Psalm Residential Care Home

Type of visit: Case Management - Other

On 9/9/2026, Licensing Program Analysts (LPA) Yi Sam Jian arrived unannounced for the purpose of conducting a case management. The purpose of the case management is to address the corresponding complaint investigation report number 14-AS-20260728081933. LPA met with administrator, Anna Aoay. LPA explained the purpose of the visit. During the investigation of the complaint, the Reporting Party (RP) reported working at the facility and was not associated with the facility. Although the facility provided receipts documenting some expenditures made on behalf of clients, the facility did not provide sufficient documentation demonstrating adequate management and accounting of client's funds. A technical violation was issued. The deficiency noted on the LIC9099-D and was discussed with the Administrator, and Appeal Rights were provided. Failure to correct the deficiency may result in civil penalties, as applicable. This report was reviewed with the Administrator, and a copy was provided to the facility.the state’s words, verbatim · CDSS document, Sep 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Sep 10, 2026

87355(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility This requirement was not met, as unassociated volunteer reported working at a licensed facility, which posed an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Sep 9, 2026

Plan of correction: Administrator reported the unassociated volunteer was not hired as worker and will not allowed to be back in facility until criminal record clearance cleared.

Type of visit: Case Management - Other

On 09/02/2026, Licensing Program Analyst (LPA) Yi Sam Jian arrived unannounced at the facility for the purpose of conducting a complaint investigation visit and was greeted by Administrator Anna Aoay. During the visit, LPA observed and was informed by facility staff that the facility did not have telephone service on the premises. Facility staff reported that the facility was relying on staff members’ personal cellular telephones to make emergency calls, including calls to 911. Technical violation issued. The facility did not provide documentation requested by LPA to verify that staff had been paid all wages owed for the applicable pay period. LPA was unable to verify whether all wages owed to staff had been paid based on the documentation provided at the time of the visit. Further documentation is needed to determine whether a violation occurred. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given and left at the facility. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Report is reviewed with administrator and a copy is provided.the state’s words, verbatim · CDSS document, Sep 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87205(a) · Plan of correction due date: Sep 10, 2026

87205(a) The licensee... shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. Based on interviews conducted, the facility did not provide supporting documents that staffs were paid in full amount of wage owed to them, which poses/posed a potential health, safety or personal rights risk to persons in care..the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: The licensee shall provide the Department with a supporting documents that staff were paid and maintain documentation of the payments by POC due date.

Allegation investigated: -Facility refrigerator is in disrepair.

On 08/26/2026 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced complaint inspection to deliver findings regarding the complaint allegations received. LPA met with administrator, Anna Aoay, LPA explained the purpose of the visit. Regarding the allegation that facility refrigerator is in disrepair, the Department conducted investigation, the LPA's direct observation of the nonfunctioning refrigerator, combined with information from the interview conducted and documentation reviewed, establish that the facility failed to maintain the refrigerator in proper working condition. The Department determined that the preponderance of evidence standard has been met, therefore the allegations above are found to be SUBSTANTIATED. The deficiency is cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and is noted on the attached LIC 9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 26, 2026 · control 14-AS-20260730124500

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 4, 2026

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 was not met as evidence by: Upon LPA's observations, refrigerating compartment of the kitchen refrigerator was not functioning and in need of repair. This serves as a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: Facility received funding from outside sources and replaced the malfunctioning kitchen refrigerator with a functioning refrigerator per LPA observation on 08/26/2026.

Allegation investigated: - Resident in care left the facility without supervision

On 08/19/2026 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced complaint inspection to deliver findings regarding the complaint allegations received. LPA met with administrator, Anna Aoay, LPA explained the purpose of the visit. Regarding the allegations that Resident in care left the facility without supervision, the Department conducted investigation, documents reviewed and interview conducted were consistent and corroborated that R2, a resident with known supervision and safety needs, left the facility without staff supervision. The Department determined that the preponderance of evidence standard has been met, therefore the allegations above are found to be SUBSTANTIATED. The deficiency is cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and is noted on the attached LIC 9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 19, 2026 · control 14-AS-20260601164935

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 20, 2026

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by Based on interviews, R2 left the facility unassisted which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: The facility will submit new appraisal for resident R2 and develope new plan on how will facility meet the need of resident R2 moving forward. The facility will submit a copy of this plan to CCL by the POC due date.

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

On 07/14/2026, Licensing Program Analysts (LPA) Yi Sam Jian arrived unannounced for the purpose of conducting a probation visit and was greeted by Administrator, Anna Aoay. The facility had been placed on probation from April 22, 2025 to April 22, 2028 and is to comply with probation stipulation conditions implemented by the department and was agreed upon with the Licensee. During a tour of the facility, the LPA observed a copy of the documented probation stipulation and the Administrator’s certification (expired 09/2026) posted on the common area bulletin board. LPA conducted interview with staff and reviewed documentation. LPA observed a new working refrigerator in the kitchen. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Report is reviewed with administrator and a copy is provided.the state’s words, verbatim · CDSS document, Aug 19, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 28, 2026

87211 Reporting Requirements(a)(1)(D) Any incident which threatens the welfare, safety or health of any resident Based on record review and interview conducted, the facility did not comply with the section cited above no incident report submitted to CCL regarding R2's elopement which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: The facility will submit new appraisal for resident R2 and develope new plan on how will facility meet the need of resident R2 moving forward. The facility will submit a copy of this plan to CCL by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87205(a) · Plan of correction due date: Aug 28, 2026

87205(a) The licensee... shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. Based on interviews conducted, the facility did not provide supporting documents that staffs were paid in full amount of wage owed to them, which poses/posed a potential health, safety or personal rights risk to persons in care..the state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: The licensee shall provide the Department with a supporting documents that staff were paid and maintain documentation of the payments by POC due date.

