The Hills of Babb

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced visit to verify facility closure, and to ensure no clients were receiving care and supervision at the facility. LPA was greeted by Licensee Allen Medina. Licensee informed LPA that last client's day on site was on April 22, 2025. On today's date, LPA conducted a tour of the physical plant. LPA observed rooms were cleared out of personal belongings and was advised that most of the furniture will be moved out. LPA observed painting supplies and preparation in one of the rooms. LPA observed no signs of residents or the facility in operation. LPA requested the facility license as it is part of the closure process, and the license was surrendered during the visit. Licensee has decided to permanently close the facility at this time. The Department will proceed with the closure as of May 4, 2025. An exit interview was conducted with staff representative and a copy of the report was provided at the end of the visit.the state’s words, verbatim · CDSS document, May 4, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a health and safety check on the residents at the facility. LPA was greeted and granted entry by staff and explained the reason for the visit. LPA was advised by licensee Allen Medina that the facility will not have any residents effective April 22, 2026 and existing residents are being relocated to other licensee owned facilities. Administrator (AD) Carla Ward stated families for three out of three residents were notified of the relocation on April 20, 2026. LPA toured the facility. LPA observed resident rooms have the required furnishings. LPA observed resident bathrooms are clean and operational. Hot water measured at 119.3 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed a sufficient supply of non-perishable food and perishable food at the facility for residents. LPA observed utilities on and operational. LPA observed three residents in the living room. Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Apr 21, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.682(a)(2) · Plan of correction due date: Apr 30, 2026

A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility...Provide each resident or the resident's responsible person with a written notice no later than 60 days before the intended eviction. This requirement is not met as evidenced by: Three out of three residents were provided a two day eviction/relocation notice which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 21, 2026

Plan of correction: AD stated they will provide a statement of acknowledgement of the regulation. AD stated new notices will be issued including the required information based on the regulation. AD to send proof to LPA by POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a health and safety check on the residents at the facility. LPA was greeted and granted entry by staff and explained the reason for the visit. LPA toured the facility. LPA observed resident rooms have the required furnishings. LPA observed resident rooms are clean and organized. LPA observed resident bathrooms are clean and operational. Hot water measured at 116.9 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed a seven day supply of non-perishable food and a two day supply of perishable food at the facility for residents. LPA observed utilities on and operational. LPA observed two residents in the living room and one resident in their room taking a nap. The facility provided evidence of liability insurance. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Apr 10, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a health and safety check on the residents at the facility. LPA was greeted and granted entry by staff and explained the reason for the visit. LPA toured the facility. LPA observed resident rooms have the required furnishings. LPA observed resident rooms are clean and organized. LPA observed resident bathrooms are clean and operational. Hot water measured at 105.2 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed a seven day supply of non-perishable food and a two day supply of perishable food at the facility for residents. LPA observed utilities on and operational. LPA observed two residents in the living room and one resident in their room taking a nap. The facility does not have evidence of liability insurance. The licensee was unable to provide documents requested as agreed upon and as noted during a noncompliance conference held on February 10, 2026. Civil penalties are being assessed. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Apr 1, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a health and safety check on the residents at the facility. LPA was greeted and granted entry by staff and explained the reason for the visit. LPA toured the facility. LPA observed resident rooms have the required furnishings. LPA observed resident rooms are clean and organized. LPA observed resident bathrooms are clean and operational. Hot water measured at 117.1 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed a seven day supply of non-perishable food and a two day supply of perishable food at the facility for residents. LPA observed utilities on and operational. LPA observed two residents in the living room and one resident in their room. The facility does not have evidence of liability insurance. The licensee was unable to provide documents requested as agreed upon and as noted during a noncompliance conference held on February 10, 2026. Civil penalties are being assessed. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Mar 26, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a health and safety check on the residents at the facility. LPA was greeted and granted entry by staff and explained the reason for the visit. LPA toured the facility. LPA observed resident rooms have the required furnishings. LPA observed resident rooms are clean and organized. LPA observed resident bathrooms are clean and operational. Hot water measured at 116.7 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed a seven day supply of non-perishable food and a two day supply of perishable food at the facility for residents. LPA observed utilities on and operational. At 11:10am, LPA observed the bathroom sink cabinet unlocked and accessible with a cleaning solution with bleach stored inside. LPA observed one resident watching TV in the living room and one resident in their room. The facility does not have evidence of liability insurance. The licensee was unable to provide documents requested as agreed upon and as noted during a noncompliance conference held on February 10, 2026. Civil penalties are being assessed. Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Mar 19, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 20, 2026

