The Hills of Broadway

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit for a Case Management. LPA was greeted by Staff at 1:30pm and met with Administrator (AD) Shaleemar "Shy" Balignasay and explained the purpose of the visit. At time of entry the facility had a census of three residents. Three of three residents were in their bedrooms reclining after lunch. One resident was observed in bed reading a book and two were taking afternoon naps. AD Balignasay reviewed the Type A citations that were given on August 7, 2026 with LPA. Emails were also sent to LPA Taylor Simerly for the Type A Plan of Corrections. Medications were in a locked cabinet and a First Aid kit with the required elements was also observed. Three of three residents have complete medication lists and bed rail orders on file. LPA was introduced to two staff members who were background cleared and associated to the facility on August 10, 2026. Two of two new staff have not received their first paychecks until August 22, 2026. LPA reviewed personnel records and staff members had health screenings, tuberculosis testing and First Aid/ Cardiopulmonary Resuscitation Training. Both staff members have the initial hours of training which include: medications, hands-on shadow training, and several emergency disaster trainings. Plan of Corrections were sent to LPA Taylor Simerly. The facility was 79 degrees Fahrenheit and windows were open with a breeze. The facility was clean and all light fixture repairs were completed. A work order for air conditioning repair was placed but the owner will be (Continued on LIC 809-C) (Continued from LIC 809) changing the air conditioning system within the week. LPA measured the hot water temperatures in two of three resident bathrooms. The hot water temperature ranged from 110.2 to 114.9 degrees Fahrenheit. LPA confirmed that staff members who were not background cleared or missing health screening files no longer are employed at the facility. Licensee is obtaining a signed Admissions Agreement for one resident. The Administrator is reviewing and updating the Medication Administrator Record (MAR) and safety stove knobs were ordered for Plan of Corrections due on August 21, 2026. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Shaleemar "Shy" Balignasay and a copy of the report and files reviewed (LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Aug 18, 2026

Type of visit: Required - 1 Year

On August 7, 2026, Licensing Program Analysts (LPAs) Taylor Simerly and Joseph Alejandre conducted an unannounced annual visit. LPAs were greeted and granted entry by Staff. LPAs explained the purpose of today’s visit. Staff attempted to call both of the licensees but did not get an answer. Licensee (LI) Allen Medina later called back and stated that he would be on his way to the facility. LI arrived to help support the remainder of the visit. The facility is licensed to serve six elderly adults, of which six can be non-ambulatory. The facility has an approved hospice waiver for five. Currently the facility has four residents. The home consists of 6 resident bedrooms, living room with a screened fireplace, dining room, and kitchen as well as 4 bathrooms and a two car garage. LPAs and staff toured the physical plant. There were no bodies of water or obstructions on the premises. LPAs observed the PUB 475 poster, posted in the living room. LPAs inspected residents’ bedrooms and bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. LPAs observed each resident had a half bed rail on their bed. One out of four residents (R1) does not have an order for bed rails. Bathroom one did not have an operational light and bathroom two did not have an operational shower light, both bathrooms were clean and plumbing fixtures all worked. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 106°F to 111.8°F, and a comfortable temperature throughout. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPAs observed that the facility was clean and appropriately furnished. LPAs observed the 3 ceiling lights in the hallway were not operational. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there were sufficient perishable and non-perishable food available, which was adequately maintained. The cook-top range did not have the knobs removed for safety. The fire extinguisher in the kitchen was charged and operable. The last fire drills were not available for review. The facility does not have a first aid kit on site, a citation is being issued. The backyard has a dedicated shaded area for resident use. There are no bodies of water located in the backyard and the gates were operational. A review of (4) residents' service files and (3) staff personnel files was conducted. R1 did not have a signed Admission Agreement and R1 and R4 did not have Need Care Plans on file. S1, S2 and S3 were missing training on file. S1 did not have a file at the facility. There was no health screening, CPR training or initial training documents for S1. LPA reviewed (1) Medication Administration Records (MARs) and found discrepancies. R2 was missing two medications that they are prescribed, Docusate-Senna and Xyzal. Medication was also found unsecured in the kitchen island. Facility has a dedicated internet device for resident use. LPAs observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See D page for details. An exit interview was conducted, and a copy of the Facility Evaluation Report and appeal rights were provided to Allen Medina, Licensee.the state’s words, verbatim · CDSS document, Aug 7, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Rose Ruppert arrived unannounced to conduct a Case Management Deficiencies Visit. LPA was greeted and granted entry by Staff #1 (S1) at 11am. LPA explained the purpose of the visit with staff and spoke to Licensee (LE) Maricel Nepomuceno over the phone. The facility currently has five residents in care. LPA interviewed two of five alert residents regarding the care provided at the facility and spoke to two of two staff members regarding care being given. Two of two staff members confirmed they were not paid on 7/22/2026 for the pay period of 7/1-7/15/2026 and one of one staff had additional back pay owed. A penalty, LIC 421FC, will be assessed for finances in the amount of $100 per day X 23 days for the amount of $2300. LPA spoke with Licensee (LE) regarding staff not being paid and LE stated staff were advised that accounts had fraudulent activity and would be restored within ten business days. One of two staff members at the facility is background cleared but is not associated to the facility. A civil penalty, LIC421IM, will be given for the amount of $500. LE was advised to associate the staff member to the facility location by end of visit. The Department did not receive notification that there is currently not an Administrator at this location. A deficiency will be given and LE will designate an Administrator to the facility by Plan of Correction date of 7/31/2026. Total amount assessed during today's visit is $2800. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Staff #1 (S1) and a copy of this report was given to the facility along with a copy of the LIC 809-D, LIC421FC, LIC421IM and Appeal Rights.the state’s words, verbatim · CDSS document, Jul 30, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(d)(3) · Plan of correction due date: Jul 31, 2026