Type of visit: Case Management - Other

On 08/05/2026, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced Case Management visit at the facility. LPA met with Administrator, Anna Villanuva-Aoay, and the purpose of the visit was explained. The purpose of this visit was to follow up on the "Decision and Order" regarding the exclusion of Staff 1 (S1). During the visit, the Administrator confirmed that S1 is no longer employed by the facility and that the licensee has received a copy of the Decision and Order. The Administrator also shared with LPA S1's social media post pictures, which indicated that S1 is currently living outside the United States. Administrator reported that S1 has no plans to return to the United States. No citations are issued during the visit. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Aug 5, 2026

Type of visit: Case Management - Other

On 07/14/2026, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced case management visit to deliver the findings of the Department's Audit of financial solvency of the facility. LPA met with Administrator, Anna Aoay. LPA explained the purpose of the visit. On 05/06/2026 and again on 07/01/2026, the Department's auditor requested that the licensee, William S. Encarnacion, submit financial and other requested documentation to the Department. As of 07/10/2026, the requested documentation had not been received by the Department. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Report is reviewed with administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jul 14, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87205(a) · Plan of correction due date: Jul 23, 2026

87205(a) The licensee... shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. On 5/6/2026 and 7/1/2026, the department auditor requested the licensee to provide the requested documentation. As of 7/10/2026, the licensee did not furnish any requested documentation.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: The licensee shall develop and provide the Department with a written plan addressing the facility's financial stability and the completion of necessary repairs and improvements to maintain the facility in compliance with applicable regulations. Documentation verifying submission of requested records and progress toward corrective actions shall be maintained at the facility and made available to the Department upon request. The facility will submit a copy of the written plan to CCL by POC due date.

Type of visit: Case Management - Incident

On 7/14/2026, LPA Yi Sam Jian conducted an unannounced Case Management - Incident. LPA met with Administrator Anna Aoay. LPA explained the purpose of the visit. Regarding the incident report received 6/29/2026 reporting altercation between two residents. During the visit LPA conducted interview. The case management will be completed at a later date. No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with the Administrator and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Jul 14, 2026

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

On 07/14/2026, Licensing Program Analysts (LPA) Yi Sam Jian arrived unannounced for the purpose of conducting a quarterly probation visit and was greeted by Administrator, Anna Aoay. The facility had been placed on probation from April 22, 2025 to April 22, 2028 and is to comply with probation stipulation conditions implemented by the department and was agreed upon with the Licensee. During a tour of the facility, the LPA observed a copy of the documented probation stipulation and the Administrator’s certification (expired 09/2026) posted on the common area bulletin board. Monthly training records required by the stipulation have been completed and documented, as implemented by the Administrator. Medications and other toxic products were properly stored in a safe, locked location inaccessible to anyone other than facility staff. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Report is reviewed with administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jul 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(21) · Plan of correction due date: Jul 15, 2026

87555(b)(21)...refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). This requirement was not met, as evidenced by LPA observations indicating refrigeration compartment of the facility main refrigerator in the kitchen was not working such that milk had to store at freezer compartment of the main refrigerator.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: The facility will develop a written plan to replace or repair refrigerator. The facility will submit a copy of the plan to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jul 23, 2026

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. This requirement was not met, as evidenced by LPA observations indicating 1 out of 3 facility bathroom's floor cracked and unknown liquid pooled near the toilet.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: The facility will develop a written plan to replace or repair bathroom floor. The facility will submit a copy of the plan to CCL by POC due date.

Type of visit: Office

On 06/04/2026, San Bruno Regional Office conducted a non-compliance conference meeting with Licensee, William Encarnacion and Administrator, Anna Aoay. Present in the meeting were Regional Manage Jackie Jin, Licensing Program Manager Brenda Chan, and Licensing Program Analyst Yi Sam Jian. During the non-compliance meeting, the following serious violations were discussed: CCR 87468.1(a)(1) Personal Rights of Residents; HSC 1569.185(e) The failure of a licensee to pay all applicable and accrued fees; CCR 87415.1(a)(2) Night Supervision: CCR 87555(b)(26) General Food Service Requirements; CCR 87463(i) Reappraisal; CCR 87303(a) Maintenance and Operation; CCR 87468.1(a)(3) Personal Rights of Residents; CCR 87609(b)(4) Allowable Health Condition; CCR 87307(a)(3)(D) Hygiene items of general use; HSC 1569.38(e) Posting of licensing reports in a conspicuous location in the facility; CCR 87213 Finance. During this meeting, the compliance plan was developed and discussed with the licensee which includes more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers. This report was reviewed with Licensee, William Encarnacion and Administrator, Anna Aoay. Regional office requested facility to submit updated LIC308 Designation of Facility Responsibility, current lease agreement by 06/18/2026.the state’s words, verbatim · CDSS document, Jun 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.185(e) · Plan of correction due date: Jun 5, 2026

HEALTH AND SAFETY CODE The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement is not met, as licensee has failed to pay annual licensing renewal fees Due date 10/04/2025 which poses an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: Licensee and administrator stated that overdue license fee were fully paid on 06/04/2026.

