The Hills of Highland

Type of visit: Case Management - Health Checks

On August 24, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Heddymae Oyson was present and also assisted on today's visit. On today's visit, there are five residents in care and there were two care giving staff present. LPA, accompanied by the AD, conducted a tour of the physical plant. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed the lights in each of the resident's bedroom to be operational. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA inspected the five bathrooms located in the facility. LPA observed bathrooms to be clean. Bathrooms are equipped with grab bars and non-skid floor mats. Hot water temperature measured between 96.8 and 97.3 degrees Fahrenheit. LPA inspected the facility's kitchen area and observed it to be clean. LPA observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed the facility has a three day emergency food and water supply stored in the pantry. LPA, accompanied by the AD, conducted a tour of the exterior portions of the facility. LPA 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 and five residents during the visit. LPA also conducted an interview with the landlord of the property, Witness #1 (W1) during the visit. W1 said that the facility did not pay their August 2026 monthly rent and current has an outstanding balance of approximately $82,000.00, which includes past owed rent, late fees, and property taxes owed. W1 also said that there is currently no installment agreement to address the facility's outstanding rent balance. CONTINUED ON LIC809-C W1 also shared that he received the following email Licensee Allen Medina which states the following: "...Full transparency, CDSS and their legal team can expedite NEW licenses because of our situation. They have also put down some stipulations for us as we transfer the business over to a new operation and licensee". However, there is currently no written agreement between CDSS and Licensee Allen Medina to expedite any facility license. Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-D pages and civil penalties will be assessed. A civil penalty will be issued for a repeat violation in the amount of $250.00 since the Licensee was previously issued a citation for California Code of Regulation Title 22 Section 87303(e)(2) on July 28, 2026. A second civil penalty will be issued for a repeat violation in the amount of $250.00 since the Licensee was previously issued a citation for California Code of Regulation Title 22 Section 87213 on July 6, 2026. An exit interview was conducted with Administrator Heddymae Oyson. A copy of the report and appeal rights were provided to the facility at time of visit.the state’s words, verbatim · CDSS document, Aug 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Aug 25, 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 interviews conducted, the Licensee does not have a sufficient financial plan as the have an outstanding rent balance of $82,000.00. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 24, 2026

Plan of correction: The Licensee stated that he will provide LPA a written financial plan on how they will address the outstanding rent balance. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87207 · Plan of correction due date: Aug 31, 2026

87207 False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not evidenced by: Based on interviews and records reviewed, the Licensee made a false & misleading statement to the landlord of the property regarding an agreement with CDSS to expedite the facility license. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 24, 2026

Plan of correction: The Licensee stated that he will review the regulation cited and will complete a statement of understanding. The Licensee agreed to provide LPA the statement via email or fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Aug 31, 2026

87303 Maintenance and Operation: (e) Water supplies ..shall be maintained as follows: (2) Faucets .. shall deliver hot water. Hot water .. shall be maintained .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not evidenced by: Based on observations, the Licensee did not ensure that the facility's water was within regulatory requirements as the hot water temperature measured between 96.8 and 97.3 degrees Fahrenheit. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 24, 2026

Plan of correction: The Administrator stated that she will adjust the hot water temperature to be within regulatory requirements. The Administrator agreed to provide LPAs a hot water temperature log once the water has been adjusted and will provide LPAs the log via email of fax by POC due date.

Type of visit: Case Management - Health Checks

On July 28, 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. Administrator (AD) Heddymae Oyson was present and also assisted on today's visit. On today's visit, there are five residents in care and there were two care giving staff present. LPAs, accompanied by the AD, conducted a tour of the physical plant. LPAs inspected the five 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 five 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 97.8 and 100.5 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 the AD, conducted a tour of the exterior portions of the facility. LPAs observed the exterior to be free of any hazards or obstructions. LPAs conducted an interview with the landlord of the property, Witness #1 (W1) during the visit. W1 said that the facility only paid a portion of their July 2026 rent and current has an outstanding balance of $70,200.00, which includes past owed rent, late fees, and property taxes owed. W1 also said that there is currently no installment agreement to address the facility's outstanding balance. CONTINUED ON LIC809-C 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 and five residents during the visit. Based on the observations made during today's visit, one deficiency is being cited on the attached LIC809-D page. A civil penalty will also be issued in the amount of $250.00 since the Licensee was previously issued a citation for California Code of Regulation Title 22 Section 87303(e)(2) on July 6, 2026. An exit interview was conducted with Administrator Heddymae Oyson. A copy of the report and appeal rights were provided to the facility at time of visit.the state’s words, verbatim · CDSS document, Jul 28, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Aug 7, 2026

87303 Maintenance and Operation: (e) Water supplies ..shall be maintained as follows: (2) Faucets .. shall deliver hot water. Hot water .. shall be maintained .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not evidenced by: Based on observations, the Licensee did not ensure that the facility's water was within regulatory requirements as the hot water temperature measured between 97.8 & 100.5 degrees Fahrenheit. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: The Administrator stated that she will adjust the hot water temperature to be within regulatory requirements. The Administrator agreed to provide LPAs a hot water temperature log once the water has been adjusted and will provide LPAs the log via email of fax by POC due date.

Type of visit: Case Management - Health Checks

On July 6, 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. Administrator (AD) Heddymae Oyson was present and also assisted on today's visit. On today's visit, there are five residents in care and there were two care giving staff present. LPAs observed residents to be in clean clothes. LPAs, accompanied by the AD, conducted a tour of the physical plant. LPAs inspected the five 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 five 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 124.3 and 126.1 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 the AD, conducted a tour of the exterior portions of the facility. LPAs observed multiple trash bags, boxes, and unused furniture on the southside of the facility. LPAs also observed palm tree branches, leaves, and debris to be present in the walkways. LPAs observed the palms trees have not been trimmed and the bushes to be overgrown. LPAs conducted an interview with the landlord of the property, Witness #1 (W1) during the visit. W1 said that the facility did not pay the July 2026 rent and currently has an outstanding balance of $65,500.00, which includes past owed rent, late fees, and property taxes. CONTINUED ON LIC809-C W1 also said that there is currently no installment agreement to address the facility's outstanding balance. On May 8, 2026, the Department notified the Licensees that they have began proceedings to revoke the license of the facility. Per Health and Safety Code Section 1569.38(e): "(e) 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 where the mail boxes are located, where the facility license is posted, or any other easily accessible location in the facility. The posting shall include all of the following information:" On today's visit, LPAs observed that the facility did not have a copy of the notice posted in the facility. 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 three staff and five residents during the visit. Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809D pages. The Licensee will be issued a civil penalty for a repeat violation in the amount of $250.00, since the Licensee was previously issued a citation for California Code of Regulation Title 22 Section 82713 on June 17, 2026. The Licensee will be issued a second civil penalty for a repeat violation in the amount of $250.00, since the Licensee was also previously issued a citation for California Code of Regulation Title 22 Section 87303(e)(2) on June 17, 2026. The Licensee will also be issued a third civil penalty for a repeat violation in the amount of $250.00, since the Licensee was also previously issued a citation for California Code of Regulation Title 22 Section 87303(a) on February 5, 2026. The Licensee will receive a total of $750.00 in civil penalties. An exit interview was conducted with Administrator Heddymae Oyson. A copy of the report and appeal rights were provided to the facility at time of visit.the state’s words, verbatim · CDSS document, Jul 6, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1568.39(e) · Plan of correction due date: Jul 6, 2026

§1569.38 Posting of licensing reports; disclosure to new residents: (e) Upon providing the notice described in subdivision (b), the licensed residential care facility shall also post a written notice.. in the facility.. This requirement is not evidenced by: Based on observation, the Licensee did not ensure that a notice regarding the proceedings was posted at the facility as LPAs did not observe it during today's visit. Staff also corroborated that the notice has not been posted. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 6, 2026

Plan of correction: The Administrator stated that she will post the notice of the proceeding in the facility. The Administrator agreed to provide LPAs proof of posting via email or fax by POC due date. LPAs will also conduct a follow up visit to confirm the notice has been posted.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87213 · Plan of correction due date: Jul 17, 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 interviews conducted, the Licensee does not have a sufficient financial plan as the have an outstanding rent balance of $65,500.00. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 6, 2026

Plan of correction: The Licensee stated that he will provide LPAs a written financial plan on how they will address the outstanding rent balance. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jul 17, 2026

87303 Maintenance and Operation: (e) Water supplies ..shall be maintained as follows: (2) Faucets .. shall deliver hot water. Hot water .. shall be maintained .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not evidenced by: Based on observation, the Licensee did not ensure that the facility's water was within regulatory requirements as the hot water temperature measured between 124.3 & 126.1 degrees Fahrenheit. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 6, 2026

Plan of correction: The Administrator stated that she will adjust the hot water temperature to be within regulatory requirements. The Administrator agreed to provide LPAs a hot water temperature log once the water has been adjusted and will provide LPAs the log via email of fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jul 17, 2026

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not evidenced by: Based on observations, the Licensee did not ensure that the exterior was clean and safe since LPAs observed multiple items in the side yard. LPAs also observed the sideyard and backyard has not been cleaned or maintained. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 6, 2026

Plan of correction: The Administrator stated that she will arrange for the items to be disposed of and for the backyard and sideyard to be cleaned. LPAs will conduct a subsequent visit to ensure the exterior has been cleaned.