87355 (d) All individuals subject to criminal record review shall be fingerprinted... (3) The licensee shall submit these fingerprints to the California Department of Justice, along with... the Federal Bureau of Investigation... prior to the individual's employment, residence, or initial presence in the facility. (Cont'd) This requirement was not met as evidenced by: Based on LPA's file review and interviews, Staff #2 (S2) was not associated to the facility. This poses an immediate health and safety risk to persons in carethe state’s words, verbatim · CDSS document, Jul 30, 2026

Plan of correction: Licensee will associate S2 prior to LPA leaving the facility and will email LPA two of two staff personnel records by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405 · Plan of correction due date: Jul 31, 2026

87405 Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator ...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for (Cont'd) management and administration of the facility as specified in this section... This requirement was not met as evidenced by: CCL did not receive notification regarding a new Administrator. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 30, 2026

Plan of correction: Licensee will designate an Administrator and email LPA with documentation by POC due date.

Allegation investigated: Facility did not issue responsible party proper refund.

On July 29, 2026, Licensing Program Analysts (LPAs) Brandon Lopez and Tran Nguyen made an unannounced visit to the facility to initiate the investigation into the allegation listed above and to deliver the complaint findings. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Licensees Allen Medina and Maricel Nepomuceno were notified via telephone but was unable to assist with today's inspection. During the course of the investigation, LPAs conducted staff interviews, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, facility did not issue responsible party proper refund, the following has been concluded: It was alleged that the facility did not issue responsible party proper refund for Resident #1 (R1). During the investigation, LPAs conducted a file review for R1, including R1's admission agreement. LPAs observed that R1 was admitted to the facility on May 2, 2025. LPAs observed that the admission agreement was signed by R1's Responsible Party, Witness #1 (W1), and a facility representative, indicating that both parties agreed to the terms of the admission agreement. CONTINUED ON LIC9099-C Substantiated LPAs observed that on page five of R1's admission agreement, is states, "Per community policy, the admission agreement is automatically terminated on the date of the resident's death. The responsible party will not be responsible for any charges after the resident's date of death." On page five, it also states, "Within 3 days of the resident's death, the community shall send a copy of this admission agreement to serve as a reminder that the admission agreement terminates upon the resident's date of death and that no further payment is required and that there is no fee for storing the resident's property..". LPAs conducted an interview with R1's responsible party, W1. W1 stated that R1's rent was paid in full for the month of June 2025, which was in the agreed amount of $8,500.00. W1 stated that R1 passed away on June 7, 2025, and the facility did not issue them a refund for the remaining twenty three days of June 2025, as agreed upon in the admission agreement. W1 stated that they are currently owed $6,516.59. W1 stated that they also sent the facility a demand letter to the Licensees on May 26, 2026, regarding the refund for R1, but that the they still has not issued them a refund. LPAs reviewed a bank statement that confirmed that W1 made a payment in the amount of $8,500.00 for R1's monthly rent for June 2025. LPAs also reviewed the certificate of death for R1 which confirmed that R1 passed away on June 7, 2025. LPAs conducted an interview with Licensee Maricel Nepomuceno. The Licensee admitted that a refund had not been issued to W1 after R1 passed away on June 7, 2025. The Licensee confirmed that W1 is currently owed the remaining twenty three days for R1's June 2025 rent. The Licensee also confirmed that they also received the demand letter from W1 on May 26, 2026. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, facility did not issue responsible party proper refund. The preponderance of evidence standards has been met; therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D. An exit interview was conducted via telephone with Licensee Maricel Nepomuceno. A copy of the report and appeal rights were provided to an authorized facility representative at time of visit.the state’s words, verbatim · CDSS document, Jul 29, 2026 · control 22-AS-20260724150920

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Aug 7, 2026

87507 Admission Agreement: (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not evidenced by: Based on interviews conducted and records reviewed, the Licensee did not ensure that a refund was issued to Resident #1's responsible party after her death. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2026

Plan of correction: The Licensee stated that they will issue a refund to Resident #1's responsible party for the remaining twenty three of June 2025. The Licensees agreed to provide LPA proof of the refund via email or fax by POC due date.

Type of visit: Case Management - Health Checks

On July 29, 2026, Licensing Program Analysts (LPAs) Brandon Lopez and Tran Nguyen made an unannounced visit to the facility to conduct a Case Management - Health Checks. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Licensees Allen Medina & Maricel Nepomuceno were notified via telephone but were unable to assist with today's inspection. On today's visit, there are five residents in care and there were two care giving staff present. LPAs, accompanied by a care giving staff, conducted a tour of the physical plant. LPAs inspected the six resident bedrooms and observed them to be free of hazards. LPAs observed the lights in each of the resident's bedroom to be operational. LPAs observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPAs observed resident beds to have clean linens and blankets. LPAs inspected the four bathrooms located in the facility. LPAs observed bathrooms to be clean. Bathrooms are equipped with grab bars and non-skid floor mats. Hot water temperature measured between 109.9 and 111.7 degrees Fahrenheit. LPAs inspected the facility's kitchen area and observed it to be clean. LPAs observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPAs observed the facility has a three day emergency food and water supply stored in the pantry. LPAs, accompanied by a care giving, conducted a tour of the exterior portions of the facility. LPAs observed the exterior to be free of any hazards or obstructions. No health or safety concerns were observed during the visit. LPAs observed all of the facilities utilities to be operational during the visit. LPAs additionally conducted interviews with two staff during the visit. CONTINUED ON LIC809-C Both staff interviewed stated that they have not been paid for the hours they have worked at the facility. LPAs also reviewed the facilities utility bills for the month of June 2026, including the electricity, gas, and water. LPAs observed that the facility has a past due balance on their electricity bill in the amount of $534.31. Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D page. A civil penalty will also being assess in the amount of $250.00, since the Licensees were previously issued a citation for California Code of Regulation Title 22 Section 82713 on July 7, 2026. An exit interview was conducted with Licensee Maricel Nepomuceno via telephone. A copy of the report and appeal rights were provided to an authorized facility representative at time of visit.the state’s words, verbatim · CDSS document, Jul 29, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Jul 30, 2026