Type of visit: POC

THIS IS AN AMENDED REPORT FROM AN ORIGINAL REPORT DATED 05/01/2026. On 05/01/2026, Licensing Program Analyst (LPA) Yi Sam Jian conducted a plan of correction visit for the quarterly probation visit that was conducted on 04/28/2026. LPA met with Administrator, Anna Aoay and explained the purpose of today's visit. LPA toured the facility’s pantry and kitchen. During the visit, licensee, William Encarnacion, replenished the pantry, refrigerator and freezer with perishable and non-perishable food items. The facility continued to operate with only two staff members covering shifts from 6:00 AM to 6:00 PM daily. At the time of visit, the following deficiencies , which were cited on 04/28/2026 were not corrected: - HSC1569.185(e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. - CCR 87415(a)(2) at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. This report is reviewed and discussed with the Administrator. A copy is provided.the state’s words, verbatim · CDSS document, May 1, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 8, 2026

Personal Rights of Residents(a)(1)To be accorded dignity in their personal relationships with staff. This requirement was not met, as evidenced by resident and staff interviews indicating licensee was disruptive to residents in care with loud music and had yelled at residents.the state’s words, verbatim · CDSS document, May 1, 2026

Plan of correction: The administrator will develop a written plan to ensure residents’ dignity and respectful treatment are upheld, addressing issue such as loud music. A copy of the plan will be submitted to CCL by the POC due date. Violation recited on 06/04/2026 during NCC office meeting.

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

THIS IS AN AMENDED REPORT FROM AN ORIGINAL REPORT DATED 04/28/2026. On 04/28/2026, Licensing Program Analysts (LPA) Yi Sam Jian arrived unannounced for the purpose of conducting a quarterly probation visit and was greeted by Administrator, Anna Aoay. The facility had been placed on probation from April 22, 2025 to April 22, 2028 and is to comply with probation stipulation conditions implemented by the department and was agreed upon with the Licensee. During a tour of the facility, the LPA observed a copy of the documented probation stipulation and the Administrator’s certification (expired 09/2026) posted on the common area bulletin board. Monthly training records required by the stipulation have been completed and documented, as implemented by the Administrator. Medications and other toxic products were properly stored in a safe, locked location inaccessible to anyone other than facility staff. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.the state’s words, verbatim · CDSS document, Apr 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.185(e) · Plan of correction due date: Apr 29, 2026

HEALTH AND SAFETY CODE The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement is not met, as licensee has failed to pay annual licensing renewal fees Due date 10/04/2025 which poses an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: Annual licensing fees and late charges will be paid BY POC DUE DATE. Proof of payment/correction to be sent to CCLD BY POC DUE DATE. Violation recited on 06/04/2026 during NCC office meeting.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87415(a)(2) · Plan of correction due date: Apr 29, 2026

In facilities caring for sixteen (16) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes. This requirement was not met, as evidenced by LPA observation and documentation collected, which poses an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: The administrator will develop a written plan to ensure that night staff on duty on the premises, and awake. The administrator will submit a copy of the plan to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(26) · Plan of correction due date: May 1, 2026

General Food Service Requirements(b)(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 was not met, as evidenced by LPA observations indicating an insufficient amount of nonperishable food available for the 17 residents at the time of inspection. This deficiency poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: The facility will submit photographic proof to CCL by POC due date that supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days are maintained on the premise.

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

On 03/04/2026, Licensing Program Analysts (LPA) Yi Sam Jian arrived unannounced for the purpose of conducting a quarterly probation visit and was greeted by Administrator, Anna Aoay. The facility had been placed on probation from April 22, 2025 to April 22, 2028 and is to comply with probation stipulation conditions implemented by the department and was agreed upon with the Licensee. During a tour of the facility, the LPA observed a copy of the documented probation stipulation and the Administrator’s certification (expired 09/2026) posted on the common area bulletin board. Monthly training records required by the stipulation have been completed and documented, as implemented by the Administrator. All staff members on duty were confirmed to be background cleared and associated with the facility. Medications and other toxic products were properly stored in a safe, locked location inaccessible to anyone other than facility staff. 5 residents were not reappraised within seven days following unusual incident or hospitalization.Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.the state’s words, verbatim · CDSS document, Mar 4, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(i) · Plan of correction due date: Mar 18, 2026

87463 reappraisal (i) When there is significant change in condition... or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not having documentation for reappraisal for 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 4, 2026

Plan of correction: The administrator will submit updated and signed reappraisal for the 5 residents to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.185(e) · Plan of correction due date: Mar 5, 2026

HEALTH AND SAFETY CODE The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement is not met, as licensee has failed to pay annual licensing renewal fees Due date 10/04/2025 which poses an immediate health, safety or personal rights risk to clients in care. Licensee was reminded to pay licensing fee on during probational visit.the state’s words, verbatim · CDSS document, Mar 4, 2026

Plan of correction: Annual licensing fees and late charges totalling $3465 will be paid BY POC DUE DATE. Proof of payment/correction to be sent to CCLD BY POC DUE DATE.

Type of visit: Case Management - Other

On 02/03/2026, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced case management visit. LPA met with Administrator, Anna Aoay and explained the purpose of the visit. During the visit, LPA delivered a copy of amended LIC9099 for a complaint report that was initially received on 08/01/2025. Report was reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Feb 3, 2026

Allegation investigated: - Staff inappropriately touches the residents while in care - Staff yell at residents in care

THIS IS AN AMENDED REPORT FROM AN ORIGINAL REPORT DATED 12/12/2025. On 12/12/2025 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced complaint inspection to deliver findings regarding the complaint allegations received. LPA met with administrator, Anna Aoay, LPA explained the purpose of the visit. Regarding the allegations that staff inappropriately touched residents while in care, the Department investigated and conducted interviews, witness accounts from multiple residents and staff were consistent and corroborated the allegations. Regarding staff yelled at residents, the Department investigated and conducted interviews, witness accounts from multiple residents and staff were consistent and corroborated the allegations. The Department determined that the preponderance of evidence standard has been met, therefore the allegations above are found to be SUBSTANTIATED. The deficiency is cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and is noted on the attached LIC 9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Dec 12, 2025 · control 14-AS-20250801113217

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 13, 2025

87468.1 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: (3) To be free from punishment, humiliation, intimidation, abuse This regulation was not met, as evidenced by interviews conducted indicating that a staff inappropriately touched a resident multiple times . These actions constitute a violation of the resident’s personal rights and poses a immediate Health and Safety risk to clients in care.the state’s words, verbatim · CDSS document, Dec 12, 2025

Plan of correction: The facility will develop a written plan to ensure that residents’ rights are protected and to outline corrective action for the staff involved in the violation. The facility will submit a copy of this plan to CCL by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Dec 19, 2025

87468.1 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 regulation was not met, as evidenced by interviews conducted indicating that a staff yelled at residents. These actions constitute a violation of the resident’s personal rights and poses a potential Health and Safety risk to clients in care.the state’s words, verbatim · CDSS document, Dec 12, 2025

Plan of correction: The facility will develop a written plan to ensure that residents’ rights are protected and to outline corrective action for the staff involved in the violation. The facility will submit a copy of this plan to CCL by the POC due date.