Type of visit: Case Management - Health Checks

On June 17, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by Licensee Allen Medina after explaining the purpose for the visit. On today's visit, LPA observed the facility has no residents in care and remains vacant. LPA was informed by the Licensee that they plan to have two residents move into the facility tomorrow, June 18, 2026. LPA, accompanied by the Licensee, conducted a tour of the physical plant of the facility. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility. LPA observed bathrooms to be clean. Bathrooms are equipped with grab bars and non-skid floor mats. Hot water temperature measured between 131.9 and 132.2 degrees Fahrenheit. LPA conducted a tour of the kitchen area. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed all of the facilities utilities, such as the electricity, water, gas, and internet, to be operational during the visit. LPA, accompanied by the Licensee, conducted a tour of the exterior portions of the facility. LPA observed the exterior to be free of any obstructions or hazards. LPA conducted interviews with the Licensee and the landlord of the property, Witness #1 (W1) during the visit. W1 said that the facility did not pay their May 2026 rent and only partially paid the June 2026 rent. W1 said that the Licensee currently has an outstanding balance of $59,500.00, which includes past owed rent, late fees, and property taxes. W1 also said that there is currently no installment agreement to address the outstanding balance. CONTINUED ON LIC809-C Based on the observations made during today's visit, deficiencies will be cited on the attached LIC809-D page. Additionally, the Licensee will be issued a civil penalty for a repeat violation in the amount of $250.00, since the Licensee was previously issued a citation for California Code of Regulation Title 22 Section 82713 on May 11, 2026. The Licensee will also be issued a civil penalty for a repeat violation in the amount of $250.00, for violating California Code of Regulation Title 22 Section 87303(e)(2). The Licensee was previously cited for this regulation on May 29, 2026. An exit interview was conducted with Licensee Allen Medina. A copy of the report and appeal rights were provided at time of visit.the state’s words, verbatim · CDSS document, Jun 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Jun 18, 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 interviews conducted, the Licensee does not have a sufficient financial plan as the have an outstanding rent balance of $59.500.00 This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: The Licensee stated that he will provide LPA a written financial plan on how they will address the outstanding rent balance. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(e)(2) · Plan of correction due date: Jun 26, 2026

87303 Maintenance and Operation: (e) Water supplies ..shall be maintained as follows: (2) Faucets .. shall deliver hot water. Hot water .. shall be maintained .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not evidenced by: Based on observation, the Licensee did not ensure that the facility's water was within regulatory requirements as the hot water temperature measured between 131.9 & 132.2 degrees Fahrenheit. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: The Licensee stated that he will adjust the hot water temperature to be within regulatory requirements. The Licensee agreed to provide LPA a hot water temperature log once the water has been adjusted and will provide LPA the log via email of fax by POC due date.

Type of visit: Case Management - Health Checks

On May 29, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by Licensee Allen Medina after explaining the purpose for the visit. On today's visit, LPA observed the facility has no residents in care and remains vacant. LPA, accompanied by the Licensee, conducted a tour of the physical plant of the facility. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility. LPA observed bathrooms to be clean. Bathrooms are equipped with grab bars and non-skid floor mats. However, LPA observed that there was no water in the facility, including in the bathrooms or in the kitchen. The Licensee confirmed during the visit that the water had been shut off by their water company. LPA reviewed the facility's water bill dated May 27, 2026, which stated that the facility had a past due balance in their water bill in the amount of $1,533.65. LPA conducted a tour of the kitchen area. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed the remaining utilities of the facility, such as the electricity, gas, and internet, to be operational during the visit. LPA, accompanied by the Licensee, conducted a tour of the exterior portions of the facility. LPA observed the exterior to be free of any obstructions or hazards. LPA conducted interviews with the Licensee and one staff during the visit. The Licensee stated that he is planning or relocating residents back into the facility by the end of June 2026. The one staff interviewed stated that they do not have any current issues with their pay. CONTINUED ON LIC809-C On today's visit, LPA consulted with the Licensee regarding his obligations under Health and Safety Code Sections 1569.38(b)(1) and 1569.38(e), due to his ongoing legal proceedings with the Community Care Licensing Division. The Licensee was advised to follow these requirements once they admit residents in the future. Based on the observations made during today's visit, a deficiency will be cited on the attached LIC809-D page and a civil penalty will be assessed. The Licensee will be issued a civil penalty for a repeat violation in the amount of $250.00, since the Licensee was previously issued a citation for California Code of Regulation Title 22 Section 87303(e)(2) on February 4, 2026. An exit interview was conducted with Licensee Allen Medina. A copy of the report and appeal rights were provided at time of visit.the state’s words, verbatim · CDSS document, May 29, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jun 8, 2026

87303 Maintenance and Operation: (e) Water supplies ..shall be maintained as follows: (2) Faucets .. shall deliver hot water. Hot water .. shall be maintained .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not evidenced by: Based on observation, the Licensee did not ensure that the facility had water as the facility's water was shut off. There are no residents in care, but the Licensee is planning on relocating residents back into the home next month. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2026

Plan of correction: The Licensee agreed to pay the remaining balance for the facility's water bill to restore the water. The Licensee agreed to provide LPA proof of payment via email or fax by POC date.

Type of visit: Case Management - Health Checks

On May 11, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by Licensee Allen Medina after explaining the purpose for the visit. On today's visit, LPA observed the facility has no residents in care and remains vacant. LPA, accompanied by the Licensee, conducted a tour of the physical plant of the facility. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility. LPA observed bathrooms to be clean. Bathrooms are equipped with grab bars and non-skid floor mats. Hot water temperature measured between 106.3 and 127.9 degrees Fahrenheit. LPA conducted a tour of the kitchen area. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed all of the facilities utilities, such as the electricity, water, gas, and internet, to be operational during the visit. LPA, accompanied by the Licensee, conducted a tour of the exterior portions of the facility. LPA observed the exterior to be free of any obstructions or hazards. LPA conducted interviews with the Licensee and two staff during the visit. One out of the two staff reported that they were up to date on their wages and were paid for the most recent pay period. However, one staff stated that they have not received the remaining of their wages for the March 7, 2026, or the March 22, 2026, pay periods. LPA conducted an interview with a Licensee during the visit. The Licensee confirmed that there was a remaining balance for the staff, however, the Licensee stated that he initiated a payment for the remaining wages to the staff on May 9, 2026. CONTINUED ON LIC809-C LPA also conducted an interview with the landlord of the property, Witness #1 (W1), during the visit. W1 said that the facility did not pay their May 2026 rent and currently has an outstanding balance of $53,500.00, which includes past owed rent, late fees, and property taxes. As of today, LPA has also not received the full extent of the financial documents that were requested during a visit to the facility conducted on April 13, 2026. Based on the observations made during today's visit, a deficiency will be recited on the attached LIC809-D page and a technical violation will be issued. Additionally, the Licensee will be issued a civil penalty for a repeat violation in the amount of $250.00, since the Licensee was previously issued a citation for California Code of Regulation Title 22 Section 82713 on March 9, 2026. The Licensee also has not corrected a deficiency that was originally cited on March 9, 2026. A civil penalty will be assessed in the amount of $100 per day, from April 29, to May 11, 2026, for a total of $1,300.00. An exit interview was conducted with Licensee Allen Medina. A copy of the report and appeal rights were provided at time of visit.the state’s words, verbatim · CDSS document, May 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: May 12, 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 observation and records reviewed, the Licensee did not provide all the requested documents to Community Care Licensing as requested. The Licensee has also not resolved previous staff wage issues. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 11, 2026

Plan of correction: The Licensee stated that he will provide LPA the requested documents and will submit a plan on how he will address the owed wages to staff. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