87213 Finances: The licensee shall have a financial plan.. shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency... This requirement was not evidenced by: Based on records reviewed and interviews conducted, the Licensees do not have a sufficient financial plan as they have a past due balance in their electricity bill and owe wages to two staff. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2026

Plan of correction: The Licensees stated that they will provide LPAs a written financial plan on how they will address the past due balance in electricity and the owed wages to staff. The Licensees agreed to provide LPA the written plan via email or fax by POC due date.

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 114.6 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed sufficient perishable and non-perishable food in the kitchen. LPA observed utilities on and operational. LPA observed six residents in the dining room having breakfast. Interviews with one out of two staff stated they are owed back pay. LPA observed notification of the proceedings to revoke the license posted at the facility for review. Resident 1 (R1)'s file did not contain a signed admission agreement, a signed personal rights document (LIC613C), incomplete information on the identification page (LIC601), and incomplete information and missing licensee/administrator signature on R1's appraisal (LIC603A). One out of two staff did not have evidence of a health screening, TB test, personnel record, and required training. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A civil penalty is being assessed for a repeat violation. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Jul 7, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Jul 8, 2026

87213 The licensee shall have a financial plan that [...] assures sufficient resources to meet operating costs for care of residents; shall maintain adequate finances. The requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure employees are receiving their paychecks timely or the full amount. This poses an immediate health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: AD stated licensee text AD back pay has begun and will be paid by tomorrow.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Jul 8, 2026

87412(a) Personnel Records The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. The requirement is not met as evidenced by: Based on interviews conducted and observations, there is no evidence of personnel records for one out of two staff which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: AD stated staff records will be sent by end of today via email to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jul 8, 2026

87506(a) Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. The requirement is not met as evidenced by: R1 does not have a complete record of the admission agreement, personal rights, appraisal, and identification page with poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: AD stated all completed resident records will be sent to LPA via email by POC due date.

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 113.9 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed sufficient perishable and non-perishable food in the kitchen. LPA observed utilities on and operational. LPA observed five residents in the dining room having breakfast. Interviews with one out of one staff stated they are owed back pay. LPA observed notification of the proceedings to revoke the license posted at the facility for review. A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. A civil penalty is being assessed for a repeat violation. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Jun 26, 2026

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

87213 The licensee shall have a financial plan that [...] assures sufficient resources to meet operating costs for care of residents; shall maintain adequate finances. Based on interviews conducted, the Licensee did not ensure employees are receiving their paychecks timely or the full amount. This poses an immediate health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Jun 26, 2026

Plan of correction: AD Carla Miranda stated Licensee Allen Medina would pay all back payments to staff by end of weekend 6/28/2026. AD to provide proof to LPA by POC due date.

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 113.9 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed sufficient perishable and non-perishable food in the kitchen. LPA observed utilities on and operational. LPA observed two residents in the living room and three residents in their rooms. Interviews with two out of two staff stated they are owed back pay. LPA observed notification of the proceedings to revoke the license posted at the facility for review. A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. A civil penalty is being assessed for a repeat violation. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Jun 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Jun 10, 2026

87213 The licensee shall have a financial plan that [...] assures sufficient resources to meet operating costs for care of residents; shall maintain adequate finances. Based on interviews conducted, the Licensee did not ensure employees are receiving their paychecks timely or the full amount. This poses an immediate health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Jun 9, 2026

Plan of correction: Licensee Allen Medina stated an updated financial plan will be submitted to LPA by POC due date to ensure back pay is paid timely.

