Princess Lodge

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Rica Uy. LPA stated the purpose of the visit. LPA toured the interior and exterior of the facility with ADM to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. The facility was observed to be clean, safe, sanitary and in good repair. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed refrigerator temperature at 40 F and Freezer at 0 F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Fire extinguishers were last inspected on 2/3/2026. The facility smoke detector and sprinkler system were inspected on 4/7/2025 by a third party vendor and passed inspection The facility emergency drill log was reviewed. The facility's last drill was on 11/20/2025. LPA toured 10 resident bedrooms. All 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 6 bathrooms. All 6 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature with a range of 105 F to 112.7 F. Page 1 of 2 During inspection of Resident Room #6, LPA observed a heater that did not have a protective cover/mechanism. LPA was able to touch the heater and felt heat radiating. LPA advised ADM to ensure heating devices shall have protective mechanisms or other measures to prevent access to the device. LPA reviewed Title 22 Regulation 87307 Personal Accommodations and Services with ADM. ADM stated understanding of the regulation. During visit, ADM removed the heater from the resident room. LPA reviewed 3 resident records. Resident records included emergency contact information, physician’s report, needs and service plans, and personal rights. LPA reviewed 3 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA reviewed 3 staff records. Staff records included fingerprint background clearance, medical assessment with TB result, personnel record, and staff training. No deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Administrator (ADM) Rica Uy and a signed copy of this report was provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Feb 19, 2026

Allegation investigated: Cleaning products are accessible to residents in care

On 5/19/2025, LPA Grace Donato conducted an unannounced complaint visit to deliver finidings. LPA met with Manager, Rica Uy & Co Administrator Olivia Velasquez and explained the purpose of the visit. For the allegation of cleaning products are accessible to residents in care, reporting party (RP) stated that their (facility) cleaning materials are not stored properly. During the initial visit, LPA Dolores toured the facility and observed that in the Laundry Room #2 was not locked with accessible laundry detergents. The laundry room is right next to residents’ bedrooms. S1 verbalized that the laundry room was not originally locked. S1 showed LPA how to lock the laundry room door, but did not know how to open the laundry room door after. Therefore, based on observations, the above allegation is determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed and copy of report and appeal rights are provided. Substantiated During LPA Dolores’ visit, 4 staff were observed to be working. During LPA Donato’s visit there were about 5 staff working, some are with residents in the dining area, some were at the living room watching tv with the residents. LPA also observed that when a resident called for help, a staff was there to attend to the resident. For the allegation of facility not following their infection control policy, RP stated that COVID protocol/infection control not properly implemented when there is an outbreak. LPA interviewed staff members. S1 stated that they do have isolation rooms in case there is an outbreak. It's located in between the office and main rooms.There's a separate entrance with ramp. LPA documented the area through photos. Food is left to the staff room in between the isolation room and hallway and is taken by a staff assigned to serve it to residents. Incident reports are also submitted to licensing. Regarding the allegation of Licensee/ADM is not carrying out his/her responsibilities and authority to carry out the policies of the facility, RP stated that owners of the facility area always out of the country and doesn’t care what’s going on in the facility. During the interviews, S1 and S2 stated that Administrators Judith and James Morales is here basically every day when they are here in the area. Based on records review, there are other staff who are qualified administrators also and are there when Licensees are not around. Although the allegations may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED. Report is reviewed and copy is provided. Regarding the allegations of Residents medications are not being administered per physician’s order and residents’ medications are accessible, Reporting Party (RP) stated that medications are not properly administered/caregivers are giving meds instead of the med-clerk/some residents are hiding medication in their room without proper documentation. Based on records review, 5 out of 5 resident’s medication administration records (MAR) have accurate logs of when medications are given to residents. It is also noted in the MAR if medications are discontinued. Facility also has an updated Centrally Store Medication & Destruction Records (CSMDR) for the 5 residents. During the visit of LPA Dolores, it was observed that a medication cart in the dining room which was observed locked. LPA Donato, on the subsequent visit, also observed this medication cart and PRN medications were locked inside a room in one of the offices. LPA Donato also toured random rooms. LPA checked all the closets and cabinets and only saw body lotions and wipes for the residents. There were no medications found in the rooms. Regarding the allegation that the facility does not have sufficient lights to ensure the comfort and safety of residents and facility is unsanitary, reporting party (RP) stated that The facility is dark not too filthy but there is an unexplainable smell when we toured. During the initial visit, LPA Dolores toured the facility and observed that the smell of the facility to smell like multiple perfumes and air fresheners. The facility was clean and sanitary with clean floors and surfaces. Resident bedrooms well kept. The beds were made, no random items and objects laying around the floor. The floors observed with no obvious dirt marking and sticky surfaces. Fire exits were free and clear of obstruction. LPA observed the hallways were dim when the lights are off. Hallways and dim spaces contain light switches. LPA observes the areas were well lit once lights were turned on. LPA Donato also visited and observed that the facility is clean and well maintained, there were night lights in the facility hallways. The residents’ rooms are well kept. page 2 of 3 For the allegation of facility has a staff member who is not fingerprinted, RP stated that Facility is harboring undocumented employee mostly working at night. LPA Dolores checked on the staff that works and lives in the facility. All three staff members who resides on the 2nd floor of the facility are all fingerprinted and associated in the facility. The facility has apartments at the back. LPA Donato crosschecked the people living there during the time of complaint and everyone is associated with the facility and fingerprint cleared, one being a non-client adult resident due to the person just residing in the apartments and not working as staff. For the allegation of Facility has a kitchen in the second floor, which is a fire hazard RP stated that Staff rooms upstairs is filthy and has a kitchen that is dangerous to fire. LPA Dolores toured the 2nd floor and it was observed that it contained a kitchen. The kitchen did not have a stove. LPA observed a vintage oven connected to the wall. S1 states the oven is not working. S1 opened the oven and LPA observed the oven was filled with storage containers. The kitchen area had 2 refrigerators, a microwave, dining table, and rice cooker. LPA observed a fire extinguisher sitting on the kitchen table. Based on observations & records review the department has determined that that these allegations are false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided. page 3 of 3the state’s words, verbatim · CDSS document, May 19, 2025 · control 26-AS-20231031153334