Type of visit: Case Management - Health Checks

On April 28, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by Licensees Allen Medina and Keak Vongphakdy after explaining the purpose for the visit. On today's visit, LPA observed the facility still has no residents in care and remains vacant. LPA, accompanied by the Licensees, conducted a tour of the physical plant of the facility. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility. LPA observed bathrooms to be clean. Bathrooms are equipped with grab bars and non-skid floor mats. LPA conducted a tour of the kitchen area. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA inspected the three fire extinguishers located in the facility. The facility was issued a technical violation during the previous visit conducted on April 13, 2026, due to the fire extinguishers not being serviced annually. During today's visit, LPA observed that the fire extinguishers still have not been serviced and were last serviced on April 8, 2025. LPA observed all of the facilities utilities, such as the electricity, water, gas, and internet, to be operational during the visit. LPA, accompanied by the Licensees, conducted a tour of the exterior portions of the facility. LPA observed the exterior to be free of any obstructions or hazards. LPA conducted interviews with three staff during the visit. Two out of the three staff reported that they were up to date on their wages. However, one staff stated that they have not received the remaining of their wages for the March 7, 2026, or the March 22, 2026, pay periods. CONTINUED ON LIC809-C LPA conducted an interview with a Licensee during the visit. The Licensee confirmed one staff has an outstanding balance for past owed wages and that the facility's rent was not paid for March or April 2026. During the previous visit conducted to the facility on April 13, 2026, LPA requested the following documents to be submitted to him by close of business day April 17, 2026, to assess the Licensees current financial situation: Proof of rent payments for March and April 2026. All utility bills (water, gas, electricity, trash, internet) for March 2026. Payroll records for March 2026. As of today, April 28, 2026, LPA has still not received the full extent of the records requested. Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-D pages. Additionally, a civil penalty will be assessed for a failure to correct. The Licensees have still not corrected a deficiency that was originally cited on March 9, 2026. A civil penalty will be assessed in the amount of $100 per day, from April 14, to April 28, 2026, for a total of $1,500.00. An exit interview was conducted with Licensees Allen Medina and Keak Vongphakdy. A copy of the report and appeal rights were provided at time of visit.the state’s words, verbatim · CDSS document, Apr 28, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87203 · Plan of correction due date: May 8, 2026

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Based on observation, the Licensee did not ensure that all fire extinguishers at the facility were serviced annually, which violates State Fire Marshal regulations. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: The Licensee stated that he will service all fire extinguishers in order to comply with State Fire Marshal regulations. The Licensee agreed to provide LPA provide of fire extinguishers being serviced via email or fax by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Apr 29, 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 observation and records reviewed, the Licensee did not provide all the requested documents to Community Care Licensing as requested. The Licensee has also not resolved previous staff wage issues. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: The Licensee stated that he will provide LPA the requested documents and will submit a plan on how he will address the owed wages to staff. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

Type of visit: Case Management - Health Checks

On April 13, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. On today's visit, LPA observed the facility still has no residents in care and remains vacant. LPA, accompanied by the staff, conducted a tour of the physical plant of the facility. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility, three of which are dedicated for resident use. LPA observed bathrooms to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. Hot water temperature measured between 124.7 and 125.7 degrees Fahrenheit. The facility was issued a citation on the previous visit for the hot water temperature, however, they were provided with a plan of correction date of April 13, 2026, to correct the citation. LPA conducted a tour of the kitchen area. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed there are three fire extinguishers mounted in the facility. LPA observed fire extinguishers are charged, however, they were last serviced on April 8, 2025, and therefore have not been serviced annually. LPA observed all of the facilities utilities, such as the electricity, water, gas, and internet, to be operational during the visit. LPA, accompanied by the staff, conducted a tour of the exterior portions of the facility. LPA observed the exterior to be free of any obstructions or hazards. LPA conducted interviews with four staff during the visit. CONTINUED ON LIC809-C Three out of the four staff reported that they were up to date on their wages. However, one staff stated that they have not received the remaining of their wages for the March 7, 2026, pay period or the March 22, 2026, pay period. The one staff stated that they have still not been updated on when they will receive their wages for these two pay periods. LPA also conducted an interview with the landlord of the property via telephone, Witness #1 (W1). W1 stated that the Licensees still have not paid the April 2026 rent, or the agreed upon installment to address the current outstanding balance. W1 said that as of today, the Licensees still owe him $42,500.00, which includes past owed rent, late fees, and property taxes. In order to assess the Licensees current financial status, LPA is requesting the following documents to be submitted to him via email by close of business day April 17, 2026: Proof of rent payments for March and April 2026. All utility bills (water, gas, electricity, trash, internet) for March 2026. Payroll records for March 2026. Based on the observations made during today's visit, no deficiencies are being cited, however, a technical violation is being issued and a civil penalty will be assessed for a failure to correct. The Licensees have still not corrected a deficiency that was originally cited on March 9, 2026, despite weekly reminders, and therefore will receive a civil penalty in the amount of $700.00. An exit interview was conducted with staff Rosendo Carlo Miranda and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 13, 2026

Type of visit: Case Management - Health Checks

On April 6, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by Administrator Eleazar Cuyson. On today's visit, LPA observed the facility currently has no residents in care and is currently vacant. LPA, accompanied by the AD, conducted a tour of the physical plant of the facility. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility, three of which are dedicated for resident use. LPA observed bathrooms to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. Hot water temperature measured between 128.3 and 129.9 degrees Fahrenheit. LPA conducted a tour of the kitchen area. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed all of the facilities utilities, such as the electricity, water, gas, and internet, to be operational during the visit. LPA, accompanied by the AD, conducted a tour of the exterior portions of the facility. LPA observed the exterior to be free of any obstructions or hazards. LPA conducted interviews with three staff during the visit. One out of the three staff reported that they were up to date on their wages. However, two staff stated that they have not received the remaining of their wages for the March 7, 2026 pay period, and have not received any of their wages for March 22, 2026 pay period. The two staff stated that they have still not been updated on when they will receive their wages for these two pay periods. LPA also conducted an interview with the landlord of the property via telephone, Witness #1 (W1). CONTINUED ON LIC809-C W1 stated that the Licensees did not pay their April 2026 rent which was due on April 1, 2026. W1 stated that as of today, the Licensees currently have an outstanding balance of $42,500.00, which includes past owed rent, late fees, and property taxes. Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809D page for the hot water temperature, since technical violations were previously issued and it has not been corrected yet. The Licensees also have not corrected a deficiency that was originally cited on March 9, 2026, despite weekly reminders, and therefore will receive a civil penalty in the amount of $700.00. An exit interview was conducted with Administrator Eleazar Cuyson. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Apr 6, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Apr 13, 2026

87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows (2)Faucets used by residents .. shall be maintained to .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not evidenced by: Based on observation, the Licensee did not ensure the hot water temperature was within regulatory requirements as LPA measured the resident bathrooms to be between 128.3 and 129.9 degrees Fahrenheit. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 6, 2026

Plan of correction: The Administrator agreed to adjust the hot water temperature to be within regulatory requirements. LPA will conduct a follow up visit to measure the hot water temperature to ensure it is within regulatory requirements.

Type of visit: Case Management - Health Checks

On March 30, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by Licensee Maricel Nepomuceno. On today's visit, LPA observed the facility currently has no residents in care and is currently vacant. LPA, accompanied by the LI, conducted a tour of the physical plant of the facility. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility, three of which are dedicated for resident use. LPA observed bathrooms to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. Hot water temperature measured between 125.6 and 127.2 degrees Fahrenheit. LPA conducted a tour of the kitchen area. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed all of the facilities utilities, such as the electricity, water, gas, and internet, to be operational during the visit. LPA, accompanied by the LI, conducted a tour of the exterior portions of the facility. LPA observed the exterior to be free of any obstructions or hazards. LPA observed that the Licensee has addressed the previous issues of the exterior portions of the facility. LPA conducted interviews with three staff via telephone during the visit. One out of the three staff reported that they were up to date on their wages. However, two out of the three staff reported issues with their wages. Two staff stated that they have not received the remaining of their wages for the March 7, 2026 pay period, which covered the hours they worked from February 4, to February 18, 2026. The two staff stated that they have not been updated on when they will receive the remaining of their wages. CONTINUED ON LIC809-C The two staff also stated that they have not received any pay for the March 22, 2026 pay period, which covered the hours they worked from February 19, to March 15, 2026. The two staff stated that they also have not been updated on when they will receive the wages for this pay period. Based on the observations made during today's visit, no deficiencies are being cited since the facility has no residents in care. However, one technical violation is being issued and a civil penalty will also being assessed for failure to correct. The Licensee has not corrected a deficiency that was originally cited on March 9, 2026, despite weekly reminders, and therefore will receive a civil penalty in the amount of $600.00. An exit interview was conducted with Licensee Maricel Nepomuceno. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 30, 2026

