R & E Senior Care

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Emily Pascua and explained the purpose of the visit. During LPA Moleski's annual inspection of this facility on 10/29/25, LPA Moleski reviewed two staff files (S1-S2). LPA Moleski observed that S1 did not have a health screening on file. S2 did not have a first aid/CPR certificate on file. LPA Moleski was told by co-licensee Randy Pozon that the documents had been misplaced, but he would locate them and send them to LPA Moleski as soon as possible. To this date, LPA Moleski has not received any such documentation. LPA Moleski reviewed S1 and S2's files again during this visit, and the documents were still missing. During this visit, LPA Moleski reviewed S3's file. S3 had a health screening on file, but the medical professional completing the form wrote that S3 is "unable to perform until further evaluation and management ... of abnormal findings on exam." S3 was present during this visit, and was informed of the unsatisfactory findings of their health screening. This facility is hereby cited per 22 CCR Sections 87411(f) and 87411(c)(1). An exit interview was held with Pascua. Appeal rights and a copy of this report were left with Pascua.the state’s words, verbatim · CDSS document, Nov 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(f) · Plan of correction due date: Nov 21, 2025

"(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. ... Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties." This requirement was not met as evidenced by: Based on record review, staff members did not have completed health screenings on file indicating good health, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Nov 17, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with an updated health screening for S3. Emily Pozon stated that S1 no longer works at this facility. Licensee agrees to remove S1 from this facility roster by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: Nov 21, 2025

"(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross." This requirement was not met as evidenced by: Based on record review, a staff member did not have first aid/CPR training on file, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Nov 17, 2025

Plan of correction: Emily Pozon stated that S2 no longer works at this facility. Licensee agrees to remove S2 from this facility roster by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Emily Pascua and explained the purpose of the visit. LPA Moleski reviewed three resident files (R1-R3) and two staff files (S1-S2). LPA Moleski toured the facility with co-licensee Randy Pozon and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski interviewed one staff member (Pozon). Residents were not able to be interviewed during this visit. No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Pozon.the state’s words, verbatim · CDSS document, Oct 29, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski spoke with licensee Randy Pozon over the phone and explained the purpose of the visit. Pozon said staff member Roselle Raymundo could sign this report in his absence. LPA Moleski toured the facility and compared the physical layout against a facility sketch received by CCLD in September 2021 which was reviewed and approved by the local fire department. LPA Moleski toured the garage and observed a small room which contained a couch and a few folded blankets. LPA Moleski did not observe personal effects, food, or other evidence that this room was being used as living quarters. LPA Moleski spoke with the caregiver on duty, Raymundo, who said that the room was used as a break room, but was not used as living quarters. LPA Moleski called Pozon, and he reiterated that it is used as a break room and/or storage room. Pozon said that it is never used as living quarters. He said the room was present when the facility opened. LPA Moleski requested that Pozon update his facility sketch to clearly identify the room and to label is as a break room and/or storage room. Pozon said he would do so. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Raymundo.the state’s words, verbatim · CDSS document, Sep 18, 2025