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: May 19, 2025

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This was not met as evidenced by: Based on observation, Laundry Room #2 was not locked with accessible laundry detergents, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2025

Plan of correction: Violation has since been corrected when the investigation started.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Deficiencies visit to follow up on deficiencies that were issued on 2/13/2025. LPA Tarin met with Staff S1 Rica Uy. LPA stated the purpose of the visit. S1 called Administrator (ADM) Olivia Velasquez via phone, ADM states she was out of the area. ADM authorized S1 to sign on her behalf. S1 states the facility has 18 residents and 5 staff. On 2/13/2025 LPAs Manuel Monter and Kenneth Madrigal conducted the facility's annual inspection. Deficiencies were issued and a Plan of Correction (POC) was developed with the ADM. The ADM stated they would repair and correct the deficiencies cited, and submit a statement of understanding by the POC due dates of 2/14/2025 and 2/20/2025. The POCs were submitted to the Department. LPA Tarin inspected the facility and it was observed to be clean, safe and in sanitary condition. LPA did not observe any leaks in the facility. LPA observed the following: dry wall in the facility bathroom has been repaired, the refrigerator is free of ice buildup, the back wall of the facility kitchen sink has also be repaired. LPA observed the backyard fence was repaired and not propped with a stick. LPA reviewed Resident R1-R4's records and observed completed needs and services plans. LPA reviewed Staff S2-S4's records and observed signed physicians reports. No deficiencies were cited during today's visit. An exit interview was conducted with S1 and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Required - 1 Year

