A · Section cited: CCR87204(b) · Plan of correction due date: Aug 29, 2024

87204 Limitations - Capacity and Ambulatory Status (b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. This requirement is not met as evidenced by: The facility converted the formal dining room to a nonamb room with a nonamb resident occupant without an approved fire clearance.the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: The room has been approved by the Oakland Building Department and would need fire inspection. LPA will create STD 850 and send to local fire department. Civil penalty of $500 is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a)(2) · Plan of correction due date: Sep 6, 2024

§1569.69 Employees assisting residents with self-administration of medication; training requirements (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets the following training requirements: 2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete six hours of initial training. This training shall consist of two hours of hands-on shadowing training, .. Staff do not have sufficient medication trainingthe state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: The Administrator states all staff who assist residents with medications will complete required training hours and submit proof to CCL by POC date.

Allegation investigated: Staff does not prevent resident from verbally and physically abusing other residents in care. Staff is overcharging resident for higher level of care that is not being provided. Licensee does not ensure facility has basic supplies.

On 8/14/24 at 10:30 a.m., Licensing Program Analyst (LPAs) Greg Clark and David Doidge arrived unannounced to deliver findings in regard to the allegations above. LPAs met with Jezrael Pascual, House Manager and explained the purpose of the visit. Allegation: Staff does not prevent resident from verbally and physically abusing other residents in care. LPAs interviewed 4 residents (R1, R2, R3 and R4) and all reported being happy with the care they are receiving at the facility and have no issues their housemates. They also reported that staff are quick to respond if they need help. This allegation is unsubstantiated. ***report continues on LIC9099C*** Unsubstantiated ***report continues form LIC9099*** Allegation: Staff is overcharging resident for higher level of care that is not being provided. LPAs reviewed R5, R6 and R7’s files. All 3 residents are diagnosed with dementia. LPAs reviewed the admission agreements for all 3 residents. LPA’s found that there was no increase in the rate residents were paying for services and that the rate matches the services outlined in the agreement. This allegation is unsubstantiated. Allegation: Licensee does not ensure facility has basic supplies. LPA’s toured the entire facility including the kitchen, dining room, bedrooms, bathrooms and storage areas. Based on observation the facility has all the necessary basic supplies to care for the residents. This allegation is unsubstantiated. This agency has investigated the complaints alleging staff does not prevent resident from verbally and physically abusing other residents in care, staff is overcharging resident for higher level of care that is not being provided, and licensee does not ensure facility has basic supplies. We have found that the complaint was 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 allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 14, 2024 · control 15-AS-20240405092549

Allegation investigated: Staff do not provide adequate supervision resulting in residents wandering away from facility. Staff does not ensure facility is free of pests resulting in residents being bit. .

On 8/14/24 at 10:30 a.m., Licensing Program Analyst (LPAs) Greg Clark and David Doidge arrived unannounced to deliver findings in regard to the allegations above. LPAs met with Jezrael Pascual, House Manager and explained the purpose of the visit. Allegation: Staff do not provide adequate supervision resulting in residents wandering away from facility. LPAs interviewed S1. S1 stated that there is still no set schedule for staff to cover the afternoons and overnights. This results in some residents wandering away from the facility and sustaining falls resulting in injuries. This allegation is substantiated. ***report continues on LIC9099C*** Substantiated ***report continues from LIC9099*** Allegation: Staff does not ensure facility is free of pests resulting in residents being bit The facility has entered into an agreement on 5/01/24 with Orkin for a monthly pest control treatment for the entire facility. LPA’s reviewed the agreement and that Orkin will be monitoring the facility for roached, ants, rate and mice. LPAs also reviewed a report from Orkin dated 4/18/24 for the bed bug treatment. The report states that facility is now clear of bedbugs and is monitored by Orkin monthly. This allegation is substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.CCLD1515. Exit interview conducted, a copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 14, 2024 · control 15-AS-20240405092549

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Aug 21, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...-This requirement is not met as evidenced by: Based on records review and interview, the licensee did not comply with the section above for not having sufficient staff which poses a potential safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

Plan of correction: Administrator to hire one additional daytime staff, and one awake night staff. Administrator will submit copy of LIC500 Personnel Report to CCL by 8/21/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 14, 2024

87303 (a) The facility shall be clean, safe, sanitary... Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents... This requirement was not met as evidenced by: Based on staff, resident, and reporting party interviews, facility failed to prevent bed bugs which poses a potential personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

Plan of correction: Deficiency cleared prior to visit.

Allegation investigated: Licensee does not ensure facility has night staff to care and supervise residents.

On 4/10/24 at 11:00 am, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to an initial 10-day complaint investigation in regard to the allegation above. LPA met with House Manager Jezrael Pascual, and informed the purpose of visit. LPA obtained copy of the current staff schedule and conducted interviews. The staff schedule showed the following: -during the day there are only 2 care staff scheduled from 7:00 am to 3:30 pm. -house manager scheduled from 8:00 am to 5:00 pm. -1 staff scheduled from 3:00 pm to 11:00 pm. -NO awake staff scheduled from 11:00 pm to 7:00 am. ***report continjes on LIC9099C*** Substantiated ***report continues from LIC9099*** Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, is being cited on the attached LIC 9099-D. Civil penalty in the amount of $500 assessed for repeat violation. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 10, 2024 · control 15-AS-20240405092549

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 17, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...-This requirement is not met as evidenced by: Based on records review and interview, the licensee did not comply with the section above for not having sufficient staff which poses a potential safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Apr 10, 2024

Plan of correction: Administrator to hire one additional daytime staff, and one awake night staff. Administrator will submit copy of LIC500 Personnel Report To CCL by 4/17/24. Immediate Civil Penalty of $500 is being assessed today for repeat violation.

Allegation investigated: Insufficient staff to meet resident needs

On 10/5/2023 at 8:21 am, Licensing Program Analyst (LPA) J Clancy-Czuleger arrived unannounced to investigate the above allegation, and met with House Manager Jezrael Pascual, and informed the purpose of visit. LPA called, and spoke over the phone with Victoria Puruganan, administrator, who stated she can not come to the facility, and authorized Jezrael Pascual to sign, and receive this report. LPA obtained copy of the current staff schedule, reviewed residents' records and conducted interviews. The staff schedule showed the following: -during the day there are only 2 care staff scheduled from 7:00 am to 3:30 pm. -house manager scheduled from 8:00 am to 5:00 pm. -1 staff scheduled from 3:00 pm to 11:00 pm. -NO awake staff scheduled from 11:00 pm to 7:00 am. Continued on LIC 9099-C... Substantiated ...Continued from LIC 9099 Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC 9099-D. Civil penalty in the amount of $250 assessed for repeat violation. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 5, 2023 · control 15-AS-20230929092934

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 19, 2023

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...-This requirement is not met as evidenced by: Based on records review and interview, the licensee did not comply with the section above for not having sufficient staff which poses a potential safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 5, 2023

Plan of correction: Administrator to hire one additional daytime staff, and one over night staff. The facility will submit copy of LIC500 Personnel Report by 10/19/23. Civil penalty of $250 is being assess for a repeat violation.