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 112.2 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed sufficient perishable and non-perishable food in the kitchen. LPA observed utilities on and operational. LPA observed five residents having breakfast in the dining area and one resident in their room. The Department began proceedings to revoke the license for the facility effective May 7, 2026. The facility is required to notify all residents and responsible parties in writing within 10 days regarding the commencement of revocation of the license. LPA spoke to five out of six responsible parties over the phone. The five responsible parties have not been notified of the commencement of revocation of the license. There is no notification of the proceedings to revoke the license posted at the facility for review. 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, May 20, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.38(b)(1) · Plan of correction due date: May 21, 2026

1569.38(b)(1) Posting of licensing reports A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following...: The department commences proceedings to... revoke the license of the facility... The requirement is not met as evidenced by: Five responsible parties have not been notified of the proceedings which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 20, 2026

Plan of correction: AD stated all responsible parties and ombudsman will be notified by certified mail regarding the commencement of revocation. AD to submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.38(e) · Plan of correction due date: May 21, 2026

1569.38(e) Posting of licensing reports Upon providing the notice described in subdivision (b), the licensed residential care facility shall also post a written notice, in at least 14-point type, in a conspicuous location in the facility, that may include posted... any other easily accessible location in the facility. The posting shall include all of the following information: The requirement is not met as evidenced by: LPA did not observe any posting regarding the revocation at the facility. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 20, 2026

Plan of correction: AD stated the legal accusation document will be posted at the facility. AD to send photo of posting 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 113.1 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed sufficient perishable and non-perishable food in the kitchen. LPA observed utilities on and operational. LPA observed six residents having breakfast in the dining area. One out of two staff stated they are owed back pay. A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. A $250 civil penalty is being assessed for a repeat violation. See LIC421FC. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, May 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: May 5, 2026

87213 Finances The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents... This 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, This poses an immediate health and safety risk to persons in care. Civil Penalty Assessed.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: Licensee Allen Medina stated he will provide proof of salary payments for all staff at the facility for the month of April through present 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 113 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed sufficient perishable and non-perishable food in the kitchen. LPA observed utilities on and operational. LPA observed four residents watching TV in the living room and one resident in their room. LPA asked one out of one staff if they have been paid on time and staff member stated they have been paid in full. Although the staff stated they have been paid in full, the licensee failed to provide proof of staff payments by proof of correction due date of April 11, 2026. A civil penalty is being assessed. An exit interview was conducted and a copy of this report was provided to Administrator Carla Miranda Ward.the state’s words, verbatim · CDSS document, Apr 21, 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 112.6 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed sufficient perishable and non-perishable food in the kitchen. LPA observed utilities on and operational. LPA observed five residents finishing breakfast in the dining area. LPA asked one out of two staff if they have been paid for services and staff stated they have been partially paid. Deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. A $250 civil penalty is being assessed for a repeat violation. See LIC421FC. 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 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Apr 11, 2026

87213 Finances The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents... This 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, This poses an immediate health and safety risk to persons in care. Civil Penalty Assessed.the state’s words, verbatim · CDSS document, Apr 10, 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 - 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 109.5 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed sufficient perishable and non-perishable food in the kitchen. LPA observed utilities on and operational. LPA observed five residents having breakfast in the dining area. The licensee was unable to provide documents requested as agreed upon and as noted during a noncompliance conference held on February 10, 2026. LPA observed one staff member who was not associated to the facility and did not have evidence of a health screening. LPA associated staff member during visit. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An immediate $100 civil penalty is assessed. An additional $600 civil penalty is being assessed for a repeat violation. See LIC421BG and LIC421FC. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Apr 1, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Apr 2, 2026

87355(e)(3) Criminal Record Clearance All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: The licensee did not request or complete a transfer of one staff member's criminal record clearance which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: LPA assisted with the transfer of the criminal record clearance during the visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(f) · Plan of correction due date: Apr 15, 2026

87411(f) Personnel Requirements All personnel...shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening...performed by a physician... This requirement is not met as evidenced by: One staff member did not have evidence of a health screening which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: AD stated the health screening will be sent to LPA by POC due date.

