Peridot Residence

Type of visit: Required - 1 Year

On 01/08/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conducted to an annual visit. LPA Pascua was greeted by Staff Member (SM), Cecilia Catbagan and explained the purpose of the visit. The purpose of the visit was for an annual visit. LPA Pascua was notified by Facility Designated Administrator (FDA), Cecil De Lara that she is currently not available to come to the facility and has Designated, Mary Jane Del Mundo as the Facility Designated Representative to continue the visit with LPA Pascua. There was one other staff member present, Marysan Murphy. This facility intends to hold 8 non-ambulatory residents. This facility also will hold a dementia plan on file and a hospice waiver for 6 residents. Current census was 6. A brief interview with FDR Del Mundo was conducted. The perspective Facility Designated Administrator (FDA), Cecil De Lara has a current RCFE Administrator certificate #7030906740. LPA Pascua reviewed 6 resident files and 4 staff files. A tour of the facility was conducted. A fire extinguisher was identified in the kitchen area and was serviced by Jorgenson Co and is valid until 01/02/2026. Smoke Detectors and carbon monoxide were observed throughout the facility and was observed to be in working condition. A tour of the kitchen area was conducted. Toxins, cleaning supplies, and knives were observed to be locked and made inaccessible. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supplies at this time. A tour of the living area was conducted. Furniture and furnishing were observed to be in good repair and could meet resident needs. A tour of the backyard was conducted. Gate and perimeter fence was in stable condition. This facility has one exit gate in which was self closing and self latching. Two sheds were identified. A tour of the 4 resident bedrooms were conducted. Bedroom #1 has a resident bathroom connected to the bedroom. All bedrooms would house 2 non-ambulatory residents at any time. All bedrooms were observed to have a sufficient amount of furniture and furnishings to meet resident needs. A tour of the resident bathrooms were conducted. Bathroom #1 had a linen closet. LPA observed a sufficient amount of linens to meet resident needs. Hot water was taken in both bathrooms to ensure hot water temperature was within the required range. Grab bars and non-skid mats were also observed and were in good repair at this time. A tour of the laundry room was conducted. Washer and dryer were identified. Laundry detergent was observed to be locked and made inaccessible. A medication closet was identified, along with FDR Del Mundo. LPA Pascua reviewed and compared Medication Administration Records with Medication. LPA Pascua provided technical assistance regarding Medication Administration Records. A tour of the garage was conducted. An additional freezer and refrigerator unit were identified. Additional facility supplies were also identified. The following documents were requested to be submitted to the department: -LIC 308 -LIC 400 -LIC 500 -LIC 610e Technical assistance was provided for Section 87465(a)(4) Based on the observations based during the visit, there are no deficiencies were observed or cited during this annual visit. An exit interview was conducted and a copy of this report was provided to the Facility at the end of this visit.the state’s words, verbatim · CDSS document, Jan 8, 2026

