St. Lourdes Home

Type of visit: Required - 1 Year

On this day, 8/20/26, at 2:30 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Justino Balintona, licensee-administrator, and informed the reason for visit. LPA also met with staff, Warlita Romero and Norma Gano. LPA toured the facility inside out with Justino Balintona. LPA inspected the dining room, kitchen, bedrooms, bathrooms, living room, side and backyards. Food supplies were observed sufficient for 2 days of perishables and 7 days of non-perishables. Central storage for medications was locked. Facility has smoke and carbon monoxide detectors that were tested and observed in operating condition. Hot water temperature in the common bathroom was tested, and measured at 110 degrees Fahrenheit. Facility disaster drills conducted every quarter and records showed last conducted 7/10/26. LPA reviewed 5 residents and 5 staff files, and interviewed 2 residents. Medications checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. ...continued on 809C LPA observed the following: at 2:50 pm, lighter and resident's medication unlocked in kitchen drawers. at 2:58 pm, Ca-Rezz incontinent wash unlocked in resident's room. at 3:01 pm, moldy shower room and rusty towel holder in residents' ensuite bathroom. at 3:29 and 3:30 pm, smoke detectors in living room and hallway have wiring exposed due to covers were missing. at 3:28 pm, cobwebs on the living room and kitchen ceiling. from 3:45 pm to 4:00 pm, Staff (S2, S3, S4 and S5) do not have hospice care training on file. at 4:30 pm, Resident R2's medical assessment (LIC602A) on file is over a year old. There's no doctor's order for half bed rails. Residents (R1, R2, R3, R4, R5) have no LIC9172 Functional Capability Assessments on file. at 5:45 pm, Resident R5's medical assessment (LIC602A) on file was dated 11/15/24. On this day, LPA obtained copies of the following updated/current documents: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan 4. $3M liability insurance certificate Deficiencies and plan and proof of corrections were discussed with the Licensee-Administrator. Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 20, 2026

Allegation investigated: Staff did not allow the Ombudsman representative to conduct a facility visit.

On this day, January 21, 2026, at 2:20 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA was granted entry by Norma Gano, staff. LPA spoke over the phone with Justino Balintona, licensee/administrator and discussed the allegation. It was alleged that an Ombudsman (OMB) attempted to conduct a general visit at the facility on January 9, 2026, was greeted by a caregiver who did not let OMB to enter the and was told the owner (licensee) was currently not at the facility. The reporting party also stated that OMB explained that OMB is the ombudsman with the identification (ID) front facing visible but the caregiver still reiterated the same thing. ......continued on 9099C Substantiated LPA interviewed Ombudsman (OMB) on January 15, 2026 and staff (S1, S2) and licensee on this day, January 21, 2026. OMB confirmed wearing an identification (ID) with inscription 'Empowered Aging' and OMB's picture on it. OMB stated introducing self to the caregiver, was told the licensee was not at the facility and didn't allow OMB entry. S1 stated OMB came on January 9, 2026. S1 stated she didn't understand what OMB was saying but observed OMB wearing shirt with 'Empowered' print on it. S1 confirmed the licensee was not at the facility at that time and that she did not allow OMB to come in. S2 stated she was the facility when OMB came. S2 at first stated hearing OMB said 'Ombudsman' but later said not hearing it. The licensee confirmed he was not at the facility when OMB arrived and that S1 called him but OMB had left after the conversation with S1. Based on information gathered, the preponderance of evidence is met, therefore the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the licensee over the phone. Licensee authorized Norma Gano to sign and receive this report. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 15-AS-20260114102414

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87468.1(a)(11) · Plan of correction due date: Feb 4, 2026

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: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice........ -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above in staff not allowing entry to Ombudsman which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 21, 2026

Plan of correction: Administrator stated he will conduct in-service training. Copy of training topics with attendees signatures to be submitted by 2/04/26.