Type of visit: Case Management - Other

On 12/12/2025, Licensed Program Analyst (LPA) Yi Sam Jian conducted a Case Management-Other visit to deliver amended findings to complaints. LPA met with Administrator Irene Anna Aoay and explained the purpose of the visit. LPA delivered amended findings for complaint number 14-AS-20250715141344 and complaint number 14-AS-20250527120745. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Dec 12, 2025

Type of visit: Case Management - Other

On 11/06/2025, Licensed Program Analyst (LPA) Yi Sam Jian arrived at the facility to deliver amended copies of LIC9099. LPA met with administrator, Anna Aoay. LPA explained the purpose of the visit. Reports were reviewed with administrator and copies were provided to facility.the state’s words, verbatim · CDSS document, Nov 6, 2025

Type of visit: POC

On 10/29/2025, Licensing Program Analyst(LPA) Yi Sam Jian arrived at the facility to conduct a Plan of Correction(POC) visit to clear the citation delivered on 10/01/2025. LPA was greeted by Administrator, Anna Aoay. LPA explained the purpose of the visit. On 10/01/2025, the facility was cited for a violation of California Code of Regulations(CCR) 87303(a) Maintenance and Operation, as the facility bathroom was not maintained in good repair. On 10/29/2025, LPA verified that bathroom floor had been replaced and all bathrooms were functional and in use by residents. On 10/01/2025, the facility was cited for a violation of California Code of Regulations(CCR) 87463(i) reappraisal, as documentation of reappraisal was missing for 10 out of 15 residents. On 10/29/2025, LPA reviewed and verified that reappraisals for all 10 residents had been completed and submitted by POC due date. An exit interview was conducted. A copy of the report was left at the facility and the POC clearance letters were emailed to the facility representative.the state’s words, verbatim · CDSS document, Oct 29, 2025

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

On 10/01/2025, Licensing Program Analysts (LPA) Yi Sam Jian arrived unannounced for the purpose of conducting a quarterly probation visit and was greeted by Administrator, Anna Aoay. Licensee, William Encarnacion was contacted and arrived later in the visit. The facility had been placed on probation from April 22, 2025 to April 22, 2028 and is to comply with probation stipulation conditions implemented by the department and was agreed upon with the Licensee. During a tour of the facility, the LPA observed a copy of the documented probation stipulation and the Administrator’s certification (expired 09/2026) posted on the common area bulletin board. Monthly training records required by the stipulation have been completed and documented, as implemented by the Administrator. All staff members on duty were confirmed to be background cleared and associated with the facility. Documentation was also observed confirming that residents signed an acknowledgment of the probation stipulation. Medications and other toxic products were properly stored in a safe, locked location inaccessible to anyone other than facility staff. LPA observed that 1 out of 3 restroom showers was not functioning properly and requires repair. Additionally, 10 out of 15 residents did not have documentation of updated reappraisals on file. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.the state’s words, verbatim · CDSS document, Oct 1, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(i) · Plan of correction due date: Oct 10, 2025

87463 reappraisal (i) When there is significant change in condition... or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 10 out of 15 residents did have documentation for reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: The administrator will develop and implement a plan to ensure that ALL RESIDENTS have documentation of an annual reappraisal every 12 months or significant change in condition. A copy of the plan will be submitted to CCL by 10/20/2025. The plan must include updated signed and dated reappraisal for residnet R2

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Oct 30, 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 was not met as evidence by:** Upon LPA's observations, 1 out of 3 restrooms showers not properly operating and 1 out of 3 restroom toilet, sink and shower in need of repair. This serves as a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: Licensee agrees to submit a written plan of how the repairs listed will be addressed. Plan to be submitted to CCL by POC due date. In addition, Licensee to submit LIC9098 Proof of Corrections form and indicating all corrections/repairs have been completed by POC due date.

Type of visit: Case Management - Other

On 10/01/2025, Licensing Program Analysts (LPA) Yi Sam Jian arrived unannounced for the purpose of conducting a Follow-Up/POC visit and was greeted by Administrator, Anna Aoay, and Licensee,William Encarnacion. A Type-B deficiency was cited during the required annual visit conducted on 09/17/2025 due to a lack of reappraisal documentation for 5 out of 5 residents. During the follow-up, the LPA reviewed updated reappraisals for all 5 residents, which were found to be updated and signed by facility and residents. A Type-B deficiency was cited during the quarterly probation visit conducted on 07/24/2025. Observations included: 1 out of 3 restroom showers not functioning properly, 1 out of 3 restroom sink and shower drains in need of repair, and flooring in 2 out of 3 restrooms requiring maintenance. The facility submitted a LIC 9098 along with photographic evidence showing that the restroom fixtures and flooring in the two identified bathrooms had been repaired. This report is reviewed and a copy this report is provided to the administrator.the state’s words, verbatim · CDSS document, Oct 1, 2025