Type of visit: Case Management - Health Checks

On March 24, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by Administrator Eleazar Cuyson. On today's visit, LPA observed the facility currently has no residents in care and is currently vacant. LPA, accompanied by the AD, conducted a tour of the physical plant of the facility. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility, three of which are dedicated for resident use. LPA observed bathrooms to be clean. LPA observed that a light in one of the five bathrooms is still not operational and has not been fixed. Bathrooms were equipped with grab bars and non-skid floor mats. Hot water temperature measured between 126.8 and 127.7 degrees Fahrenheit. LPA conducted a tour of the kitchen area. LPA observed kitchen appliances to be clean and operational. However, LPA observed two cockroaches to be present in the kitchen's sink area. LPA observed the six burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed that the paint in the kitchen pantry area is still peeling and still has not been addressed by the Licensee. LPA observed all of the facilities utilities, such as the electricity, water, gas, and internet, to be operational during the visit. LPA, accompanied by the AD, conducted a tour of the exterior portions of the facility. LPA observed that the side yard located on the north side of the facility has not been addressed by the Licensee. LPA observed the grass is still overgrown, bushes are still overgrown, weeds are still present in the yards, the palm trees have not been trimmed, and debris to be present in the walkway. CONTINUED ON LIC809-C LPA also observed the roof of the house and it's gutters to still be dirty and full of debris. Additionally, LPA observed the outdoor furniture in the backyard still has not been replaced, and remains in poor condition. LPA conducted interviews with three staff via telephone during the visit. One out of the three staff reported that they were up to date on their wages. However, two out of the three staff reported issues with their wages. The two staff stated that they only received partial pay for the March 7, 2026, pay period, which covered the hours they worked from February 4, to February 18, 2026, and have not been updated on when they will receive the remaining of their wages. The two staff also stated that they have not received any pay for the March 22, 2026 pay period, which covered the hours they worked from February 19, to March 15, 2026. The two staff stated that they also have not been updated on when they will receive the wages for this past pay period. The three staff reported that the next pay period was on March 26, 2026, which coverers the hours they worked from March 16, to March 22, 2026. Based on the observations made during today's visit, no deficiencies are being cited since the facility has no residents in care. However, two technical violations are being issued and civil penalties will also being assessed for failures to correct. The Licensee still has not corrected a deficiency that was original cited on February 5, 2026 despite weekly reminders, and therefore will receive a civil penalty in the amount of $600.00. The Licensee has also not corrected a deficiency that was cited on March 9, 2026, despite weekly reminders, and therefore will receive a civil penalty in the amount of $600.00. The total amount of civil penalties that are being assessed on today's visit is $1,200.00. An exit interview was conducted with Administrator Eleazar Cuyson. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Case Management - Health Checks

On March 18, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by Licensee Allen Medina. On today's visit, LPA observed the facility currently has no residents in care and is currently vacant. LPA, accompanied by the LI, conducted a tour of the physical plant of the facility. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility, three of which are dedicated for resident use. LPA observed bathrooms to be clean. LPA observed that a light in one of the five bathrooms is still not operational and has not been fixed. Bathrooms were equipped with grab bars and non-skid floor mats. Hot water temperature measured between 118.7 and 119.6 degrees Fahrenheit. LPA observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed that the paint in the kitchen pantry area is still peeling and still has not been addressed by the Licensee. LPA observed all of the facilities utilities, such as the electricity, water, gas, and internet, to be operational during the visit. LPA, accompanied by the LI, conducted a tour of the exterior portions of the facility. LPA observed that the backyard and the side yard located on the southside of the facility have been cleaned, weeds have been addressed, and trees have been trimmed. CONTINUED ON LIC809-C However, LPA observed that the side yard located on the north side of the facility has not been addressed by the Licensee. LPA observed the grass is still overgrown, bushes are still overgrown, weeds are still present in the yards, the palm trees have not been trimmed, and debris to be present in the walkway. LPA also observed the roof of the house and it's gutters to still be dirty and full of debris. Additionally, LPA observed the outdoor furniture in the backyard still has not been replaced, and is still not in good condition. LPA conducted interviews with three staff via telephone during the visit. One out of the three staff reported that they were up to date on their wages. However, two out of the three staff reported that they only received partial pay for the March 7, 2026, pay period, which covered the hours they worked from February 4, to February 18, 2026. The two staff stated that they have not been updated on when they will receive their remaining wages for the March 7, 2026 pay period. All three staff stated that the next pay period was on March 22, 2026, which coverers the hours they worked from February 19, to March 15, 2026. Based on the observations made during today's visit, no deficiencies are being cited per Title 22 of the California Code of Regulations. However, civil penalties will also be assessed on today's visit for failures to correct. The Licensee has not corrected a deficiency that was original cited on February 5, 2026 and therefore will receive a civil penalty in the amount of $900.00. The Licensee has also not corrected a deficiency that was cited during the previous visit, conducted on March 9, 2026, and therefore will receive a civil penalty in the amount of $900.00 for The total amount of civil penalties that are being assessed on today's visit is $1,800.00. An exit interview was conducted with Licensee Allen Medina. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 18, 2026

Type of visit: Case Management - Health Checks

On March 9, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by Licensee Allen Medina. On today's visit, LPA observed that facility current has a census of one resident. However, there were no residents physically present at the facility during today's visit. Per the LI, the one resident will be discharged from the hospital tomorrow, but will be relocating to another licensed facility. LPA, accompanied by the LI, conducted a tour of the physical plant of the facility. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility, three of which are dedicated for resident use. LPA observed bathrooms to be clean. LPA observed that a light in one of the five bathrooms is still not operational and has not been fixed. Bathrooms were equipped with grab bars and non-skid floor mats. Hot water temperature measured between 125.7 and 127.4 degrees Fahrenheit. LPA observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed that the paint in the kitchen pantry area is still peeling and still has not been fixed. LPA observed all of the facilities utilities, such as the electricity, water, gas, and internet, to be operational during the visit. CONTINUED ON LIC809-C LPA, accompanied by the LI, conducted a tour of the exterior portions of the facility. LPA observed that the side yard and backyard are still overgrown. LPA observed the grass is still overgrown, bushes are still overgrown, weeds are still present in the yards, the palm trees have not been trimmed, and debris to be present in the walkways. LPA observed the roof of the house and it's gutters to still be dirty and full of debris. Additionally, LPA observed the outdoor furniture in the backyard still has not been replaced, and is still not in good condition. LPA conducted interviews with three staff via telephone during the visit. The three staff interviewed reported that they were supposed to be paid on March 7, 2026, for the hours they worked from February 4, to February 18, 2026. However, they have not been paid as of today. LPA also conducted an interview with the landlord of the property, Witness #1 (W1), via telephone during the visit. W1 stated that the facility currently has an outstanding balance of $30,007.94, however, there is currently an agreement in place to address the outstanding balance. Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D page, and technical violation is also being issued. Civil penalties will also be assessed on today's visit in the amount of $250.00 for a repeat violation and $500.00 for a failure to correct. The Licensee is receiving the same citation that was issued during a previous visit conducted on February 25, 2026. The Licensee has also not corrected a deficiency that was original cited on February 28, 2026.The total amount of civil penalties that are being assessed on today's visit is $750.00. An exit interview was conducted with Licensee Allen Medina. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Mar 10, 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 observation and records reviewed, the Licensee did not provide all the requested documents to Community Care Licensing as agreed upon. Additionally, the Licensee did not ensure staff have been paid on schedule. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 9, 2026

Plan of correction: The Licensee stated that they will provide a written plan to LPA on when they will submit the requested documents on how they will address the owed wages of staff. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

