The Hills of Canadian

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 staff who arrived shortly after and explained the reason for the visit. Licensees Maricel Nepomuceno and Allen Medina and Administrator Rosendo Carlo Miranda arrived shortly after. 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 the furniture will be moved out. LPA observed items packed in plastic containers. LPA observed no signs of residents or the facility in operation. Licensee Allen Medina stated that they did not issue an written 60 day eviction notice to the five residents that were relocated to different facilities. Licensees informed LPA that last client's day on site was on July 23, 2025. LPA requested the facility license as it is part of the closure process, and the license was surrendered during the visit. LPA informed the above facility representatives of the licensing procedure for future facility operation if desired. The Department will proceed with the closure as of July 29, 2025. Deficiencies are being cited on the attached LIC809-D. An exit interview was conducted with Administrator Rosendo Carlo Miranda. A copy of the report and Appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.682(a)(2) · Plan of correction due date: Jul 30, 2025

1569.682 Transfer of resident upon forfeiture of license or change in use of facility... : (a)... prior to transferring a resident.... (2) 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 evidenced by: The licensee failed to provide a 60 day written notice to the residents that were relocated to a different facility. This poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Licensee agreed to complete a statement of understanding regarding the regulation listed. Licensee agreed to submit the statement of understanding to LPA via email or fax by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(d) · Plan of correction due date: Aug 5, 2025

87211 Reporting Requirements: (d) The licensee shall notify the Department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their representatives, in writing within two business days of any of the following specified events, or knowledge thereof: This requirement was not evidenced by: LPA connected with the landlord via email who stated that the facility was one month behind on rent. This information was not disclosed to the Department prior. This poses/posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Licensee agreed to complete a statement of understanding regarding the regulation and agreed to keep the department informed on any future events. The Licensee agreed to submit the statement of understanding to LPA via email or fax by POC date.

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 Mercy Falcon, Care Staff and explained the nature of the visit. The facility has five 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, restrooms, bedrooms, and common areas. LPA inspected facility bathrooms and hot water temperature was measured between 113.7 and 116.2 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 Administrator Rosendo Miranda. There is shaded area for residents. Outside grounds were free of hazards at the time of visit. LPA reviewed 2 staff files and 2 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) Joseph Alejandre made an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicant Maricel Nepomuceno and toured the facility. An initial application to operate an Residential Care Facility for the Elderly (RCFE) was submitted to CCL on June 13, 2024. The facility is to have a capacity of 6 non-ambulatory residents with zero (0) bedridden. LPA observed the following. This is a change of ownership application with residents in care. Facility phone number is 714-617-4516. LPA observed the PUB 475 poster posed in the entry way. Structure: The facility is a single story house with an attached 2 car garage with 5 bedrooms (room 1 is for staff, bedrooms 4, 5 can be shared), 4 bathrooms, living room with a screened fireplace, dining room and a kitchen. Air/Heating: Central air/heating system installed with a central panel to control entire house. The air conditioning was operating during the visit. Resident Bedrooms: There are 4 resident Bedrooms. The bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings and linens. Medications, First-Aid Kit & Book: The first aid kit and the first aid manual are stored in the dining room. The first aid kit has all the required elements. Medications will be stored in the closet next to the kitchen and kept locked. Reading Material, Games, Equipment & Materials: Magazines and games are stored in the living room. There is a large screen TV mounted in the living room. At this time the facility does not have internet access. Fire clearance: Fire Clearance approved by the Costa Mesa Fire Department Inspector Arnold Antonio on July 10, 2024. Component III: Component three waived. Applicant is a Licensee/Administrator of a Licensed Facility. The facility is ready to be licensed. Applicant was informed today that the final approval will be processed by CAB (Central Applications Bureau) in Sacramento. Exit interview was conducted and a copy of this report was left with the applicant. Bathrooms: All four bathrooms are clean and operational. Linens & Hygiene Supplies: Adequate supply of linen stored in hall closet. Extra hygiene supplies are stored in the garage. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food served for one week. Food Service: LPA observed a two day perishable and a seven day non-perishable food supply on hand in the kitchen in the kitchen. Smoke Detectors/Carbon Monoxide Detectors: Smoke detectors/carbon monoxide detectors tested operational. The fire extinguisher in the kitchen and the fire extinguisher in the hallway are fully charged. Appliances: There is a 5 burner gas stove, an oven, microwave oven, dishwasher and refrigerator in the kitchen. The washer and dryer are in the garage. All appliances are clean and operational. Toxins: The cleaning supplies are kept locked in the garage. Water Temperature: Hot water measured 116.8 degrees Fahrenheit in all bathrooms. Resident & Staff Files: The Resident and Staff Records will be kept locked in the closet next to the kitchen.the state’s words, verbatim · CDSS document, Aug 19, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 4 COMP II Participants: Maricel Nepomuceno (Corp. Board Member) & Rosendo Carlo Miranda (Administrator) Interview Method: Virtual interview via Microsoft Teams On July 18, 2024, applicant(s)/administrator participated in COMP II for the below pending facilities: The Hills of Canadian/306006405, The Hills of Broadway/306006406. Identification of the applicant(s) and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant(s) 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, Jul 18, 2024