Pacific Care Home IV

Type of visit: Required - 1 Year

On 05/05/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with co-administrator Moddie Andaya and explained the purpose of today's visit. Currently there are 6 residents in place and 3 staff, one included is the co-administrator. The facility is licensed for age range 60 and over. All may be non-ambulatory and one may be bedridden in room #1. Hospice waiver for 4 residents. There is currently 1 resident on hospice at this time. This is a two level facility. The ground floor primarily consists of the garage area which also contains a facility refrigerator and laundry area. Facility temperature is comfortable Facility emergency food supplies such as canned goods are also on the ground floor in a large storage closet. Residents reside on the main floor, the upper floor, where the front door leads to when entering the facility. There are 6 resident rooms. All rooms contain a full bathroom. Water temperature is tested resident rooms as 107F.. Cleaning supplies in the kitchen are observed as locked beneath the kitchen sink. Facility knives are observed to be locked in a drawer adjacent to the kitchen sink. Additional food supplies are located on the ground floor in the garage in a locked large closet. Kitchen food supplies are observed to be in place with 2 day fresh food supply and canned goods fulfilling the 7 day emergency food supply. A tour of the outside of the facility is conducted. Emergency routes are free and clear of any obstructions. Smoke detectors and carbon monoxide detectors are located through out the facility. The facility is also equipped with 2 fire alarm pull stations, one in the front, and one in the back of the facility. LPA observed 2 fire extinguishers in the facility with inspection tags dated 03/04/2026. Continued on next page... Page 2 Facility conducts emergency drill quarterly. The last drill that was conducted is logged and posted in the main hallway with a date of 03/16/2026. Linens are in place for resident use in each resident room as well as being stored in the garage as well in a large closet. LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Medications, medical kit, and sharps are stored in locked medication closet in the main hallway. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hygiene supplies are in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA reviewed staff and resident files on this day which appear to be current based on review. Staff training records are observed to be current and in place. Administrator certificate for Rafael Jison is observed as expired on 03/27/2026 but according to him, he has already renewed and is awaiting his new certificate. There are two other co-administrators with current administrator certificates. This report is reviewed with Moddie Andaya. A copy of this report is provided on this day. No citations issued.the state’s words, verbatim · CDSS document, May 5, 2026

Type of visit: Required - 1 Year

On 03/27/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with co-administrator Moddie Andaya and explained the purpose of today's visit. Currently there are 6 residents in place and 4 staff. The facility is licensed for age range 60 and over. All may be non-ambulatory and on may be bedridden in room #1. Hospice waiver for 4 residents. There are currently 3 residents on hospice at this time. This is a two level facility. The ground floor primarily consists of the garage area which also contains a facility refrigerator and laundry area. Facility temperature is comfortable Facility emergency food supplies such as canned goods are also on the ground floor in a large storage closet. Residents reside on the main floor, the upper floor, where the front door leads to when entering the facility. There are 6 resident rooms. All rooms contain a full bathroom. Water temperature is tested in the kitchen at 110F and 105F in room 3. Cleaning supplies in the kitchen are observed as locked beneath the kitchen sink. Facility knives are observed to be locked in a drawer adjacent to the kitchen sink. Additional food supplies are located on the ground floor in the garage in a locked large closet. Kitchen food supplies are observed to be in place with 2 day fresh food supply and canned goods fulfilling the 7 day emergency food supply. A tour of the outside of the facility is conducted. Emergency routes are free and clear of any obstructions. Smoke detectors and carbon monoxide detectors are located through out the facility. The facility is also equipped with 2 fire alarm pull stations, one in the front, and one in the back of the facility. LPA observed 2 fire extinguishers in the facility with inspection tags dated 05/20/2025. Facility conducts emergency drill quarterly. The last drill that was conducted is logged and posted in the main hallway with a date of 01/15/2025. Linens are in place for resident use in each resident room as well as being stored in the garage as well in a large closet. Continued on next page... Page 2 LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Medications, medical kit, and sharps are stored in locked medication closet in the main hallway. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hygiene supplies are in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA reviewed staff and resident files on this day which appear to be current based on review. Staff training records are observed to be current and in place. Administrator certificate for Rafael Jison is observed as current expiring 03/27/2026 Report is reviewed with Moddie Andaya. A copy of this report is provided to the facility. No citations issed.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds, consisting of 6 private client bedrooms--all with full private bathrooms--and 2 staff bedrooms--one staff room has 2 beds and the other has 3 beds. The common area consists of living/dining area and kitchen. Laundry and storage area is adjacent to a staff room. No accessible bodies of water or fire safety hazards observed. PPE supply consists of surgical masks and gloves only. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. An updated Disaster and Mass Casualty Plan is posted. There are 5 residents present, and 3 staff. Four residents are receiving hospice services. Client records and staff records are reviewed, including criminal record clearances or exemptions for facility staff. Rafael Jison is a certified RCFE administrator that oversees facility operations. The following updated form is requested to be submitted to CCLD BY 6/7/24: • LIC 309 Administrative Organization Proof of current Liability Insurance is given to LPA today, along with LIC 308, LIC610, LIC500. Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.the state’s words, verbatim · CDSS document, May 31, 2024