87309(a) Storage Space and Access ...the licensee shall ensure that disinfectants, cleaning solutions, ...and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: A bottle of cleaning solution with bleach was found stored in the bathroom sink cabinet unlocked and accessible to residents which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Staff member locked the cabinet during the visit. AD stated in-service training will be completed and proof will be submitted to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management and Health and Safety visit. LPA was greeted and granted entry by Staff #1 (S1) and explained the purpose of the visit. At time of visit two residents were seated and listening to music, while waiting for lunch. Both residents were groomed and dressed for the day. A third resident was eating lunch in their bedroom and stated to LPA they were doing fine. LPA toured the facility with Licensee Maricel Nepomuceno. Licensee Allen Medina was touring a prospective resident family. LPA toured the facility and discovered the storage room was used as a staff bedroom. A deficiency will be cited. Licensees and Administrator will remove bedding and staff items from storage room and staff member will reside at another location. LPA interviewed two of two staff members. Two of two staff members received partial payment for the pay period 2/4-2/18/2026. A Civil Penalty will be assessed for 87213 Finances from 3/04 - 3/11/2026 for $100/day X 8 days = $800. The facility does not have current liability insurance. A Civil penatly will be assessed for Liability Insurance HSC 1569.605 at $100/day X 8 days from 3/04 - 3/11/2026 for $100/day X 8 days = $800. Total assessed is $1600. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Licensees Maricel Nepomuceno and Allen Medina and a copy of this report was given to the facility along with a copy of the LIC 809-D, LIC 421-FCs and Appeal Rights.the state’s words, verbatim · CDSS document, Mar 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a)(2)(B) · Plan of correction due date: Mar 12, 2026

87307 (a) ... The facility shall be large enough to provide comfortable living accommodations...for the residents, staff... who may reside in the facility... (2) Resident bedrooms shall be provided...the following requirements: (B) No room commonly used for other purposes shall be used as a a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area,... This requirement was not met as evidenced by: LPA observed live-in staff residing in a storage area. This poses an immediate health and safety risk for staff.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Licensees and Administrator (AD) will remove bedding and personal items out of the storage area and the staff member will reside at a different location outside of the facility. AD willl email LPA by POC due date,

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management visit to conduct a health and safety check for the residents in care. LPA was greeted and granted entry by Staff #1 (S1) at 10:35am. LPA spoke with Administrator (AD) Rosendo "Carla" Ward regarding the purpose of the visit. LPA toured the facility and observed the water/trash, electricity, cable/internet and gas were operational. The refrigerator had more than two-days of perishable items and additionally a grocery order was to be delivered today. LPA observed the pantry had the required seven-days non-perishable items. The facility was clean and there were no odors. The temperature in the facility was 70 degrees Fahrenheit. LPA toured the exterior of the home and there were no hazards or obstacles in pathways. LPA interviewed three of three residents regarding the quality of care. Two of three residents stated utilities have remained on, they are being properly fed and they have no issues with care provided. LPA interviewed Staff #1 (S1) who also resides at the facility. S1 has not been paid for the most recent pay period of 2/4-2/18/2026 but was told payment would occur today. At the time of visit, this was not observed. LPA spoke with AD via phone, who stated the facility does not have current liability insurance. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations and Health and Safety Code. Civil Penalties are being assessed for Failure to Correct/Repeat Violation at $100 per day X 10 days for not having current liability insurance from 2/22-03/03/2026 for $1000. A Civil Penalty for finances is being assessed at #100 per day X 5 days from 2/27-03/03/2026 for $500. Total assessed is $1500. An exit interview was conducted with Staff #1. AD gave permission for Staff #1 (S1) to sign licensing reports. A copy of this report was given to the facility along with a copy of the LIC 811 and LIC 421-FCs.the state’s words, verbatim · CDSS document, Mar 3, 2026

Type of visit: Case Management - Health Checks

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a case management health check visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. During the visit, LPA toured the facility and observed the following: Facility appears clean and sanitary. Utilities are functional during today's visit including electricity, gas and water. LPA observed a prepared lunch to be fish, white rice, vegetable medley and cut fruit. LPA observed two day perishables and seven day non-perishables as well as emergency food and water. Staff stated grocery delivery is once a week on Tuesday. Interviews with staff indicated the staff were still owed wages from their last paycheck and were unsure when the wages owed would be paid. Based on observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was provided.the state’s words, verbatim · CDSS document, Feb 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Feb 27, 2026

87213 Finances The licensee shall have a financial plan that conforms to the requirements of Section 87155, ... shall submit such financial reports as may be required upon the written request of the licensing agency. The requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not have an adequate financial plan in place to ensure staff are paid on schedule, Staff are still owed wages from the last pay period. This poses an immediate health and safety risk to persons in care. Civil Penalty Assessed.the state’s words, verbatim · CDSS document, Feb 26, 2026