Type of visit: Required - 1 Year

On 09/17/2025, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced annual inspection. LPA met with administrator, Anna Aoay. LPA explained the purpose of the visit. The ground level had 10 bed rooms for residents, and 3 bathrooms, 1 toilet room, living room, office, 1 staff room, kitchen, patio courtyard, closet, and furnace room. 1 bathroom under reconstruction. Backyard was fenced, secured, and in good condition. All outdoor and indoor passageway were free and clear of obstruction. No accessible bodies of water or fire safety hazards observed. Kitchen was inspected, sufficient supply of food observed. Infection control practices reviewed. Medications, toxins and sharps stored appropriately and inaccessible to clients, a comfortable temperature was maintained, hot water temperature inspected to be compliant, furnishing and lighting was sufficient for comfort and safety. Carbon monoxide detector and smoke detector system inspected and met the requirements. fire extinguisher checked and fully charged. Facility has a written emergency disaster plan. Licensee has at least one completed first aid kit located in the office. Deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in additional civil penalties. This report is reviewed and discussed with the administrator; a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 17, 2025

Type of visit: Case Management - Other

On 09/04/2025 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced case management visit to follow up on a death report submitted on 08/27/2025. LPA met with administrator Anna Aoay, purpose of the visit explained to administrator. The facility reported on 08/27/2025, Resident R1 passed away and that the immediate cause of death was not disclosed. According to the death report submitted to Community Care Licensing (CCL), R1 was found unresponsive on the floor by his roommate R2, who then notified facility night staff S1 at 6:20AM. S1 subsequently called 911, and the San Francisco Medical Examiner later pronounced R1 deceased. During today’s visit, LPA reviewed and collected relevant documentation and conducted interviews with facility staff. Resident R2, R1’s roommate, was not available for interview at the time of the visit. The administrator stated that the facility will request a copy of the official death certificate once it becomes available. No citations issued. Report discussed with administrator.the state’s words, verbatim · CDSS document, Sep 4, 2025

Allegation investigated: Staff does not ensure food served is of good quality to residents in care

On 08/21/2025, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unnannounced 10-day complaint visit. LPA met with administrator, Anna Villanuva-Aoay, LPA explained the purpose of the visit. Regarding the allegation that facility staff do not ensure food served is of good quality, the reporting party claimed that staff have been serving expired and spoiled food to residents. During the visit, LPA inspected the kitchen and food storage areas, observing all food to be properly stored, labeled, and within expiration dates, with no expired or spoiled items present. A review of 30-day menus showed meals were balanced, and interviews with staff confirmed regular food deliveries, proper discarding of expired items. Resident interviews indicated that none reported receiving spoiled or expired food, and 4 out of 5 residents expressed satisfaction with the meals provided. Base on interviews, and observations during the course of investigation, this allegation is unsubstantiated. Although the above investigations 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 allegation is UNSUBSTANTIATED. This report is reviewed and discussed with administrator. A copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 21, 2025 · control 14-AS-20250820091316

Allegation investigated: Staff are not providing residents with needed hygiene supplies

On 07/29/2025, Licensed Program Analyst (LPA) Yi Sam Jian arrived at the facility to deliver conclusionary finding for this complaint received by the Department. LPA was greeted by administrator, Anna Villanuva-Aoay, and explained the purpose of the visit. Regarding the allegations that Staff are not providing residents with needed hygiene supplies, the Department has investigated the above allegations. Based on observations and interviews with staff and residents during the investigation, it was determined that the preponderance of evidence standard has been met, therefore the allegations above are found to be SUBSTANTIATED. The deficiency is cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and is noted on the attached LIC 9099-D. Report is reviewed with administrator and a copy is provided. Substantiatedthe state’s words, verbatim · CDSS document, Jul 29, 2025 · control 14-AS-20250715141344

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Aug 8, 2025

Personal Accommodations and Services(a)(3)Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident(D)Hygiene items of general use such as soap and toilet paper This requirement was not met, as evidenced by observations, resident and staff interviews indicating that the licensee failed to provide sufficient personal hygiene items to residents upon requested. This deficiency poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: The administrator will develop a written plan to ensure that residents are provide with hygiene items upon request. The administrator will submit a copy of the plan to CCL by POC due date.

Allegation investigated: Facility staff are not preventing physical altercations between residents

On 07/29/2025, Licensed Program Analyst (LPA) Yi Sam Jian arrived at the facility to deliver conclusionary finding for this complaint received by the Department. LPA was greeted by administrator, Anna Villanuva-Aoay, and explained the purpose of the visit. During the visit, LPA conducted interviews with staffs and client. Regarding the allegation that Facility staff are not preventing physical altercations between residents. The Department has investigated the above allegation. Based upon interivews with staff and residents, there is contradicting information received.The resident involved in the incident confirmed during the interview that staff intervened during the physical altercation, and that the residents involved have since been separated and are no longer roommates. The 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. Report is reviewed with administrator and a copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 29, 2025 · control 14-AS-20250606160420

Allegation investigated: -Licensee did not ensure sufficient food items were available at the facility for residents in care -Staff did not provide personal care items to resident in care -Staff's behavior poses a risk to residents in care

On 07/24/2025, Licensed Program Analyst (LPA) Yi Sam Jian arrived at the facility to deliver conclusionary finding for this complaint received by the Department. LPA was greeted by administrator, Anna Villanuva-Aoay, and explained the purpose of the visit. Regarding the allegations that did not ensure sufficient food items were available at the facility for residents in care, Staff did not provide personal care items to resident in care, and Staff's behavior poses a risk to residents in care, the Department has investigated the above allegations. Based on observations and interviews with staff and residents during the investigation, it was determined that the preponderance of evidence standard has been met, therefore the allegations above are found to be SUBSTANTIATED. The deficiency is cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and is noted on the attached LIC 9099-D. Report is reviewed with administrator and a copy is provided. Substantiatedthe state’s words, verbatim · CDSS document, Jul 24, 2025 · control 14-AS-20250527120745