On February 13, 2025, at 12:45 PM, Licensing Program Analysts (LPA), Kenneth Madrigal and Manuel Monter, conducted an unannounced Required 1 - Year Visit. LPAs stated the purpose of the inspection visit and met with Staff 1 (S1) who contacted Olivia Velasquez, Administrator Designee (AD) and was granted entry to the facility. Olivia stated that “Judith Morales, the Administrator (ADM) is out of the country.” LPAs called Judith Morales on the phone, but ADM did not pick up the phone, so LPAs left a voicemail. AD stated there are 7 facility staff, and 17 residents present at the time of the visit. The facility has 16 resident rooms, 8 resident bathrooms, one dining room, two living rooms, one office, one kitchen area, one laundry area, one storage area, and 98 sprinklers. During today's visit, the LPAs toured the facility inside and out with AD. In the kitchen area, all the sharps and chemicals are locked and inaccessible to residents in care. In the kitchen area, a portion of the wall above the faucet and below the glass wood cabinet has exposed drywall. The facility room temperature is 75 degrees Fahrenheit. In the hallway leading to the storage room and perpendicular to the laundry room, there is a water leakage. (Photographs were taken.) In the bathroom between resident rooms 6 and 5, there are exposed wall. The bathroom between resident room 1 and two, S1 stated that there was plumbing issues. AD stated "the drain backed up happened this morning and the maintenance worker is resolving it." Across from the washer and dryer machine, there is a ceiling wall that is damaged. In bedroom #10, LPAs observed a container of Ultra Clean Detergent which the door of bedroom #10 was not locked and the door was open and was accessible to residents in care. S1 removed the detergent during the visit. LPAs observed the bathroom near resident room 15, the wall had stains and the ceiling fan had lint. LPAs observed the fridge perpendicular to resident room #6 had stains and ice buildup and observed food on the ground. See LIC 809C. Page 1 of 3. Pursuant to California Code of Regulations (CCR), Title 22, Division 6, deficiencies are being cited during today's visit based on LPAs observations, please see LIC 809D. The Department is issuing an immediate civil penalty of $250 for each repeat violation for the following deficiencies: 87303 Maintenance and Operation (a) was cited on February 22, 2024. An Exit Interview was conducted with the Administrator Designee which includes the review of this Evaluation Report and a provided copy of this report to the Administrator Designee. Appeal Rights were provided to AD. END OF REPORT. Page 3 of 3. While touring the backyard, LPAs observed directly next to the bedroom 16 exit outside, has a garden tool that is accessible to residents in care. LPAs observed a storage shed next to the gazebo which had a window opened with tools and chemicals when reaching the window. LPAs observed the wood fence being propped to prevent the fence from falling. In the outside premises, the exterior door of Room #12, the screen door is not attached. In the exterior, one of the wood handrails for the ramp for Room #3 is fragile and wiggles when used as support. When entering the second story directly from the outside, LPAs observed in front of staff rooms, chemicals and tools are accessible to residents in care. LPAs randomly tested three (3) resident bathrooms where the water temperature is recorded between 112 to 116 degrees Fahrenheit. In the living room, there were facility activities occurring for the residents such as music performance. Based on a review, the fire department conducted an inspection of for the sprinkler system which was in February 2024. The fire extinguisher was last serviced on January 8, 2025. LPAs reviewed 4 Resident Records and 4 Staff Records. LPAs requested to review R1 to R4’s Appraisals Needs and Services. AD stated, “forms have not been filled out yet.” 3 out of 4 staff records did not have a signed Health Screening form by the Physician. LPAs also reviewed the Centrally Stored Medication and Destruction Record for 4 residents. LPAs reviewed facility disaster drill log, which stated January 25, 2025, was the last drill conducted. Additionally, LPAs audited the First Aid Kit, which has all the tools and equipment necessary for an emergency such as tweezers and scissors. LPAs requested a copy of the updated facility sketch plan. See LIC 809 C. Page 2 of 3.the state’s words, verbatim · CDSS document, Feb 13, 2025