Plan of correction: Licensee to submit a financial plan outlining how to meet the operating costs of the facility including paying wages to staff and forward proof to LPA by POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a health and safety check on the residents at the facility. LPA was greeted and granted entry by staff and explained the reason for the visit. LPA toured the facility. LPA observed resident rooms have the required furnishings. LPA observed resident rooms are clean and organized. LPA observed resident bathrooms are clean and operational. Hot water measured at 105.2 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed a seven day supply of non-perishable food and a two day supply of perishable food at the facility for residents. LPA observed utilities on and operational. LPA observed two residents watching TV in the living room and one resident in their room. The facility does not have evidence of liability insurance. The licensee was unable to provide documents requested as agreed upon and as noted during a noncompliance conference held on February 10, 2026. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Feb 20, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Feb 21, 2026

87213 Finances The licensee shall have a financial plan that conforms to the requirements of Section 87155, ... shall submit such financial reports as may be required upon the written request of the licensing agency. The requirement is not met as evidenced by: The licensee agreed to provide documents requested by the Department by February 6, 2026 at 3pm. The licensee failed to provide documents by the agreed date which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 20, 2026

Plan of correction: Administrator Carla Miranda stated Licensee Allen Medina will provided all documents requested by the Department by end of day today. Licensee to provide proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.605 · Plan of correction due date: Feb 21, 2026

Liability insurance... all residential care facilities for the elderly... shall maintain liability insurance covering injury to residents and guests in the amount of... three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. The requirement is not met as evidenced by: The facility does not have evidence of current liability insurance which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 20, 2026

Plan of correction: Adminstrator Carla Miranda stated Licensee Maricel Nepomuceno has applied for liability insurance for the facility and will take affect by February 27, 2026. Licensee to provide proof to LPA by POC dude date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a health and safety check on the residents at the facility. LPA was greeted and granted entry by staff and explained the reason for the visit. LPA toured the facility. LPA observed resident rooms have the required furnishings. LPA observed resident rooms are clean and organized. LPA observed resident bathrooms are clean and operational. Hot water measured 113.9 degrees Fahrenheit. LPA observed the kitchen is clean and organized. At 12:35pm, LPA did not observe a two day supply of perishable food at the facility for residents. LPA observed utilities on and operational. LPA observed one resident in the living room and three residents in their rooms. Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Feb 5, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(26) · Plan of correction due date: Feb 6, 2026

87555(b)(26) General Food Service Requirements 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 is not met as evidenced by: LPA observed there is insufficient perishable food for a minimum of two days which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: AD stated a food order had been placed and was due to arrive today. Food order arrived during the visit.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a health and safety check on the residents at the facility. LPA was greeted and granted entry by staff and explained the reason for the visit. LPA toured the facility. LPA observed resident rooms have the required furnishings. LPA observed resident rooms are clean and organized. LPA observed resident bathrooms are clean and operational. Hot water measured between 116.6 and 118 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed sufficient food at the facility for residents. LPA observed utilities on and operational. LPA observed residents in the living room watching TV. LPA reviewed facility records obtained. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 12, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Fred Arias conducted a case management visit for the purpose of conducting a health and safety check. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. During the inspection, LPA toured the facility. LPA observed fruit flies in the kitchen. No other health and safety issues observed. Property utilities were working, such as electricity, gas and water. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA conducted health and safety checks on residents and observed no concerns. LPA interviewed residents in care and staff. Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Oct 24, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Oct 31, 2025

87555(b)(27) General Food Service Requirements All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. The requirement is not met as evidenced by: Based on LPA observations, a multitude of fruit flies are hovering in the kitchen area which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: AD stated they will purchase fruit fly traps and place throughout the facility. LPA to return to verify facility has not fruit flies.