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 113.3 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed sufficient perishable and non-perishable food in the kitchen. LPA observed utilities on and operational. LPA observed five residents having coffee or water in the dining area. The licensee was unable to provide documents requested as agreed upon and as noted during a noncompliance conference held on February 10, 2026. A civil penalty is being assessed for a repeat violation. See LIC421FC. 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 112.6 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed sufficient perishable and non-perishable food in the kitchen. LPA observed utilities on and operational. LPA observed three residents watching TV in the living room and two residents in their rooms. The licensee was unable to provide documents requested as agreed upon and as noted during a noncompliance conference held on February 10, 2026. A civil penalty is being assessed for a repeat violation. See LIC421FC. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Mar 19, 2026

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) at 10:30am. Staff notified Administrator (AD) Rosendo "Carla" Miranda Ward of the purpose of the visit. Upon entry, LPA greeted three of four residents who were watching Little House on the Prairie. The three residents greeted LPA and were engrossed in the television show. LPA observed four of four residents were groomed and dressed for the day. LPA spoke to the fourth resident, who was on the Internet in their bedroom. There were no odors detected and facility was clean. A gardener was outdoors watering the lawn. The facility temperature was 68 degrees. LPA observed utilities were in working order. The refrigerator had two days of perishable items and there were seven days of non-perishable items on hand. A grocery order was delivered on March 10, 2026. LPA measured the hot water temperature in two of two bathrooms. The temperature ranged between 113.7 to 114.6 degrees Fahrenheit. LPA interviewed two of two staff who stated they received partial payment for the pay period 2/4-2/18/2026 on March 11, 2026. Staff are unsure when the remainder of the payroll would be distributed. The facility has current liability insurance and the Plan of Correction was cleared on March 9, 2026. A Civl Penalty will be assessed for 87213 Finances from 3/4-3/11/2026 at $100/day X 8 days. Total amount assessed is $800. The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Staff #1 (S1) and a copy of this report was given to the facility along with a copy of the LIC 421-FC.the state’s words, verbatim · CDSS document, Mar 11, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management visit and health and safety visit. LPA was greeted and granted entry by Staff #1 (S1) at 8:30am. LPA spoke with Administrator (AD) Rosendo "Carla" Ward via phone. AD was at another facility and was not able to come for the visit. LPA toured the facility and observed the water/trash, electricity, internet/cable, and gas were operational. The refrigerator had the minimum of two-days perishables and pantry had seven-days of non-perishable food on hand. S1 showed LPA the current grocery order that will be delivered to the facility today. The facility was clean and there were no odors detected. The facility was at a comfortable temperature of 69 degrees. LPA conducted a health and safety check on five of five residents in care. Two of five residents were having breakfast and one resident was awaiting a family member to go to an appointment. LPA observed a fourth resident in the bedroom on the Internet and a fifth resident was not feeling well in their bedroom. LPA interviewed four of five residents regarding their quality of care. Four of five residents shared they have great care from the two staff members present, the utilities have remained on and they have plenty of food choices. LPA interviewed AD via phone and two of two staff members. AD stated the facility has current liability insurance and it was emailed to LPA during the time of the visit. AD and two of two staff members shared they were not paid for the last pay period of 2/04/26-2/18/26. LPA toured the exterior of the property and exterior is maintained and there are no hazards or obstructions in pathways. (Continued on LIC 809-C) (Continued from LIC 809) The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations and Health and Safety Code. A Civil Penalty is being assessed for Failure to Correct/Repeat Violation at $100 per day from 2/27/26-03/03/26 for five days. Total assessed is $500. 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-FC.the state’s words, verbatim · CDSS document, Mar 3, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced health and safety case management visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Carla was available via telephone. 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 breakfast to be eggs, toast with peanut butter and refried beans with salsa. LPA observed two day perishables and seven day non-perishables as well as emergency food and water. Interviews with staff indicated the staff were still owed wages from their last paycheck and were unsure when the wages owed would be paid. LPA Mendivil observed facility temperature to be 67 degrees, staff stated heater has not worked for about 1 month. Facility was cited for this issue on 02/20/2026 and it has not been corrected. A civil penalty issued for failure to correct. 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 112.6 degrees Fahrenheit. LPA observed the kitchen is clean and organized. At 8:45am, LPA did not observe a seven day supply of non-perishable food at the facility for residents. At 9:10am, LPA observed the thermostat temperature at 61 degrees Fahrenheit. The heating elements in the home were observed to be non-functional. LPA observed utilities on and operational. LPA observed two residents having breakfast in the dining area and four other residents in their rooms. 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. A civil penalty is being assessed for a repeat violation. See LIC421IM. 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(26) · Plan of correction due date: Feb 21, 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 nonperishable food for a minimum of one week 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 placed an order of food during the visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(b)(1) · Plan of correction due date: Feb 21, 2026