Type of visit: Case Management - Other

On 8/21/2025 at 2:30 PM Licensing Program Analyst (LPA) Shakaricka Hughes and Licensing Program Manager (LPM) Czarrina Camilon-Lee arrived at the facility to conduct a case management visit to the facility to deliver an Order to Licensee/Facility of Immediate Exclusion from Facility. LPA met with licensee/administrator Emily Pascua and explained the purpose of today's visit. LPA Hughes handed the Order to Licensee/Facility of Immediate Exclusion from Facility letter to Emily and explained that facility staff (S1), if present in the facility needed to leave immediately. Facility staff (S1) is to be removed from all shifts and disassociated from the facility in Guardian. An exit interview was held with administrator Emily, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Emily Pascua and explained the purpose of the visit. Upon arrival, LPAs Moleski and Williams observed a resident (R1) sitting in a chair with large amounts of dark-colored bruising covering their face. LPAs Moleski and Williams asked Pascua about the cause of these injuries, and she said R1 had fallen on 10/21/24. LPA Moleski reviewed an incident report submitted to the Community Care Licensing Division on that same date. According to the incident report, R1 went to the bathroom around 2:30 p.m. and fell, hitting their head and right forearm. Immediately after the fall, R1 exhibited redness to their left eye and forehead, and had a wound on their upper nose. R1's right forearm had an open wound, a skin tear, and bruising, according to the incident report. The report further stated that first aid was provided to R1, including antibiotic ointment and gauze for R1's wounds, and R1's responsible party was notified. In an interview, Pascua said that 911 was not called. She said that R1's responsible party was texted immediately after the incident and asked whether or not R1 should be sent to the hospital, but R1's responsible party did not respond to her inquiry until the next day. Pascua said that R1's responsible party told her that R1 did not need to be sent to the hospital. 22 CCR Section 87465(g) states that "the licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health." Pascua admitted that 911 should have been called after the incident described above. [continued on 809-C] LPAs Moleski and Williams reviewed three resident files (R1-R3) and two staff files (S1-S2). LPA Moleski observed all residents (R1-R3) did not have needs and services plans on file. LPA Moleski observed that R3 was diagnosed with stage three pressure ulcers on both buttocks while at a skilled nursing facility (SNF) as of 2/4/23, according to admission records from the SNF. R3's LIC 602 dated 2/15/23 indicated that R3 still had at least one stage 3 pressure ulcer on their buttocks. R3's preadmission appraisal, signed by Pascua, the resident, and the resident's responsible party as of 2/21/23, indicated that R3 had two stage three pressure ulcers on both buttocks. R3 signed this facility's admission agreement on that same date, 2/21/23. Pascua confirmed that R3 had never received hospice care while at this facility. Pascua said the wounds have since healed. LPAs Moleski and Williams toured the facility with Pascua and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 112 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. While touring the facility, LPAs Moleski and Williams and Pascua observed an unlocked bathroom cabinet which contained a disinfectant. In a different bathroom in a resident room, LPAs Moleski and Williams and Pascua observed an unlocked cabinet with a container of powdered cleaner with bleach. Additionally, LPAs Moleski and Williams and Pascua observed multiple medications for R3 left in unlocked drawers and cabinets in that bathroom. The medications included various creams, eyedrops, powders, and lidocaine patches. R3 is not able to store their own medications, according to R3's most recent LIC 602 on file, dated 3/3/23. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives in the kitchen. LPA Williams interviewed one staff member (S1) and two residents (R1-R2). This facility is hereby cited per 22 CCR Sections 87465(g), 87615(a)(1), 87465(h)(2), and 87309(a), and HSC Section 1569.695(e)(2). An exit interview was held with Pascua. Appeal rights and a copy of this report were left with Pascua.the state’s words, verbatim · CDSS document, Oct 24, 2024

Allegation investigated: Facility staff forced resident to drink medicine Facility staff verbally abused residents

THIS REPORT HAS BEEN GENERATED TO INCLUDE VERBIAGE INADVERTENTLY LEFT OUT OF THE PREVIOUSLY AMENDED REPORT. Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct an investigation of the above-mentioned allegations on 5/1/24 at 8:30a. LPA met with Emily Pascua and stated the purpose of the visit. LPA toured the facility and interviewed resident #1 (R1) - (R4) and the Administrator and Caregiver Randy Pozon during this visit. LPA requested a list of staff with contact information, food receipts, facility utility bills, and resident roster. There is 1 resident on hospice during this visit. Based on interviews and review of paid utility bills and food receipts for January - April 2024. During the interviews of R1-R4 on 5/1/24, LPA obtained information that the staff are not being verbally abusive. In a re-interview of residents on 5/31/24, residents continue to concur that staff are not yelling in the facility nor at residents and that residents are not forced to do anything. The allegations above are deemed Unfounded. "The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint." Per California Code of Regulations, nothe state’s words, verbatim · CDSS document, May 31, 2024 · control 27-AS-20240422144541

Allegation investigated: Facility staff served expired foods to residents

AMENDED TO SUBSTANTIATED LICENSEE AGREED Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct an investigation of the above mentioned allegations on 5/2/24 at 7:30a. LPA met with Emily Pascua and stated the purpose of the visit. On 5/1/24, LPA toured the facility, interviewed resident #1 (R1) - (R4), Administrator and Caregiver Randmelvin L Pozon. LPA requested a list of staff with contact information, food receipts, facility utility bills, and resident roster. Based on a subsequent visit today,"Facility staff served expired foods to residents", LPA observed opened freezer burned food items in the freezer in the garage that was not labeled or dated. Licensee stated that those will be thrown away today. The above allegation is SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099D during this visit. Licensee was provided a copy of their rights (LIC9058) and their signature acknowledges receipt of these rights. Exit interview held, a copy of report was provided. Substantiatedthe state’s words, verbatim · CDSS document, May 2, 2024 · control 27-AS-20240422144541