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 5 residents and the home currently has 5 residents, with 3 residents on hospice. Administrator (AD) Eli Cuyson arrived shortly to conduct facility tour. LPA along with staff toured the facility at 1:50 PM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of 5 resident bedrooms, living room, dining room, staff room and kitchen as well as 4 bathrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured 110.2 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Two auditory exit alarms in room 2 and 4 were non-operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. One out of four kitchen stove burners were not operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. Exit door in room 4 could not be opened. Keypad lock leading into the garage where chemicals are stored is non-operational. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 08/28/2025. Outside grounds were toured. Walkways around the home were clear of hazards. There is shaded outdoor seating for residents. Exit gates are unlocked and operational. Facility conducts activities in the form of exercise and music therapy. LPA reviewed five resident files and two staff files. Resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in a locked closet. Five out of five resident files did not include an updated record of centrally store medication. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Sep 30, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Fred Arias is conducting this case management visit for the purpose of conducting a health and safety check. LPA arrived at the facility and was greeted and granted entry to the facility by staff and explained the nature of the visit. The facility has three residents in care. LPA observed there was one staff on site along with Administrator (AD) Rosendo Carlo Miranda. Caregiver was observed to be assisting residents. During the visit LPA toured the inside of the facility, bathrooms, bedrooms, and common areas. LPA inspected facility bathrooms and hot water temperature was measured between 118.2 and 118.9 Fahrenheit Degrees. LPA inspected food supply; adequate amount was observed to be within regulations. The facility has a two-day supply of perishables and seven-day supply of non-perishables food available as required by regulations. LPA observed hallways and walkways were free of obstruction. LPA toured outside grounds with AD. There is shaded area for residents. Outside grounds were free of hazards at the time of visit. LPA reviewed 1 staff file and 3 resident files. Required documentation for staff and residents were present in the files. This report was reviewed with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 20, 2025

Type of visit: Office

On today's date, Licensing Program Managers (LPM) Alisa Ortiz and Licensing Program Analysts (LPAs) Michael Tea and Brandon Lopez met with Licensee Allen Medina, Maricel Nepomuceno, and Keak Vongphakdy on this day for the purpose of discussing financial operations and distress and reporting requirements The following was discussed: Licensee's responsibilities of facility oversight Licensee's requirement to maintain control of facility and property Licensee’s responsibility to maintain financial solvency Licensee’s responsibility to communicate with the department Report of suspected dissolution of partnership Report continued on LIC809-C The following was agreed upon during today's meeting: The Licensee has clarified the dissolution of partnership is not related to license, but rather a separate business deal. The dissolution of partnership will not impact licensee’s facilities. The Licensee has reported they are in communication with landlords for properties leased and will maintain a valid lease and control of property. The Licensee will maintain payment of all facilities bills and ensure sufficient staffing to meet residents needs, the Licensee will communicate any health and safety concerns related to residents in care to the department immediately. The following items are to be provided to the Department: Updated LIC 500 Personnel Report identifying all current working staff and their agreed upon schedules by close of business May 29, 2025. Updated lease agreements with letters from landlords voiding any outstanding evictions or unlawful detainers by close of business May 23, 2025. A copy of loan contract to support financial solvency by close of business May 29, 2025. An exit interview was conducted Licensee Allen Medina, Maricel Nepomuceno, and Keak Vongphakdy. A copy of this report, LIC 809, was provided to Licensee Allen Medina, Maricel Nepomuceno, and Keak Vongphakdy.the state’s words, verbatim · CDSS document, May 22, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Rosendo “Carla” Miranda, Licensees Allen Medina and Marciel Nepomuceno. An application to operate an Residential Care Facility for the elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by CCL on January 4, 2024. Structure: The facility is a one-story house with five bedrooms, two full size bathrooms, two half bathrooms, one living room, one kitchen, one dining room, one activity room, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate on one side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the garage and underneath the kitchen sink. Resident & Staff Files: Records will be kept in a locked in a file cabinet. Medications, First-Aid Kit & Book: Medication will be stored in a locked in a cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements. Pool/Jacuzzi: No bodies of water were observed. Fire Extinguisher: Fire extinguisher is fully charged with service tag dated February 15, 2024. Reading Material, Games, Equipment & Materials: The facility has activity books, arts and crafts supplies, board games, puzzles, and other recreational materials for resident use stored in the activity room. Fire clearance: Was approved by a fire inspector of City of Costa Mesa Fire Prevention on August 14, 2024. Special conditions noted, “6 non-ambulatory residents.” Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. Bedrooms Staff: There is one staff bedroom. Bathrooms: All bathrooms have working plumbing. Hot water measured between 116.4- and 117.1 degrees Fahrenheit. Linens & Hygiene Supplies: A supply of extra linen was stored in a cabinet located in the activity room. Emergency Phone Numbers, Exit Plan: Posted and available, means of exiting, and emergency phone numbers. Food Service: A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand. Smoke Detectors: Smoke detectors and carbon monoxide detectors tested operational. Appliances: Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to designated AD.the state’s words, verbatim · CDSS document, Oct 9, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): COMP II Participants: ROSENDO CARLO MIRANDA-ADMINISTRATOR AND ALLEN MEDINA-APPLICANT Interview Method: Telephone interview On 8/28/24, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Aug 28, 2024