Type of visit: Required - 1 Year

On this day, August 13, 2025, at 12:40 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Warlita Romero and Norma Gano. LPA called and spoke over the phone with Justino Balintona, licensee-administrator, and informed the reason for visit. LPA asked, and licensee-administrator authorized Norma Gano to be with LPA during inspection. Licensee-administrator arrived around 1:15 pm. LPA started inspection with Norma Gano and continued with licensee-administrator. LPA inspected the dining room, kitchen, bedrooms, bathrooms, living room, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was locked. Facility has smoke and carbon monoxide detectors that were tested and observed in operating condition. Hot water temperature in the common bathroom was tested, and measured at 111.6 degrees Fahrenheit. Facility conducts drills and record showed last conducted July 12, 2025. Fire extinguisher checked and receipt showed purchased May 20, 2025. LPA reviewed 5 residents and 5 staff files, and interviewed 4 residents. Medications checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. ...continued on 809C LPA observed the following: -at 12:55 pm, medications in kitchen drawer without lock. -at 1:10 pm, Ca-Rezz incontinent wash, Hydrocortisone cream, lighter in unlocked closet in the hallway. -at 1:15 pm, Ca-Rezz in the common bathroom. -at 1:20 pm, unlocked scissors in the resident's room. -at 1:22 pm, Hydrocortisone cream, Ca-Rezz incontinent wash and shaving cream in another resident's room. -at 1:31 pm, scissors, mallet, hammer, screw drivers, lubricant in a plastic storage container in the backyard. -at 3:00 pm, staff (S2) does not have postural support training for 2024. -at 3:15 pm, staff (S3) who was hired in 2024 has only 16 hours of the total 40 hours required training. -at 3:20 pm, staff (S4) does not have postural support training for 2024. -at 3:32 pm, staff (S5) has not completed the required 40 hours of training within the required first 2 weeks of employment. -at 4:15 pm, resident (R2) has multi Vitamins and Ferrous sulfate administered but these are not included on the medications/supplements listed on LIC602A dated 5/27/25. -at 4:50 pm, resident (R3) has 1 medication on listed in After Visit Summary dated 8/05/25 but facility does not have the medication. -at 5:35 pm, resident's (R4) two prescribed medications filled on 6/18/25 and one filled on 7/18/25 not listed on LIC622 Centrally Stored Medication and Destruction Record. Facility does not have 3 of the prescribed medications. Tylenol (Acetaminophen) order is 325 mg but the one in facility's hand is 500 mg. LPA obtained copies of the following updated/current documents: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan 4. $3M liability insurance certificate .......continued on 809C Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of section 87309(a) within 12 month period and will continue for $100.00/day if not corrected. Failure to submit proof of corrections for the other deficiencies may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with the licensee-administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, LIC421FC Civil Penalty Assessments, and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 13, 2025

Type of visit: Case Management - Incident

On this day, 2/28/25, at 11:05 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) for resident (R1) submitted by the facility and received by LPA on 2/27/25. LPA was granted entry by staff, Norma Gano. LPA called and spoke over the phone with Justino Balintona, licensee-administrator, and informed the reason for visit. Licensee arrived at around 11:35 am. UIR indicated that on 2/27/25, the licensee noticed R1 was not in his room. The whole house was searched and the other resident's room's door leading to the outside was ajar and fence gate open. The immediate surroundings were searched and police assistance requested. R1 was located along the road 3 blocks from the facility with abrasion on the right forehead. R1 was brought to the hospital. LPA checked and observed all exit doors have auditory signals but unarmed. LPA also observed the following: staff's (S1 and S2) medications in the living room; disinfectant spray in the dining area. LPA met and interviewed R1. LPA observed bandage in R1's forehead and bruise in the left palm. LPA also interviewed the staff. LPA reviewed R1's file and obtained copy of LIC602A Physician's Report and LIC601 Identification and Emergency Contact Information. LIC602A showed R1 has major neuro cognitive disease and will be at risk if R1 leaves unassisted. .....continued on 809C Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section 87705(d) and $250.00 for repeat violation of section 87309(a) within 12 month period and will continue for $100.00/day for each if not corrected. Deficiencies and plan and proof of corrections were discussed with the licensee Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, LIC421IM and LIC421FC Civil Penalty Assessments, and copy of this report provided.the state’s words, verbatim · CDSS document, Feb 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Mar 1, 2025

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement.. -This requirement is not met as evidenced by: -Based on observation , record review and interview, the licensee did not comply in R1 able to leave unnoticed and the auditory signals of all exit doors disarmed which posed an immediate risk to the person in care. R1 sustained injuries. Civil penalty is assessed.the state’s words, verbatim · CDSS document, Feb 28, 2025

Plan of correction: Licensee installed auditory signals on fence gates. Licensee tumed on the auditory signals on exit doors while LPA was at the facility. In addition, licensee to in-service the staff and submit proof by 3/01/25. A $500.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Mar 1, 2025

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents...... --This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in unlocked staff medications and disinfectant spray which posed immediate risks to persons in care. This is a repeat violationthe state’s words, verbatim · CDSS document, Feb 28, 2025

Plan of correction: Staff and licensee locked the items while LPA was at the facility. In addition, licensee to in-service the staff and submit proof by 3/01/25. A $250.00 civil penalty is assessed