87303(b)(1) Maintenance and Operation The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement is not met as evidenced by: LPA observed the temperature of the facility at 61 degrees F 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 an appointment for AC/Heating services will be made today for service today or tomorrow to repair the heating element. Adminstrator to provide proof of repair 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 between 112.6 and 113 degrees Fahrenheit. LPA observed the kitchen is clean and organized. At 9:20am, LPA did not observe a two day supply of perishable food at the facility for residents. LPA observed utilities on and operational. LPA observed residents having breakfast and later in the living room watching TV. LPA reviewed facility records obtained. 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 been placed and will be delivered today. AD will send a picture of the food delivery along with receipt 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 between 112.6 and 113.5 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 and inspected the facility and observed no health and safety issues. The facility is in good repair. Property utilities are 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 in care and observed no health or safety concerns. LPA interviewed residents in care and staff. Based on the observations made during today’s inspection, no deficiencies are being cited at this time. An exit interview was conducted and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Oct 24, 2025

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 6 residents, with 1 resident on hospice. Administrator (AD) Carla Miranda arrived shortly to conduct facility tour. LPA along with AD toured the facility at 1:40 PM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of 6 resident bedrooms, living room, dining room, and kitchen as well as 4 bathrooms. At 1:41 PM, LPA observed the cabinet under the kitchen sink unlocked containing sharps and cleaning chemicals. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. 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 between 109.4 degrees F and 114.4 degrees F in all bathrooms check. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguisher was fully charged. 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 07/18/2025. 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. First aid kit contained all required items including tweezers, scissors and thermometer. Continued on LIC809-C dated 08/08/2025 Facility conducts activities in the form of exercise and games. LPA observed the emergency food and water supply. LPA reviewed six resident files and two staff files. All resident files contained required documentation including admission agreements, physician reports, and resident appraisals. 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. Medications are being administered per physician order. 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, Aug 8, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. 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 four residents in care. LPA observed there were two staff on site. Caregivers were observed to be assisting residents and cleaning facility. 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 109.4 and 111.7 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 staff. There is shaded area for residents. Outside grounds were free of hazards at the time of visit. LPA reviewed 2 staff files and 4 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) Jessica Cho conducted an announced subsequent Pre-Licensing visit to follow-up on the issues that were present during the initial visit on August 6, 2024. LPA Cho was allowed entry and met with Applicant Maricel Muceno and Administrator Rosendo MIranda. The following items required correction: To deep clean the kitchen appliances, inside the refrigerator/freezer, kitchen drawers/pantries, entire floor, and all bathrooms including showers. To treat stains/spots on furniture. To organize and remove clutter in the garage. To repair the leak from the garage refrigerator, install a missing drawer handle in the kitchen drawer, holes in the hallway(s) To spot treat/paint the walls, doors, and kitchen cabinetry On today's visit the aforementioned items have been addressed and corrected. The items reviewed during this visit are in compliance. The Pre-Licensing is now complete. The licensee will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. Component III is waived due