Type of visit: Case Management - Health Checks

On March 4, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Licensee Allen Medina was notified via telephone but was unable to assist with today's inspection. On today's visit, LPA observed that facility current has a census of one resident. However, there were no residents physically present at the facility during today's visit. Per staff on duty, the one resident still remains at a Skilled Nursing Facility and a return date to the facility has not been scheduled yet. LPA, accompanied by a care giving staff, conducted a tour of the physical plant of the facility. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility, three of which are dedicated for resident use. LPA observed bathrooms to be clean. LPA observed that a light in one of the five bathrooms is still not operational. Bathrooms were equipped with grab bars and non-skid floor mats. Hot water temperature measured between 115.9 and 119.2 degrees Fahrenheit. LPA observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed that the paint in the kitchen pantry area is still peeling and still has not been fixed. LPA observed all of the facilities utilities, such as the electricity, water, gas, and internet, to be operational during the visit. CONTINUED ON LIC809-C LPA, accompanied by a care giving staff, conducted a tour of the exterior portions of the facility. LPA observed that the side yard and backyard are still overgrown. LPA observed the grass is still overgrown, bushes are still overgrown, weeds are still present in the yards, the palm trees have not been trimmed, and debris to be present in the walkways. LPA observed the roof of the house and it's gutters to still be dirty and full of debris. Additionally, LPA observed the outdoor furniture in the backyard still has not been replaced, and is still not in good condition. LPA conducted interviews with three staff during the visit. Three out of the three staff interviewed reported that they received their owed wages from the pay period of February 13, 2026, and were currently up to date on their pay. The three staff interviewed reported that their next pay date is on March 7, 2026. LPA observed that the Licensee has still not paid the facility's annual fees for the year of 2025 and currently has an outstanding balance of $742.00 for the facility's annual fees. Based on the observations made during today's visit, no deficiencies are being cited per Title 22 of the California Code of Regulations. However, civil penalties will be assessed on today's visit, for failures to correct. The Licensee has not corrected a deficiency that was cited during a previous visit to the facility on February 25, 2026, and as a result, will receive a $800.00 civil penalty. The Licensee has not corrected two deficiencies cited during a previous visit to the facility February 18, 2026, as a result, will receive two civil penalties in the amount of $800.00 each. The Licensee has not corrected two deficiencies that was cited during a previous visit to the facility February 5, 2026, and as a result, will receive two civil penalties. One civil penalty will be in the amount of $600.00, and the second will be in the amount of $800.00. The total amount of civil penalties that are being assessed on today's visit is $3,800.00. An exit interview was conducted with Licensee Allen Medina via telephone. Licensee Allen Medina authorized the care giving staff present to sign the report on his behalf. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 4, 2026

Type of visit: Case Management - Health Checks

On February 25, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Licensee Allen Medina was notified via telephone but was unable to assist with today's inspection. On today's visit, LPA observed that facility current has a census of one resident. However, there were no residents physically present at the facility during today's visit. Per staff on duty, the one resident remains at a Skilled Nursing Facility and a return date to the facility has not been scheduled yet. LPA, accompanied by a care giving staff, conducted a tour of the physical plant of the facility. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility, three of which are dedicated for resident use. LPA observed bathrooms to be clean. LPA observed that a light in one of the five bathrooms is still not operational. Bathrooms were equipped with grab bars and non-skid floor mats. Hot water temperature measured between 117.4 and 119.6 degrees Fahrenheit. LPA observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed that the paint in the kitchen pantry area is still peeling and still has not been fixed. LPA observed all of the facilities utilities, such as the electricity, water, gas, and internet, to be operational during the visit. CONTINUED ON LIC809-C LPA, accompanied by a care giving staff, conducted a tour of the exterior portions of the facility. LPA observed that the side yard and backyard are still overgrown. LPA observed the grass to be overgrown, bushes to be overgrown, weeds to present in the yards, the palm trees have not been trimmed, and debris to be present in the walkways. LPA observed the roof of the house and it's gutters to still be dirty and full of debris. Additionally, LPA observed the outdoor furniture in the backyard has not been replaced. LPA additionally conducted interviews with four staff during the visit. Four out of the four staff interviewed reported that they were supposed to be paid on February 13, 2026, for the hours they worked from January 21, to February 3, 2026. However, one staff stated that they have only received partial pay as of yesterday, February 24, 2026. Three staff stated that they have not received any pay for that pay period, therefore, the Licensees are twelve days behind on the scheduled pay date. Two out of the four staff interviewed also stated that they have been paid late in previous pay periods. Two out of the four staff stated that they are owed back pay from previous pay periods. Additionally, all four staff reported that they have not received any pay for the first pay period of February 2026, and have not been told when they will be paid for that pay period. LPA observed that the Licensee has still not paid the facility's annual fees for the year of 2025 and remains with a balance of $495.00 for the facility's annual fees. Additionally, during the Non-Compliance Conference held on February 10, 2026, the Licensees agreed to the following terms: Licensees plan to downsize and consolidate facilities. The Licensees stated that they will provide a plan to the Department on which facilities they will consolidate by close of business February 12, 2026. Licensees plan to pay a minimum balance of the outstanding utility bills for all 16 of their licensed facilities. The Licensee stated that they will provide proof of payments for the utility bills to the Department by close of business February 13, 2026. Licensees plan to pay off all their debt, including overdue balances for rent/mortgage payments and utility bills. The Licensees stated that they will also obtained liability insurance for all 16 of their licensed facilities. The Licensees stated that they will provide a plan to the Department by close of business February 17, 2026, on when they plan to pay off all of their debt and obtain liability insurance for their facilities. CONTINUED ON LIC809-C As of the agreed upon due date of February 13, 2026, the Licensee did not provide any proof of payments for the utility bills for the facility. As the agreed upon due date of February 17, 2026, the Licensee did not submit a plan to the Department on how they will pay off all of their debt for this facility. LPA also conducted an interview with the landlord of the property, Witness #1 (W1), who stated the facility currently has an outstanding balance of $27,508.20, for past due rent, late fees, and property taxes. Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D page. Additionally, civil penalties will be assessed on today's visit, for a repeated violation and for failure to correct. The Licensee is receiving the same citation that was issued during the Case Management - Health Checks inspection conducted to the facility on February 18, 2026, and as a result, will receive a civil penalty in the amount of $250.00 for a repeated violation. The Licensee still has not corrected the deficiency that was cited during the complaint visit conducted to the facility on February 5, 2026. As a result, the Licensee will receive a civil penalty in the amount of $700.00 for a failure to correct. The Licensee has also not corrected the deficiency that was cited during the Case Management - Health Checks inspection on February 18, 2026. As a result, the Licensee will receive a civil penalty in the amount of $700.00. The total amount of civil penalties that are being assessed on today's visit is $1,650.00. An exit interview was conducted with Licensee Allen Medina via telephone. Licensee Allen Medina authorized the care giving staff present to sign the report on his behalf. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Feb 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Feb 26, 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 observation and records reviewed, the Licensee did not provide all the requested documents to Community Care Licensing as agreed upon. Additionally, the Licensee did not ensure staff have been paid on schedule. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 25, 2026

Plan of correction: The Licensee stated that they will provide a written plan to LPA on when they will submit the requested documents on how they will address the owed wages of staff. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

Type of visit: Case Management - Health Checks

On February 18, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Licensee Allen Medina was notified via telephone but was unable to assist with today's inspection. On today's visit, LPA observed that facility current has a census of one resident. However, there were no residents physically present at the facility during today's visit. Per staff on duty, the one resident remains at a Skilled Nursing Facility and a return date to the facility has not been scheduled yet. LPA, accompanied by a care giving staff, conducted a tour of the physical plant of the facility. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility, three of which are dedicated for resident use. LPA observed bathrooms to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. Hot water temperature measured between 116.2 and 116.6 degrees Fahrenheit. LPA observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed all of the facilities utilities, such as the electricity, water, gas, and internet, to be operational during the visit. CONTINUED ON LIC809-C LPA additionally conducted interviews with three staff. Three out of the three staff interviewed stated that they were supposed to be paid on February 13, 2026, for the hours them worked from January 21, to February 3, 2026. However, the three staff stated that they have not been paid yet and they have not been told when they will be paid. LPA observed that the Licensee has not paid the facility's annual fees for the year of 2025 despite previous reminders. The Licensee currently has a balance of $742.00 for the facility's annual fees. Additionally, the Department requested the Licensee to provide the following documents for this facility by 3 PM, February 6, 2026, to assess their current financial situation: Financial records (balance sheets, income statements, general ledgers) from October 2025 to January 2026. Rent payments from October 2025 to January 2026. Utility bills (electricity, water, gas, internet) from October 2025 to January 2026. Payroll records from October 2025 to January 2026. As of the agreed upon due date, the Licensee did not provide any payroll records for the facility. The Licensee did not provide any balance sheets or income statements for the facility. The Licensee did not provide the general ledger for January 2026 for the facility. The Licensee did not provide the rent payments from November 2025 to January 2026. The Licensee also did not submit the full extent of the utility bills requested. Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809D page. Additionally, civil penalties will be assessed on today's visit, for failures to correct and for a repeat violation. The Licensee did not correct the deficiency that was cited during the complaint visit that was conducted to the facility on February 5, 2026. The Licensee did not correct two deficiencies that were cited during the case management visit that was conducted to the facility on February 5, 2026. The Licensee is also receiving the same citation that was issued during the complaint visit conducted to the facility on February 5, 2026. The total amount of civil penalties that are being assessed on today's visit is $3,850.00. An exit interview was conducted with Licensee Allen Medina via telephone. Licensee Allen Medina authorized the care giving staff present to sign the report on his behalf. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Feb 18, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Feb 19, 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 observation and records reviewed, the Licensee did not provide all the requested documents to Community Care Licensing as agreed upon. Additionally, the Licensee did not ensure staff have been paid on schedule. This poses an immedate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: The Licensee stated that they will provide a written plan to LPA on when they will submit the requested documents on how they will address the owed wages of staff. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87156(a) · Plan of correction due date: Feb 25, 2026

87156 Licensing Fees: (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement was not evidenced by: Based on observation and records reviewed, the Licensee did not pay the facility's annual fees for 2025 depsite previous reminders. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: The Licensee stated that he will pay the facility's annual fees. The Licensee agreed to provide LPA proof of payment via email or fax by POC date.