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Jul 31, 2025

Personal Accommodations and Services(a)(3)Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident(D)Hygiene items of general use such as soap and toilet paper This requirement was not met, as evidenced by observations, resident and staff interviews indicating that the licensee failed to provide personal hygiene items to residents upon requested. This deficiency poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: The administrator will develop a written plan to ensure that residents are provide with hygiene items upon request. The administrator will submit a copy of the plan to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(26) · Plan of correction due date: Jul 31, 2025

General Food Service Requirements(b)(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 was not met, as evidenced by LPA observations indicating an insufficient amount of food available for the 17 residents at the time of inspection. This deficiency poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: The administrator will develop a written plan to ensure that Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premise. The administrator will submit a copy of the plan to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 31, 2025

Personal Rights of Residents(a)(1)To be accorded dignity in their personal relationships with staff. This requirement was not met, as evidenced by resident and staff interviews indicating licensee was disruptive to residents in care with loud music and had yelled at residents.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: The administrator will develop a written plan to ensure residents’ dignity and respectful treatment are upheld, addressing issues such as loud music and yelling. A copy of the plan will be submitted to CCL by the POC due date.

Allegation investigated: Licensee is not ensuring there is one working shower for every ten persons

On 07/24/2025, Licensed Program Analyst (LPA) Yi Sam Jian and Dominic Tobola arrived at the facility to deliver conclusionary finding for this complaint received by the Department. LPA was greeted by administrator, Anna Villanuva-Aoay, and explained the purpose of the visit. Regarding the allegation that licensee is not ensuring there is one working shower for every ten persons. The Department has investigated the above allegation. Based on observations and interviews, the facility has three bathrooms with showering capacity, but only two are functional, serving 16 residents and three staff members. Based upon interivews with staff and residents, there is contradicting information received.The 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. Report is reviewed with administrator and a copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 24, 2025 · control 14-AS-20250611094444

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

On 7/24/2025, Licensing Program Analysts (LPA's) Tobola & Jian arrived unannounced for the purpose of conducting a quarterly probation visit and was greeted by Administrator, Anna Aoay. Licensee, William Encarnacion was contacted and arrived later in the visit. The facility had been placed on probation from April 22, 2025 to April 22, 2028 and is to comply with probation stipulation conditions implemented by the department and was agreed upon with the Licensee. Upon a tour of the facility, LPA's found that cleaning supplies and other potentially harmful toxins and items were secured in designated laundry room. Staff were actively washing resident laundry during the time of visit and supervising the items. LPA's observed the facility postings on the kitchen bulletin, hallway and front door but did not observe documentation of the probationary stipulations visibly posted. LPA spoke with the Administrator who stated that the stipulation was not posted. Administrator located copy of the documented probation stipulation and posted it in the common space bulletin. Monthly training records as per stipulation have been completed and documented for 3 out of 3 caregiver staff implemented by the Administrator. All staff on duty were confirmed to be cleared and associated. During the tour, LPA's observed 1 out of 3 restrooms showers not properly operating and 1 out of 3 restroom sink and shower drains in need of repair. Additionally, 2 out of 3 restroom flooring is in need of repairs as it presents a potential trip hazard due to broken or loose flooring. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.the state’s words, verbatim · CDSS document, Jul 24, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.38(e) · Plan of correction due date: Jul 24, 2025

1569.38 Posting of licensing reports; disclosure to new residents (e) ..the notice described in subdivision (b), the licensed residential care facility shall also post a written notice.. in a conspicuous location in the facility.. This was not met as evidence by:** Based upon LPA observation and interview with Licensee, it was found that the documented stipulation of probation was not posted in a conspicuous location in the facility. This serves as a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: Licensee and Administrator immediately placed the documented stipulation of probation in a conspicuous location of the facility. Deficiency cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jul 31, 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 was not met as evidence by:** Upon LPA's observations, 1 out of 3 restrooms showers not properly operating and 1 out of 3 restroom sink and shower drains in need of repair. Additionally, 2 out of 3 restroom flooring is in need of repairs as it presents a potential trip hazard due to broke or loose flooring. This serves as a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: Licensee agrees to submit a written plan of how the repairs listed will be addressed. Plan to be submitted to CCL by POC date 7/31/2025. In addition, Licensee to submit LIC9098 Proof of Corrections form and receipt of repair services indicating all corrections/repairs have been completed by POC date 8/31/2025.