to the applicant operating licensed facilities and having completed Component III. LPA provided a refresher consultation in the initial answering questions for the Applicant. This concludes the Pre-Licensing inspection. An exit interview was conducted with Applicant Maricel Muceno and Administrator Rosendo Miranda, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Aug 15, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility announced for the purpose of conducting a Pre-Licensing visit for a change of ownership using the Care Inspection Tool. LPA conducted the visit with Applicant Maricel Nepo, Administrator Rosendo Miranda and Quality Assurance Specialist (QAS) Brian Mahinay. An initial application to operate a Residential Care Facility for the Elderly (RCFE), age range 60 and over, for (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by the Department of Social Services on August 28, 2023. LPA toured the interior and exterior portion of the facility and observed the following accompanied by the Applicant , Administrator, QAS: Structure: The facility is a single story residential property comprised of six resident bedrooms, five resident bathrooms with full baths, a living room, dining area, kitchen, storage room, an attached laundry room/two car garage, and a backyard. There is a private home behind the facility on the same lot with a private entry that will be occupied by the Administrator. The address is 354 Unit B Broadway, Costa Mesa, CA 92626. The backyard has two exit gates on one side of the property. There is a shaded seating area. LPA did not observe any obstacles or hazards in the backyard. One door inside the house is delayed egress and approved via fire clearance. Signal System: The facility utilizes a signal system where staff is alerted from a central location (kitchen). Bedrooms: The resident bedrooms had all required components, are spacious, and easily accommodates the residents’ furnishings. Bathrooms: Bathrooms were not clean. Grab bars were secure. Linens and Hygiene Supplies: Clean linens were observed to be fully stocked. Appliances: Stove burners, microwaves, washers, and dryers were inspected and operable. Appliances require a deep cleaning. Resident and Staff Files: Resident and staff records will be maintained on site. Reading Material, Games, Equipment, & Materials: The facility maintains reading material and games in the facility. Emergency Phone Numbers/Exit Plan: Posted in the entry way area and available for review. Postings: The See Something, Say Something (PUB475) and the Ombudsman Posters were posted in the entry area of the facility. The Rights of the Resident Councils, Resident's Rights, Theft & Loss Policy, Activity Schedule, and Admission Agreement were posted and is accessible in the state folder in the entry way. Food Service and Menu: Supply of seven day non-perishable and two day perishables were observed. The sample menu was available for review. The emergency food/water supply was stored in the garage. Smoke and Carbon Monoxide Detectors: The dual purpose smoke detector and carbon monoxide alert systems were tested and found to be operational. Fire Extinguishers: Two fire extinguishers were mounted, fully charged, and serviced on October 4, 2023. Fire Clearance: Approved on July 10, 2024 for 6 non-ambulatory residents. Toxins and Sharps: Cleaning supplies, toxins, and sharps were secured and inaccessible. Water Temperature: The water temperature in the resident bathrooms measured at 111.7, 113.7, 114.0, 111.9, and 110.1 degrees Fahrenheit. Medications, First Aid Kit & Manual: The First Aid Kit was checked and found to be in order. The facility has the current edition of the First Aid Manual. Component III: Component III is waived due to the applicant operating licensed facilities and having completed Component III previously. The following items need correction prior to licensure: To deep clean the kitchen appliances, inside the refrigerator/freezer, kitchen drawers/pantries, entire floor, and all bathrooms including showers. To treat stains/spots on furniture. To organize and remove clutter in the garage. To repair the leak from the garage refrigerator, install a missing drawer handle in the kitchen drawer, holes in the hallway(s) To spot treat/paint the walls, doors, and kitchen cabinetry Facility does not appear ready for licensure. Any items noted above during today’s visit are to be corrected by An exit interview was conducted with Applicant Joanne Casten, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Aug 6, 2024