Allegation investigated: Staff did not complete required training Resident records are incomplete Administrator not present at the facility a sufficient number of hours Facility is in financial distress Facility is in disrepair

On February 5, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by Licensee Allen Medina after explaining the purpose for the visit. During the course of the investigation, LPA conducted a tour of the physical plant of the facility, interviewed residents, interviewed staff, reviewed and obtained pertinent documents to this complaint. Regarding the allegation, staff did not complete required training, the following has been concluded: LPA reviewed the files for five staff. LPA observed that all five staff had valid CPR/First Aid training cards. However, LPA observed that three staff did not complete the required initial training upon hire and that they did not have any documented training on file. Additionally, LPA observed that two staff did not complete the required annual training for the year of 2025 and that they did not have any training on file for that year. LPA conducted interviews with all five staff. Five out of the five staff interviewed corroborated the allegation. CONTINUED ON LIC9099-C Substantiated Staff interviewed stated that they did not complete any training upon hire or that they did not complete any annual training for the year of 2025. Regarding the allegation, resident records are incomplete, the following has been concluded: LPA reviewed the records for the three residents of the facility. LPA observed that the resident records were incomplete for all three residents. LPA observed that the Admission Agreement on file for Resident #1 (R1) was not signed by a facility representative. LPA observed that there was no Pre-Admission Appraisal on file for R1. LPA observed that there was no Reappraisal on file for R1 and the Reappraisal on file for Resident #2 (R2) was outdated. LPA also observed that there were no functional capability assessments on file for the three residents in of the facility. Regarding the allegation, Administrator not present at the facility a sufficient number of hours, the following has been concluded: LPA reviewed the facility's personnel report dated January 30, 2026 which stated that the current facility Administrator (AD) is present at the facility three hours on Monday and three hours on Friday, for a total of six hours a week. LPA conducted an interview with the current facility AD. The AD stated that he took over operation of the facility in December 2025. The AD stated that he is currently overseeing five licensed facility's. Additionally, the AD admitted that he is currently not follow the personnel report schedule and has only been at the facility once or twice since December 2025. During the course of the investigation, LPA observed the facility to be in disrepair, staff training has not been completed, resident records are incomplete, and the facility is in financial distress. Therefore, it does not appear that the Administrator is present at the facility a sufficient number of hours to permit adequate attention to the management and administration of the facility. Regarding the allegation, facility is in financial distress, the following has been concluded: LPA spoke with the landlord of the property, Witness #1 (W1), who stated that the Licensee currently owes him $26,450.00. W1 said that $4,750.00 is owed from September through December 2025 for rent late fees and partial property taxes owed. W1 also said that $21,700.00 is from missed rent payments and late fees before September 2025. During the Case Management visit conducted to the facility on February 4, 2026, LPA observed that the facility was experiencing a water shut off. Staff present during the visit confirmed that the water was shut off due to the facility having an outstanding balance with the water company. LPA spoke with Licensee Allen Medina and Maricel Nepomuceno who confirmed the facility had an outstanding balance with the water company for a total of $2,247.03. The Licensees were unable to provide the remaining utility bills for the facility to determine if they are up to date on their payments. CONTINUED ON LIC9099-C LPA conducted five staff interviews. Three out of the five staff interviewed confirmed that they are up to date on their salary and were paid on time for January 2026. However, the three staff stated that they have been paid late in previous pay periods. Additionally, two out of the five staff interviewed stated that they have not received all of the wages that are owed to them and that they have been paid late in the previous pay periods. Regarding the allegation, facility is in disrepair, the following has been concluded: LPA conducted a tour of the facility, including the interior and exterior portions. LPA observed that a light in one of the five bathrooms was not operational. LPA observed that the paint in the kitchen pantry area was peeling. LPA observed that the air filters located in the hallways were extremely dirty and full of debris. Two staff present stated that the air filters had not been changed in months. LPA observed that the side yard and backyard were overgrown. LPA observed the grass to be overgrown, bushes to be overgrown, weeds to present in the yards, the palm trees have not been trimmed, and debris to be present in the walkways. Three staff stated that the facility has not had a gardener in months. LPA observed the roof of the house and it's gutters to be dirty and full of debris. Additionally, LPA observed the outdoor furniture in the backyard to be dirty and faded. One resident interviewed stated that she no longer goes outside because of how dirty it is and due to the outdoor furniture not being in good condition. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the five allegations The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D pages. An exit interview was conducted with Licensee Allen Medina. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Feb 5, 2026 · control 22-AS-20260126155937

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Feb 20, 2026

87411 Personnel Requirements - General: (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirment was not evidenced by: Based on observation and records reviewed, the Licensee did not ensure that five staff had received the proper intiial or annual training. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: The Licensee stated that he will have the five staff complete the required training. The Licensee agreed to provide LPA proof of the training for the five staff via email or fax by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(17) · Plan of correction due date: Feb 20, 2026

87506 Resident Records: (b) Each resident’s record shall contain at least the following information: (17) Documents and information required by the following: This requirement was not evidenced by: Based on observations and records reviewed, the Licensee did not ensure that three resident records were complete. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: The Licensee stated that he will conduct an in service training with staff regarding proper documentation in record files. The Licensee agreed to provide LPA proof of training via email or fax by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Feb 20, 2026

87405 Administrator - Qualifications and Duties: (a) All facilities shall have a.. certified administrator... and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility ... This requirment was not evidenced by: Based on records reviewed and interviewed conducted, the Licensee did not ensure the Administrator was present at the facility a sufficient amount of hours to ensure compliance. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: The Licensee stated that he will create a plan on how he will ensure an Administrator is present at the facility a sufficient amount of hours to remain in compliance. The Licensee agreed to provide the plan to LPA via email or fax by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 27, 2026

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not evidenced by: Based on observations, the Licensee did not ensure the facility was in good repair as LPA noted a light not operational, paint peeling, the yards being overgrown, and outdoor furniture to be in disrepair. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: The Licensee stated that he will make the necessary repairs to the facility. LPA will conduct a subsequent visit to ensure that all repairs have been made.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Feb 6, 2026

87213 Finances: The licensee shall have a financial plan... that assures sufficient resources to meet operating costs for care of residents... This requirement was not evidenced by: Based on observations, interviews, and records reviewed, the Licensee does not have an adequate financial plan to meet the needs of the residents. The facility has an outstanding rent balance, water was shut off due to non-payments, staff have not received full wages or were not paid on time. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: The Licensee stated that he will create a financial plan to ensure the needs of the residents and of the facility are met. The Licensee agreed to provide LPA the financial plan via email or fax by POC date.

Type of visit: Case Management - Health Checks

On February 5, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA is following up on the visit that was conducted yesterday, please see LIC809 report dated February 4, 2026. In additional, the visit is being conducted in conjunction with the complaint visit for complaint control 22-AS-20260126155937. LPA was greeted and granted entry into the facility by Licensee (LI) Allen Medina after explaining the purpose for the visit. On today's visit, the facility has a census of three residents, however, no residents were physically present during the visit. LPA, accompanied by the LI, conducted a tour of the physical plant. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the five bathrooms located in the facility, three of which are dedicated for resident use. LPA observed bathrooms to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. The water in each bathroom was operational and hot water measured between 116 and 119.8 degrees Fahrenheit. LPA observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed all of the facility's utilities, such as the electricity, gas, water, and internet, to be operational during the visit. CONTINUED ON LIC809-C During the complaint visit, LPA reviewed the medication administration records for January and February 2026 for the three residents of the facility. LPA observed that the medication administration record for R1 was incomplete for both January and February 2026. LPA also observed the medication administration record for R2 was incomplete for January 2026. LPA observed that facility staff failed to initial the medication administration records for R1 and R2, indicating that the medications were dispensed according to their prescribed orders. During the complaint visit, LPA was also informed that R2 was abruptly removed from the facility on January 29, 2026. The two staff present when R2 was removed from the facility stated that they believe she was taken by family. However, the two staff stated that they were unable to confirm the identity of who exactly removed R2. In additional, the staff stated that they did not have the family sign in on the facility's visitation log, despite signing in being a facility policy. In addition, California Code of Regulation Title 22 Section 87205 Accountability of Licensee Governing Body states: (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. Based on the recent visits conducted to the facility, it does not appear that the licensee has provided sufficient supervision as the facility is in disrepair, the facility in financial distress, resident records are incomplete, staff training has not been completed, and the facility does not have an Administrator present a sufficient amount of hours. Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-D pages. An exit interview was conducted with Licensee Allen Medina. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Feb 5, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Feb 20, 2026