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(a) · Plan of correction due date: May 3, 2024

General Food Service Requirements The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Observation Based on Confirmation from Licensee those food items will be removed today. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 2, 2024

Plan of correction: Licensee shall submit by fax a statement indicating the Title 22 regulations regarding food will be upheld at all times.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 5/2/24 at 7:30a. LPA met with Emily Pascua and Randmelvin L Pozon regarding todays visit. During the complaint visit on 5/1/24, LPA provided a LIS Roster and reviewed it with the Licensee. It was discussed that the staff in pending status should not be working until cleared and associated. Licensee stated they were not hiring Staff # 2 (S2) as the finger prints continue to be in pending status. LPA inquired about the staff working during this shift. Both Emily Pascua and Randmelvin L Pozon stated that they are the caregivers working now and the others left. LPA went outside to the front yard and saw 2 caregivers leaving the facility from the side of the home. LPA requested to see their identifications and requested to see the staff files from Emily. Both S1 and S2 stated they did not have identification. LPA requested again some form of identification. They both presented passports. Upon further review, S1 is finger print cleared and associated to the facility. Licensee admitted that although it was stated yesterday that S2 would not be hired because of pending status, S2 has worked in the facility for 1 year. This information was confirmed by S2 during this visit. Community Care Licensing does not have any previous staff roster printouts which contained S2's name. Licensee stated they do not have previous rosters which are shredded once updated. S2 provided copies of live scan and finger print documents dating back to 2023 which indicate she was cleared. Licensee has submitted an email to the Guardian Department to inquire about the pending status. A review of the facility files for S1 and S2, they were observed to be either missing or incomplete. Both did not include pertinent Licensing forms. LPA provided a copy of the LIC311F Records to be maintained at the facility-Residential Care Facility for the Elderly. Civil Penalty assessed in the amount of $500.00. (See LIC421IM) Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; additional civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(f) · Plan of correction due date: May 3, 2024

Criminal Record Clearance Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the department. This requirement is not met as evidenced by: LIS and Guardian does not include S2's name as associated and finger print cleared Based on Confirmation from Licensee and S2, S2 has been working for 1 year in the facility. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 2, 2024

Plan of correction: Administrator shall submit an email to the Guardian Department inquiring what are the next steps. POC Cleared during this visit by observation of email sent. You are hereby notified that an immediate civil penalty of $500.00 is assessed for a violation that resulted in staff working with finger print clearance and association. (See LIC421IM)

From the deficiency page — Deficiency type: Type A · Section cited: CCR87412(a)-(h) · Plan of correction due date: May 3, 2024

Personnel Records The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: records review Based on observation during visit, records are either missing or incomplete This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 2, 2024

Plan of correction: Licensee shall submit a plan on when all documents will be completed and placed in staff files. Fax by POC due date

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: May 3, 2024

False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on Confirmation from Licensee and S2, that S2 has been working for 1 year in the facility. In addition, S1 and S2 stated that they did not have any identification. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 2, 2024

Plan of correction: Licensee shall submit a statement that in-service training will be conducted with all staff regarding the Title 22 regulations "False Claims".

Allegation investigated: Facility staff forced resident to drink medicine Facility staff verbally abused residents

AMENDED LICENSEE AGREED Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct an investigation of the above mentioned allegations on 5/1/24 at 8:30a. LPA met with Emily Pascua and stated the purpose of the visit. LPA toured the facility and interviewed resident #1 (R1) - (R4) and the Administrator and Caregiver Randy Pozon during this visit. LPA requested a list of staff with contact information, food receipts, facility utility bills, and resident roster. There is 1 resident on hospice during this visit. Based on interviews and review of paid utility bills and food receipts for January - April 2024. The allegations above are deemed Unfounded. "The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint." Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided. Unfoundedthe state’s words, verbatim · CDSS document, May 1, 2024 · control 27-AS-20240422144541