Type of visit: Post Licensing

On 01/08/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to this facility to conducted to an annual visit. LPA Pascua was greeted by Staff Member (SM), Cecilia Catbagan and explained the purpose of the visit. The purpose of the visit was for an annual visit. LPA Pascua was notified by Facility Designated Administrator (FDA), Cecil De Lara that she is currently not available to come to the facility and has Designated, Mary Jane Del Mundo as the Facility Designated Representative to continue the visit with LPA Pascua. There was one other staff member present, Marysan Murphy. This facility intends to hold 8 non-ambulatory residents. This facility also will hold a dementia plan on file and a hospice waiver for 6 residents. Current census was 6. A brief interview with Applicant, Cecil De Lara. The perspective Facility Designated Administrator (FDA), Cecil De Lara has a current RCFE Administrator certificate #6066497740 and expires on 03/21/2025. LPA Pascua reviewed 6 resident files and 4 staff files. All files were current and up to date. A tour of the facility was conducted. A fire extinguisher was identified in the kitchen area and was serviced by Jorgenson Co and is valid until 01/02/2026. Smoke Detectors and carbon monoxide were observed throughout the facility and was observed to be in working condition. A tour of the kitchen area was conducted. Toxins, cleaning supplies, and knives were observed to be locked and made inaccessible. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supplies at this time. A tour of the living area was conducted. Furniture and furnishing were observed to be in good repair and could meet resident needs. A tour of the backyard was conducted. Gate and perimeter fence was in stable condition. This facility has one exit gate in which was self closing and self latching. Two sheds were identified. A tour of the 4 resident bedrooms were conducted. Bedroom #1 has a resident bathroom connected to the bedroom. All bedrooms would house 2 non-ambulatory residents at any time. All bedrooms were observed to have a sufficient amount of furniture and furnishings to meet resident needs. A tour of the resident bathrooms were conducted. Bathroom #1 had a linen closet. LPA observed a sufficient amount of linens to meet resident needs. Hot water was taken in both bathrooms to ensure hot water temperature was within the required range. Grab bars and non-skid mats were also observed and were in good repair at this time. A tour of the laundry room was conducted. Washer and dryer were identified. Laundry detergent was observed to be locked and made inaccessible. A medication closet was identified, along with FDR Del Mundo. LPA Pascua reviewed and compared Medication Administration Records with Medication. LPA Pascua provided technical assistance regarding Medication Administration Records. A tour of the garage was conducted. An additional freezer and refrigerator unit were identified. Additional facility supplies were also identified. The following documents were requested to be submitted to the department: -LIC 308 -LIC 400 -LIC 500 -LIC 610e Technical assistance was provided for Section 87465(a)(4) Based on the observations based during the visit, there are no deficiencies were observed or cited during this annual visit. An exit interview was conducted and a copy of this report was provided to the Facility at the end of this visit.the state’s words, verbatim · CDSS document, Jan 8, 2026

Type of visit: Prelicensing

On 01/13/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to this facility to conducted to a Pre-Licensing visit. LPA Pascua met with Applicant, Cecil De Lara and explained the purpose of the visit. The purpose of this visit was to conduct a pre-licensing visit. This facility intends to hold 8 non-ambulatory residents. This facility also will hold a dementia plan on file and a hospice waiver for 6 residents. Current census was 0. A brief interview with Applicant, Cecil De Lara. The perspective Facility Designated Administrator (FDA), Cecil De Lara has a current RCFE Administrator certificate #6066497740 and expires on 03/21/2025. A tour of the facility was conducted. A fire extinguisher was identified in the kitchen area and was serviced by Armor Fire Co and is valid until 07/19/2025. Smoke Detectors and carbon monoxide were observed throughout the facility and was observed to be in working condition. A tour of the kitchen area was conducted. Toxins, cleaning supplies, and knives were observed to be locked and made inaccessible. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supplies at this time. A tour of the living area was conducted. Furniture and furnishing were observed to be in good repair and could meet resident needs. A tour of the backyard was conducted. Gate and perimeter fence was in stable condition. This facility has one exit gate in which was self closing and self latching. A tour of the 4 resident bedrooms were conducted. Bedroom #1 has a resident bathroom connected to the bedroom. All bedrooms would house 2 non-ambulatory residents at any time. All bedrooms were observed to have a sufficient amount of furniture and furnishings to meet resident needs. A tour of the resident bathrooms were conducted. Bathroom #1 had a linen closet. LPA observed a sufficient amount of linens to meet resident needs. Hot water was taken in both bathrooms to ensure hot water temperature was within the required range. Grab bars and non-skid mats were also observed and were in good repair at this time. A tour of the laundry room was conducted. Washer and dryer were identified. Laundry detergent was observed to be locked and made inaccessible. This facility will be housing resident medication in a locked closet next to the laundry room. First aid kit was present and had the required components. A tour of the garage was conducted. An additional freezer and refrigerator unit were identified. Additional facility supplies were also identified. Based on the observations made during this visit, there are no deficiencies observed during this Pre-Licensing visit. This applicant has passed this pre-licensing visit. This applicant has already completed Comp I and Comp II. A review of Comp III was conducted. An exit interview was conducted and a copy of this report was provided to the Applicant at the end of this visit.the state’s words, verbatim · CDSS document, Jan 13, 2025

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 8 Census (if any clients in care): COMP II Participants: Cecil DeLara & MaryJane del Mundo Interview Method: Telephone interview On December 31, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Medications/Activities/Transportation 3. Staffing requirements 4. General provisions 5.Pre Licensing Inspection readinessthe state’s words, verbatim · CDSS document, Dec 31, 2024