Type of visit: Required - 1 Year

On this day, August 7, 2024, at 10:30 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Warlita Romero and Margarita Corazon Mariano. LPA called and spoke over the phone with Justino Balintona, licensee-administrator, and informed the reason for visit. LPA asked, and licensee authorized Warlita Romero to be with LPA during inspection. Licensee-administrator arrived after about 25 minutes. Facility has Infection Control Plan that was submitted on 8/19/22. LPA started inspection with Margarita Corazon Mariano and continued with administrator. LPA inspected the dining room, kitchen, bedrooms, bathrooms, living room, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was locked. Facility has smoke and carbon monoxide detectors that were tested, and observed functional. Hot water temperature in the common bathroom was tested, and measured at 108 degrees Fahrenheit. Facility conducts drills and record showed last conducted 7/08/24. LPA reviewed 4 staff and 5 residents files, and interviewed 2 staff. Facility does not handle residents' cash resources. Medications checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. LPA observed the following: -at 10:42 am, refrigerator's vegetable crispers with mold, rotten bitter melon leaves, rotten asparagus and lettuce. ...continued on 809C (page 2) Page 2 -at 10:52 am, Voltaren, athlete's foot and hydrocortisone ointments in the drawer in one of the resident's room, and CaRezz continent and Chloehexine gluconate rinse in the closet in this resident's room. -at 11:07 am and 11:09 am, broken drawer knobs in 2 resident rooms and missing drawer knob in the drawer by the hallway. -at 11:10 am, razors in the common bathroom. -at 11:12 am, bathroom cabinets with heavily peeled varnish and soiled bath tub. -at 11:17 am, ensuite bathroom's shower door with mildew. -at 11:20 am, Raid insect killer, gallons of liquid sanitizer, expired canned foods and rotten cauliflower in unlocked storage in the backyard. - at 11:24 am, automotive agents, bug and windshield cleaner, stain remover, rusted metal cart in the backyard. -at 11:38 am, staff's medications in the living room. -at 1:49 pm, resident's (R2) LIC602A Physician's Report revealed R2 is bedridden and dependent on others with all activities of daily living (ADLs). LPA observed R2 unable to reposition on his own. -at 2:50 pm, resident (R1) has doctor's order for Mupirocin (3x/day), Asprin 81 mg (1 tab/day), Colchicine, but facility does not have these meds. Acetaminophen 315 mg (PRN) but at facility's hand is 500 mg. HydrAlazine order is 50 mg 3x/day but at facilty's hand is 25 mg 3x/day. Quetiapine 25 mg 1 tablet daily but label on this medication is 2x/day. Vitamin D3's order is 25 mcg (1,000 IU) but on hand is 50 mcg (2,000 IU) and facility administers 50 mcg daily. Voltaren, multi Vitamins & stool softener have no order on file. -at 3:35 pm, resident (R4) has order for 2.5 mg Lisinopril but facility does not have this medication. -at 4:00 pm, resident (R5) has discontinued order for Lisinopril 20 mg but facility is administering this medication. Has order for Albuterol 2.5 mg but facility does not have this medication. Has Quetiapine 25 mg but no doctor's order on file. ....continued on 809C (page 3) Page 3 LPA received the following updated/current documents on this day: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section 87202(a)(2). Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with the licensee-administrator. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 7, 2024

Allegation investigated: Staff dispensed medication that was not prescribed to resident.

On 12/22/2023 at 10:20am, Licensing Program Analysts (LPAs), L. Hall and T. Syess-Gibson arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegation above. LPAs met with Corzaon Mariano, Caregiver and explained the reason for the visit. Administrator Justion Balintona, arrived at 10:55am. During the investigation LPA interviewed Staff 1 (S1), obtained and reviewed the following documents for R1: admission agreement and physician's report. During interview with S1 he admitted that he offered the melatonin to R1, there was not a prescription, and R1 took the medication. During record review LPAs observed the facility did not have a medical administrative record (MAR) for R1. R1 no longer resides at facility. Continued on 9099C. Substantiated Continued from LIC9099. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Dec 22, 2023 · control 15-AS-20231220122433

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Dec 23, 2023

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication... there shall be a signed, dated written order from a physician... maintained in the residents file, and a label on the medication. This requirement was not met as evidence by: Based on observation and record review the Licensee did not comply with the section cited above in administering over-the-counter medication to R1 which poses a potential health and safety risk for person in care.the state’s words, verbatim · CDSS document, Dec 22, 2023

Plan of correction: Administrator agreed to review regulation 87465 and submit self-certification that the regulation has been reviewed and will be abided by going forward to CCLD by POC date.