Type of visit: Case Management - Annual Continuation

This is a continuation of the required annual inspection done on 2/14/2024. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced continuation visit for the required annual inspection and met with administrator/house manager (ADM/HM) Randi Cabrera. Current census during today's visit is 20 residents 1 out of 20 is in rehabilitation, and 19 staff. LPA observed that the kitchen has a commercial grade gas stove with griddle and range hood. LPA observed that the range hood accumulated grease and grime that could pose imminent danger to persons in care. A used paper towel was observed stuck between the vent hood and the cabinet on the top left side. A used paper towel was placed on the griddle left bottom corner (photos were taken). Water temperatures for the bathroom and the kitchen was measured and ranges from 105 degrees Fahrenheit to 120 degrees Fahrenheit. During inspection of the facility, LPA observed that the conference room had an accordion door, behind the accordion door are facility’s decorating supplies (Christmas decors), 2 oxygen tanks, some furniture, and unused wheelchairs. The items in the room obstructed a designated emergency exit door. LPA observed a recliner upon exiting the door from the conference room, which obstructs the access to the walkway. LPA toured the residents’ and observed that emergency exits from the resident's room are clear from any obstructions, sliding doors are working and door alarms are in good working condition. LPA observed that residents’ rooms and common areas are clean and well maintained. All bathrooms have anti-skid mat and grab bars, sufficient supply of toilet rolls and paper towels. Resident rooms have ample storage, sufficient area for visiting families and clean beddings. Walkways inside the facility is clean and free from obstructions. continued to page 2 LIC 809C Continued from Page 1 - LIC 809 page 2 of 3 While inspecting the exterior perimeter and the backyard LPA observed a gazebo near the maintenance shed with tools that are in the open and can easily be accessed and poses imminent danger to persons in care. From the kitchen exit to the exterior, LPA observed a garbage dumpster, a wheel burrow and asphalt compactor obstructing the walkway and gate towards the front exterior of the facility and designated as an emergency exit, LPA reviewed 5 resident records herein referred to as R1 to R5, and their centrally stored medication and destruction record (CSMDR). LPA observed that R1 has two expired medication that was not discarded and noted on the destruction record. R3 has medication that was not listed on the CSMDR. LPA reviewed the 5 staff record, herein referred to as S1 to S5 and found training and personnel record updated. The following deficiencies were cited based on the California Code of Regulations (CCR) Title 22. Deficiencies were observed on 2/14/2024 inspection and today's visit. (87303)(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors . 80087(d) Buildings and Grounds- All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. 87705 Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). continued to page 3 LIC 809C Continued from page 2 page 3 of 3 Deficiencies continued. 87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (D)Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4). Any on-the-job training provided for the requirements in Section 87411(d)(4) may also count towards the requirement in this subsection. An exit interview was conducted with administrator/house manager Randi Cabrera and a copy of this report and appeals right was provided.the state’s words, verbatim · CDSS document, Feb 22, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mita Partoza conducted an unannounced annual inspection at the facility. LPA met with Facility Manager Rica Uy (FM) and Randi Cabrera facility administrator. Current facility census count 20 resident. 1 out 20 is undergoing rehabilitation. During the visit, LPA toured the facility with the facility manager (FM) Rica Uy and Administrator (ADM) Randi Cabrera, the tour includes the living room, dining room, kitchen, 14 resident bedrooms. The 2nd floor area dedicated for staff and the outdoor perimeter, the parking area and the maintenance area. The facility has 16 bedrooms some shared and some single occupancy. The 9 bathrooms on the ground floor are either in between 2 rooms and some are not shared. The facility has an office, a staff break room and a 2nd floor staff area for staff who lives in the facility. The 2nd floor has 4 bedroom and a kitchenette used by staff. The door leading to the staff 2nd floor area is kept locked. The laundry room doubles as a cleaning supplies and toxic material storage and is kept locked at all times. The dry food storage room stores sufficient supply for 7 days non-perishable food for resident and staff and 2 days of perishable food supply. Due to time constraint LPA will continue with the annual required inspection at a later date. No deficiencies were cited per California Code of Regulations, Title 22 during today's visit. This report was reviewed with administrator Randi Cabrera.the state’s words, verbatim · CDSS document, Feb 14, 2024