87208 Plan of Operation: (a)The licensee shall have and maintain a current, written definitive plan of operation for the facility. .. and may be cited for not doing so ... This requirement was not evidenced by: Based on interviews conducted, the Licensee did not ensure staff followed the facility's plan of operation since staff did not ensure visistors signed into the vistor log. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: The Licensee stated that he will conduct an in service training with staff regarding the vistor log policy. The Licensee agreed to provide LPA proof of training via email or fax by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 6, 2026

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility..(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not evidenced by: Based on observations and records reviewed, the Licensee did not ensure the medication administration records for two residents were completely accurately. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: The Licensee stated that he will conduct an in service training with staff regarding the proper documentation of resident's medication administration records. The Licensee agreed to provide LPA proof of the training via email or fax by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87205(a) · Plan of correction due date: Feb 6, 2026

87205 Accountability of Licensee Governing Body: (a) The licensee.. shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations... This requirment was not evidenced by: Based on observations, interviews, and records reviewed, the Licensee has not provided sufficient supervision as the facility is in disrepair, in financial distress, and does not have an Administrator present a sufficient amount of hours. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: The Licensee stated that he will complete a statement understanding the regulaion and will commit to provide enough supervision over the facility. The Licensee agreed to provide the statement to LPA via email or fax by POC date.

Type of visit: Case Management - Deficiencies

On February 4, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility in conjunction with the complaint visit for complaint control 22-AS-20260126155937. Administrator (AD) Eleazar Cuyson was notified via telephone and later arrived to assist with the inspection. On today's visit, the facility has a census of three residents, however, there was only one resident physically present during the visit. LPA observed two care giving staff present. LPA observed the resident to be in clean clothes. LPA, accompanied by a caregiver staff, conducted a tour of the physical plant. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the three bathrooms located in the facility, two of which are dedicated for resident use. LPA observed bathrooms to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. LPA observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the six burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed the remaining utilities, such as the electricity, gas, and internet, to be operational during the visit. LPA additionally conducted interviews with three staff and the one resident present during the visit. Three out of the three staff interviewed confirmed that they are up to date on their salary and have been paid on time. CONTINUED ON LIC809-C At time of LPA's arrival, at 12:45 PM, the facility was experiencing a water shut off. Licensee Allen Medina and Maricel Nepomuceno were made aware of the situation via telephone. Licensee Allen Medina and Maricel Nepomuceno stated that the water had been shut off due to the facility having an outstanding balance with their water bill. Care giving staff on duty informed LPA that water was shut off at approximately 12:45 PM. Licensee Allen Medina and Maricel Nepomuceno were unable to restore the water during the visit. As a result, the resident, with their consent and the consent of their Responsible Party, was temporarily relocated to a different licensed facility, due to the water being shut off. LPA reviewed the files for the three residents of the facility. LPA observed that the Admission Agreement on file for Resident #1 (R1) was not signed by a facility representative. LPA observed that there was no Pre-Admission Appraisal on file for R1. LPA observed that there was no Reappraisal on file for R1 and the Reappraisal on file for Resident #2 (R2) was outdated. LPA also observed that there were no functional capability assessments on file for the three residents in of the facility. LPA additionally observed that one care giving staff present during the visit, Staff #4 (S4) was not background cleared. Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-D pages. Civil penalties will also be assessed during today's visit. An exit interview was conducted with Administrator Eleazar Cuyson. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Feb 4, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c) · Plan of correction due date: Feb 20, 2026

87457 Pre-Admission Appraisal: (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs... This requirement was not evidenced by: Based on observations and records reviewed, the Licensee did not ensure there was a Pre-Admission Appraisal on file for Resident #1 (R1). This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: The Administrator stated that he will complete a Pre-Admission Appraisal for R1. The Adminstrator agreed to provide LPA the Pre-Admission Appraisal for R1 via email or fax by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Feb 20, 2026

87463 Reappraisals: (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first... This requirement was not evidenced by: Based on records reviewed, the Licensee did not ensure there was a Reappraisal on file for Resident #1 (R1) and that the Reappraisal for Resident #2 (R2) was updated as frequently as necessary. This poses a potential health, safety, & personal rights risk.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: The Administrator stated that he will complete Reappraisals for R1 and R2. The Administrator agreed to provide LPA the Reappraisals for R1 and R2 via email or fax by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87459(a) · Plan of correction due date: Feb 20, 2026

87459 Functional Capabilities: (a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to.. This requirement was not evidenced by: Based on observations and records reviewed, the Licensee did not ensure that there were functional capability assessments on file for the three residents of the facility. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: The Administrator stated that he will complete functional capability assessments for all three residents. The Administrator agreed to provide the functional capability assessments for all three residents via email or fax by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(c) · Plan of correction due date: Feb 20, 2026

87507 Admission Agreements: (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative.. This requirement was not evidenced by: Based on observation and record review, the Licensee did not ensure that Resident #1 (R1) Admission Agreement was signed by a facility representative. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: The Administrator stated that he will sign R1's Admission Agreement. The Administrator agreed to provide the signed copy of R1's Admission Agreement via email or fax by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Feb 5, 2026

87303 Maintenance and Operation: (e) Water supplies ..shall be maintained as follows: (2) Faucets .. shall deliver hot water. Hot water .. shall be maintained .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not evidenced by: Based on observation, the Licensee did not ensure the facility had water as the facility was experiencing a water shutoff upon LPA's arrival. The facility remained without water for the duration of the visit. This poses and immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: The Licensee agreed to paid the outstanding balance for the facility's water bill to restore the water. The Licensee agreed to provide LPA proof of payment via email or fax by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: Feb 5, 2026

87303 Criminal Record Clearance: (e) All individuals subject to a criminal record review ..shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement was not evidenced by: Based on observation and record review, the Licensee did not ensure all staff had a criminal record clearance as one care giving staff present during the visit, Staff #4 (S4) was not background cleared. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: The Administrator stated that he will contact Guardian regarding S4's status. The Administrator stated that he will provide LPA a written plan once Guardian is contacted to ensure S4 has a criminal record clearance. The Administrator will provide the written plan to LPA via email or fax by POC date.

Type of visit: Case Management - Health Checks

On January 7, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Licensee Allen Medina was notified via telephone but was unable to assist with today's inspection. On today's visit, LPA observed six residents in care and two care giving staff present. LPA observed residents eating breakfast in the dining room. LPA observed residents to be in clean clothes. LPA, accompanied by a caregiver staff, conducted a tour of the physical plant. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed the lights in each of the resident bedrooms to be operational. LPA inspected the four shared resident bathrooms and observed them to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. The water in each of the resident bathrooms was operational and measured between 109.5 to 114.6 degrees Fahrenheit. LPA observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the five burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply in the kitchen pantry. No health or safety concerns were observed during the visit. LPA observed all of the facilities utilities to be operational during the visit. LPA additionally conducted interviews with staff and residents during the visit. CONTINUED ON LIC809-C Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with an authorized facility representative and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 7, 2026

Type of visit: Case Management - Other

On December 17, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Licensee (LI) Allen Medina was notified via telephone and later arrived to assist with the inspection. The Case Management inspection is being conducted to follow up on the annual inspection conducted on November 4, 2025. During the annual inspection, Licensees Allen Medina and Keak Vongphakdy agreed to submit the following to Community Care Licensing close of business day November 14, 2025: Payroll records for all sixteen licensed facilities for August, September, and October 2025. Utility bills for all sixteen licensed facilities for August, September, and October 2025. Food receipts for all sixteen licensed facilities for August, September, and October 2025. Rent payments for all sixteen licensed facilities for August, September, and October 2025. However, Community Care Licensing did not receive the complete records for all sixteen licensed facility's by the due date as agreed upon. Additionally, the Licensees were granted an extension to submit the complete records by close of business December 10, 2025. However, Community Care Licensing once again did not receive the complete records for all sixteen licensed facility's. Community Care Licensing will be granting one final extension to submit the requested documents for all sixteen licensed facility's by close of business December 19, 2025. Community Care Licensing is also requesting the following to be submitted by the due date: Updated LIC404 Financial Information Release and Verification forms for all sixteen licensed facility's. Based on the information above, a deficiency is being cited on today's visit. An exit interview was conducted with Licensee Allen Medina. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Dec 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(c) · Plan of correction due date: Dec 19, 2025

87755 Authority of the Licensing Agency: (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours.... This requirement is not evidenced by: The Licensees did not submit the requested documents for all sixteen licensed facility's by the due date as agreed upon during the annual inspection conducted on November 4, 2025. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 17, 2025

Plan of correction: The Licensees agreed to submit the requested documents for all sixteen licensed facility's to LPA by POC date.