Type of visit: Office

On 6/11/25, Licensing Program Analysts (LPAs) Dominic Tobola, Yi Sam Jian and Licensing Program Manager (LPM) April Cowan met with Administrator, Anna Aoay. During the meeting, LPM, Cowan and LPAs, Jian & Tobola went over and elaborated each item of the Stipulation and Waiver; And Order (“Stipulation”) that was effective on April 22, 2025. During the meeting, LPM elaborated on the stipulation order regarding the facility's license revocation, exclusion and administrator certificate revocation which have been stayed with probation from April 22, 2025 to April 22, 2028 pursuant to the following conditions: A. Respondent must strictly comply with all laws and regulations governing Residential Care Facilities for the Elderly (RCFEs). B. The Department may conduct unannounced inspections during probation to ensure full regulatory compliance. C. A qualified administrator must work at least 20 hours per week at the facility, and the Respondent cannot serve as the administrator. D. All individuals at the facility must have verified criminal clearances or exemptions before their presence and maintain proof on-site. E. Respondents must monitor everyone at the facility to ensure no one is under the influence of illicit drugs. F. Residents must be reappraised within seven days following any unusual incident or hospitalization. G. Staff must receive monthly Title 22 training, with attendance records kept and make-up sessions required within seven days unless otherwise approved. H. Unusual incidents must be reported to Licensing by the next working day with a written report submitted within seven days. Continued in 809-C I. Medications and toxic substances must be safely stored in locked areas accessible only to authorized staff. J. The facility must be maintained in a clean, safe, and sanitary condition at all times. K. All administrators must complete specified training during the probationary period. L. Current and prospective residents and their families must be informed of the probationary license and sign an acknowledgment kept in the resident’s file. M. The Stipulation must be visibly posted at each facility throughout the probationary period. The revocation of licensee's administrator certificate shall also be stayed with probation from April 22, 2025 to April 22, 2028. licensee shall be granted a probationary certificate pursuant to the following conditions: A. Respondent may only serve as administrator for Respondent Corinthian and is prohibited from serving as administrator for Respondent Psalm. B. Respondent must complete 40 hours of Department-approved training—25 hours in person—covering RCFE regulations, resident rights and care, behavior observation, facility safety, incident reporting, resident assessments, and medication handling. LPM also went into further detail on the remaining sections of the stipulation including future application for a license registration certification or approval, tolling of probationary period, completion of probation, violation of stipulation term, Department's authority, monitoring fee, waiver of hearing rights, waiver of appeal/modification rights, waiver of claims, public record, signatures, counterparts, effective date, no oral modification, and representations RE: corporate licensee. All meeting participants indicated that they understood the stipulation order. No deficiencies cited during this visit. This report was reviewed with William Encarnacion, Licensee and Anna Aoay, Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 11, 2025

Type of visit: Case Management - Incident

*****This is an amended report from original dated 12/27/2024 earlier today************* Licensing Program Analyst (LPA) Yi Sam Jian met with Administrator, Anna Villanuva-Aoay, (S1) for this case management visit. Purpose of the visit explained. On December 24, 2024, the Department received a death regarding an elderly resident (R1). At 7:30AM, a staff person found R1 in his bedroom in bed and R1 appeared pale and unresponsive. Staff called another staff, administrator arrived, and 911 was called. Paramedics arrived and took R1s vital signs and pronounced resident dead. Regional office is in process of gathering additional information and to obtain the cause of death. LPA gathered information and reviewed R1s file. The following documents were obtained during the visit regarding R1: · Physician’s Report dated 10/10/2023 Functional Capability Assessment · Resident Appraisal dated 8/2017 (Continued on next page 809-C) Based on review of documents and information obtained from staff interviews, the following was determined: the last time staff interacted with R1 was the evening before on 12/23/2024 at approximately 9:00PM as R1 was reading a book before going to sleep. Interviews conducted indicated no unusual concern about R1 and everything appeared normal. The following morning on 12/24/2024, during morning check at approximately 7:30AM, staff person, Elaine Jose (S1) found R1 in bed and he appeared to be pale and unresponsive. S1 then went to alert another caregiver Jay Tacras (S2). S2 performed CPR on R1 attempting to revive him however was unsuccessful. At approx. 7:45AM, the administrator arrived at facility and assessed R1; 911 was then called. Paramedics arrived shortly after called and attempted CPR. Attempts to revive R1 were unsuccessful and R1 was declared deceased by paramedics. Staff called the family and responsible party and informed of the situation. The immediate cause of death is unknown currently. LPA requested facility to obtain the death certificate and forward to the licensing office for further review. After death certificate received, there may be further follow up regarding this incident. The death certificate shall be sent to the licensing office by January 4, 2025. This report is emailed to facility representative and a copy of this report must be made available for public review upon request.the state’s words, verbatim · CDSS document, Dec 27, 2024

Type of visit: Case Management - Incident

On 12/23/2024, the Licensing Program Analyst (LPA) Yi Sam Jian arrived at the facility for an unannounced case management visit to follow up on an incident report submitted by the facility to the department on the same day. The report indicated that on 12/22/2024, R1 had left the facility, missed both breakfast and lunch, and suffered a fall outside. R1 was taken to St. Mary’s Hospital and returned to the facility by 2:00 PM on 12/22/2024, back to baseline. The LPA met with the Administrator, Anna Villanueva-Aoay, and explained the purpose of the visit. Upon reviewing R1’s records, the LPA found that R1 is ambulatory. The Appraisal/Needs and Services Plan noted that R1’s physical health is to enjoy walking outside at baseline. The Physician’s Report indicated that R1 is "able to leave the facility unassisted" with no reported "wandering behavior." The Physician has cleared R1 to leave the facility unassisted. The Client Assessment Checklist in the admission also noted that R1 does not have an AWOL risk or wandering tendencies. During an interview with the Administrator, it was confirmed that R1 enjoys going outside for walks, and R1 did not suffer any major injury from the fall occurred outside the facility. During the visit, the LPA observed that staff were actively monitoring the front door, and staff was signing in and out all individuals entering and exiting the facility. No deficiencies were cited. This report was reviewed and discussed with the Administrator, and a copy was provided.the state’s words, verbatim · CDSS document, Dec 23, 2024

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

On 12/9/24, Licensing Program Analyst (LPA), Grace Donato conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Administrator Anna Aoay and Licensee William Encarnacion followed after. LPA explained the purpose of the visit. A non-compliance conference was held on June 15, 2023. During non-compliance meeting, the following violations were discussed Basic Services, Reporting Requirements, Maintenance and Operation, Personal Accommodations, Incidental Medical and Dental Care, Criminal Record Clearance, Reappraisal, Personal Rights of Residents in All Facilities, Prohibited positions or employment; grounds; notice; removal; appeal; petition for reinstatement, Administrator Qualifications and Duties, Accountability of Licensee Governing Body, Observation of the Resident, Title 22, Division. 6, Chapter 8 During the visit, LPA reviewed the compliance plan with the new Administrator (ADM). ADM has been overseeing the running of the facilty, Licensee is available to help anytime needed and is still involved. Facility has been constantly checking residents rooms if there are any forms of drug paraphernalia. Residents are all updated with their current annual check ups. If appointments are needed it is addressed by the ADM right away. Residents are also receiving medications on time. Medication cabinet is locked. LPA toured several rooms and observed no medication on site. Facility is reporting unusual incidents to Licensing on a timely manner. Facility is clean and well maintained. Bathrooms are clean. No smell of smoke along the hallways. Hallways and rooms are mopped. All staff are currently fingerprinted and associated to the facility. Residents money are all kept separated. For one resident (R1) who has a behavior of hoarding, facility has been folding the clothes and have provided bins for storage. If R1 wants to go over the clothing, R1 picks whatever clothes they want, the clothing are scattered and staff will fold them back and store it. Behavior has also been discussed to the case manager. Staff has provided documentation on how these are addressed. Excluded person (P1) has not come in to the facility anymore and is aware that cops will be called. Residents are also aware not to let excluded individual in. P1 is being helped by a social worker but won't cooperate by living in an are where they can be placed. It was mentioned by the Licensee that P1 hangs out outside the house but doesn't get inside. Facility is not a locked facility but during curfew, at 8pm, residents are home and doors are locked. Residents are still able to go out if they want to but has to let staff know. Residents have been enjoying festivities as shown in photos provided by the administrator. LPA interviewed four residents and everyone said that they are happy here in the facility. No citations issued today. Report is reviewed with and a copy is provided.the state’s words, verbatim · CDSS document, Dec 9, 2024

Type of visit: Required - 1 Year

On 09/30/2024, Licensing Program Analyst (LPA) Grace Donato and LPA Yi Sam Jian conducted an unannounced annual inspection. LPA met with administrator, Anna Villanueva. LPA explained the purpose of the visit. The ground level had 10 bed rooms for residents, and 3 bathrooms, 1 toilet room, living room, office, 1 staff room, kitchen, patio courtyard, closet, and furnace room. Backyard was fenced, secured, and in good condition. All outdoor and indoor passageway were free and clear of obstruction. No accessible bodies of water or fire safety hazards observed. Kitchen was inspected, sufficient supply of food observed. Infection control practices reviewed. Medications, toxins and sharps stored appropriately and inaccessible to clients, a comfortable temperature was maintained, hot water temperature inspected to be compliant, furnishing and lighting was sufficient for comfort and safety. Carbon monoxide detector and smoke detector system inspected and met the requirements. fire extinguisher checked and fully charged. Facility has a written emergency disaster plan. Licensee stated there are no firearms or ammunition at the facility. Licensee has at least one completed first aid kit located in the office. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Facility provided a copy of Liability insurance and updated sketch of the facility. No Deficiencies cited. Report reviewed and discussed with Anna Villanueva.the state’s words, verbatim · CDSS document, Sep 30, 2024

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

On 5/23/24, Licensing Program Analyst (LPA), Grace Donato conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Caregiver Jay Tacras and Administrator William Encarnacion followed after. LPA explained the purpose of the visit. A non-compliance conference was held on June 15, 2023. During non-compliance meeting, the following violations were discussed Basic Services, Reporting Requirements, Maintenance and Operation, Personal Accommodations, Incidental Medical and Dental Care, Criminal Record Clearance, Reappraisal, Personal Rights of Residents in All Facilities, Prohibited positions or employment; grounds; notice; removal; appeal; petition for reinstatement, Administrator Qualifications and Duties, Accountability of Licensee Governing Body, Observation of the Resident, Title 22, Division. 6, Chapter 8 During the visit, LPA reviewed the compliance plan with the Administrator. When LPA arrived, residents were resting in their bedrooms and some are watching tv in the living room. LPA toured the facility and it was observed that the flooring in certain areas are still fixed. Based on interview with Administrator, residents are regularly brought for check ups. There is still a scheduled NOC shift. There are constant check ups and reminders to resident to bring prohibited drugs in the facility. Administrator certificate has been updated. Everyone working in the facility are all associated and fingerprinted. All incident reports are being reported in a timely manner to Licensing. LPA also confirmed and observed that an excluded individual is not at the facility anymore and staff are doing their best to keep said individual from entering the facility. No citations issued today. Report is reviewed with and a copy is provided.the state’s words, verbatim · CDSS document, May 23, 2024

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

On 12/11/23, Licensing Program Analyst (LPA), Grace Donato conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Administrator, William Encarnacion and explained the purpose of the visit. A non-compliance conference was held on June 15, 2023. During non-compliance meeting, the following violations were discussed Basic Services, Reporting Requirements, Maintenance and Operation, Personal Accommodations, Incidental Medical and Dental Care, Criminal Record Clearance, Reappraisal, Personal Rights of Residents in All Facilities, Prohibited positions or employment; grounds; notice; removal; appeal; petition for reinstatement, Administrator Qualifications and Duties, Accountability of Licensee Governing Body, Observation of the Resident, Title 22, Division. 6, Chapter 8 During the visit, LPA reviewed the compliance plan with the Administrator. When LPA arrived, residents were prepping for an activity. LPA toured the facility and it was observed that the flooring in certain areas has been addressed and fixed. Based on interview with Administrator, residents are regularly brought for check ups. There is a scheduled NOC shift. There are constant check ups and reminders to resident to bring prohibited drugs in the facility. Administrator also submitted requirements for renewal of license for Administrator and is currently pending for review. Everyone working in the facility are all associated and fingerprinted. All incident reports are being reported in a timely manner to Licensing. LPA also confirmed and observed that an excluded individual is not at the facility anymore and staff are doing their best to keep said individual from entering the facility. No citations issued today. Report is reviewed with and a copy is provided.the state’s words, verbatim · CDSS document, Dec 11, 2023