Type of visit: Required - 1 Year

On November 4, 2025, Licensing Program Analysts (LPAs) Brandon Lopez and Garlli Tat made an unannounced visit to the facility to conduct the required annual inspection. LPA were greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Licensees (LIs) Allen Medina and Keak Vongphakdy were notified via telephone and later arrived to assist with the inspection. LPAs observed that Administrator Bhonalyn Ladia has a valid Administrator certificate which expires on January 29, 2027. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for six. The facility is a single story home with five resident bedrooms, one of which is shared, two staff bedrooms, five resident bathrooms, a living room, a dining room, a kitchen, a staff office, and a detached two car garage. LPAs, accompanied by the LIs, conducted a tour of the interior portions of the facility. On today's visit, LPAs observed six residents in care and two care giving staff present. LPAs observed residents relaxing in the living room and in their respective bedrooms. LPAs observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPAs inspected the five resident bedrooms and observed them to be free of hazards. LPAs observed resident 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 observed additional linens to be stored in a hallway closet. LPAs inspected the five resident bathrooms and observed them to be clean. LPAs observed resident bathrooms to be equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 111.7 and 113.3 degrees Fahrenheit. LPAs observed the two staff bedrooms to be clear of any hazards. LPAs observed the facility has a two day perishable and a seven day non-perishable food supply on hand in the kitchen. CONTINUED ON 809-C LPAs observed kitchen appliances to be clean and operational. The five burner gas stove lights unassisted. LPAs observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed chemicals and toxins to be stored in a locked cabinet in the kitchen pantry. LPAs observed a First Aid Kit to be stored in the pantry and it had all the required components. LPAs observed the facility has a three day emergency food and water supply stored in the pantry. LPAs observed fire extinguishers to be mounted on the walls in the kitchen pantry and in the resident hallway. Fire extinguishers were observed to be charged and serviced as of April 9, 2025. LPAs tested the wired smoke detectors and the individual carbon monoxide detectors which tested operational. LPAs observed the facility conducted their last emergency disaster drill on August 11, 2025. LPAs observed the centrally stored medication to be kept in the locked staff office. LPAs observed all utilities to be operational at time of visit. LPAs, accompanied by the LIs, conducted a tour of the exterior portions of the facility. LPAs observed the exterior to be free of obstructions and hazards. LPAs observed a shaded outdoor seating area with furniture for resident use. LPAs observed the perimeter gates of the facility to be self latching and can be opened in an evacuation. LPAs inspected the detached two car garage located in the front yard. LPAs observed the two car garage to be used for storage and kept locked for resident safety. There are no bodies of water on the premises. LPAs reviewed the six resident files. LPAs observed there was no Reappraisal on file for Resident #3 (R3). LPAs also observed that the Reappraisals on file for Resident #2 (R2), Resident #4 (R4), and Resident #5 (R5) were outdated. LPAs reviewed residents' medication and medication records. LPAs reviewed four staff files. All staff are background cleared and associated to the facility. LPAs observed the facility does not currently have liability insurance. Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-D. LPAs also advised the LIs of the facility's outstanding balance for their annual fees. LPAs also requested the following documents to be submitted to them via email by close of business day November 14, 2025: Payroll records for all sixteen licensed facilities for August, September, and October 2025. Utility bills for all sixteen licensed facilities for August, September, and October 2025. Food receipts for all sixteen licensed facilities for August, September, and October 2025. Rent payments for all sixteen licensed facilities for August, September, and October 2025. An exit interview was conducted with Licensees Allen Medina and Keak Vongphakdy. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Case Management - Other

On September 12, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced Case Management visit. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Licensee (LI) Allen Medina was notified via telephone and later arrived to assist with the visit. LPA is conducted the Case Management visit to deliver findings for complaint 22-AS-20250527154814 for closed facility Hills of Browning, The - 306006314. An exit interview was conducted with Licensee Allen Medina and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 12, 2025

Type of visit: Case Management - Other

On July 2, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management visit. The Case Management visit is being conducted to meet with the Administrator of Hills of Browning, The #306006314, Mar Jason Dasco. The visit is also being conducted to complete the 10-day visit in reference to complaint number 22-AS-20250626151202. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Administrator (AD) Mar Jason Dasco was present and assisted LPA with the inspection. On today's visit, LPA observed six residents in care and two care giving staff present. LPA observed residents relaxing together in the living room area. LPA, accompanied by the AD, conducted a tour of the physical plant. LPA observed the physical plant to be free of any obstructions or hazards. LPA additionally conducted one interview with the AD in reference to complaint number 22-AS-20250626151202. Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Mar Jason Dasco and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 2, 2025

Type of visit: Case Management - Health Checks

On June 25, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced Case Management visit for a Health and Safety check. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Administrator (AD) Mar Jason Dasco was notified via telephone and later arrived to assist with the inspection. On today's visit, LPA observed six residents in care and two care giving staff present. LPA observed residents eating breakfast in the dining room which included cereal, fruit, and coffee. LPA observed residents to be in clean clothes. LPA, accompanied by the AD, conducted a tour of the physical plant. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed the lights in each of the resident bedrooms to be operational. LPA inspected the three shared resident bathrooms and observed them to be clean. The water in each of the resident bathrooms were operational. Hot water temperature measured between 105.6 to 107.7 degrees Fahrenheit. LPA observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the five burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the pantry by the kitchen. No health or safety concerns were observed. LPA additionally conducted interviews with staff and residents. Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with an authorized facility representative and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 25, 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: Case Management - Other

Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management inspection. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Administrator (AD) Mar Jason Dasco later arrived to assist with the inspection. On today's visit, LPA observed five residents in care and two care giving staff present. LPA observed residents eating breakfast in the dining room. Residents appeared happy and in good health. LPA, accompanied by the AD, conducted a tour of the physical plant. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed the lights in each of the resident bedrooms to be operational. LPA inspected the five shared resident bathrooms and observed them to be clean. The water in each of the resident bathrooms were operational. Hot water temperature measured between 108.7 and 109.5 degrees Fahrenheit. LPA observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the five burner gas stove to be operational and lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in a pantry. LPA conducted interviews with staff and residents present at time of visit. Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Mar Jason Dasco and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 6, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. Facility is a single story residential home. LPA along with Licensee Maricel Nepomuceno and Administrator Justin Duclayan toured facility at 3:45 PM and observed the following: Fire clearance approval was received on 09/17/24. Structure: Facility is a one story, 6 bedroom (4 private Residents bedrooms, 1 shared resident bedroom and 1 staff room area) 5 full bathrooms house with detached garage and a beige exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms meet Licensing requirements. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall and operating landline Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Smoke Detectors: Smoke detectors and carbon monoxide detector are centrally wired and were tested operational. Facility has 3 Fire extinguishers which are mounted and charged. Facility has audible alarms on all sliding/exit doors. Appliances: Electric Stove and refrigerator are operational. Toxins: LPA observed toxins secured in laundry storage area. Sharps are secured in drawer. Water Temperature: Tested and recorded between 108.5 to 111.7 degrees F. in facility bathrooms. Reading Material Games, and Equipment: facility does exercises, puzzles, bingo and has activity directors. Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on both sides of facility as required. LPA observed shaded outdoor seating and golf green area. Backyard has outside covered Jacuzzi that is non operational. CONTINUED 809C Administrator's Certificate on file for Justin Duclayan observed on wall effective 10/3/2024- 10/2/2026 Component III Orientation was waived during this pre-licensing visit due to licensee presently operating several facilities. No deficiencies noted during todays visit. The pre-licensing visit has been completed. This location is ready for licensure. An exit interview was conducted with Administrator and a copy of report was left at facilitythe state’s words, verbatim · CDSS document, Oct 25, 2024

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 4 COMP II Participants: Name - Maricel Nepomuceno CEO/ Justin Duclayan Administrator Interview Method: Telephone interview On October 4, 2024, 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 the 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, Oct 4, 2024