The Hills of Shay Del

Allegation investigated: Facility staff handled resident in a rough manner resulting in bruising

On July 9, 2026, at 2:00 PM Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA Kim met with Administrator (ADMIN) Heddymae Oyson and explained the purpose of the visit. ADMIN Oyson could not stay for the visit and stated that Staff Rosendo Carlo Ward could sign on behalf of the facility. The investigation consisted of the following. LPA Kim toured the facility. LPA Kim reviewed and obtained copies of the following records for one Resident: Admission Agreement, Identification and Emergency Information, Physician's Report, Appraisal Needs and Services Plans, and other pertinent records. LPA reviewed and obtained the Personnel Record, Resident Roster, and other pertinent records. LPA Kim conducted interviews with six staff and one witness The investigation revealed the following: Continued on LIC9099C Substantiated Allegation: Facility staff handled resident in a rough manner resulting in bruising It is alleged that bruising on both wrists and upper arms that appeared consistent with grab marks from resident #1’s (R1) caregiver. Based on interviews conducted, four out of six staff and one out of one witness corroborated the allegation. One out of six staff denied the allegation. One out of six staff and one out of one resident could not confirm or deny the allegation. On April 18, 2026, S5 and S6 stated they found the bruises prior to giving R1 a shower. They noticed the bruises and reported to the administrator. S6 stated that they notified R1’s responsible party, when they arrived to the facility on April 18, 2026. S3, S4, S5, and S6 stated that bruises were found on R1’s left and right wrists and upper arms. The bruising was due to caregivers grabbing or holding the resident in a rough manner. S3 and S6 stated on April 11, 2026, there were no bruise marks on R1, but on April 18, 2026, there were bruise marks evident on R1's left and right wrists and left and right upper arm areas.. S3 stated S1 and S2 admitted to them that they handled the resident in a rough manner which led to the bruising. S1 stated the bruising most likely occurred on April 15, 2026. S1 stated that S1 and S2 attempted to transfer R1 back to bed from the toilet, but R1 was fighting with S1 and S2. In order to prevent a fall or any other incident they needed to hold R1 down on their arms and wrists. Witness #1(W1) stated that the bruises were most likely from April 15, 2026, and that in April, there were no evidence of the bruises prior when they visited on April 18, 2026. W1 stated they were told from a doctor R1 went through a traumatic event because there was evidence of bruises on the left and right wrists and left and right upper arms, and there was evidence of muscle strain on R1’s neck and upper back. W1 stated that the doctor stated the bruising and muscle strains indicate trauma and that R1 was handled a rough manner. Based on record review, S3 and W1 provided photos of R1 that were taken on April 18, 2026. The bruises are located on both wrists and the upper arms of R1. They are a dark purple color. Medical record dated on April 23, 2026, stated that R1 had bruising on their left and right wrists and upper arms, muscle strain on the neck, and muscle strain on the upper back. Staffing records verified S1 and S2 worked on April 14, 2026, and April 15, 2026, and S6 worked on April 11, 2026, April 12, 2026, April 18, 2026, and April 19, 2026. Based on observation, on May 6, 2026, LPA verified that R1 had bruising on their left and right wrists and upper arm. Continued on LIC9099C Based on interviews, record review and observation, R1 was mishandled in a rough manner that led to bruises. While transferring R1, S1 and S2 handled the resident in a rough manner that led to bruises and muscle strains on their neck and upper back. Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility staff handled resident in a rough manner resulting in bruising is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. A deficiency is being cited on the attached LIC9099D. Exit interview was conducted, and a copy of the report, LIC9099D, LIC811, and the appeal rights were provided to Staff Rosendo Carlo Ward.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 22-AS-20260428141306

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 23, 2026

87464 (f)(1) Basic services shall at a minimum include. Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above. Resident #1 (R1) was handled in a rough manner on April 15, 2026, that led to bruises where their physical health, safety, or welfare were endangered. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Licensee stated they will ensure all staff are trained on how to transfer residents who have dementia and send proof of completed training and copy of the training material to CCLD via email to edward.kim@dss.ca.gov by POC due date July 9, 2026.

Type of visit: Case Management - Health Checks

On July 9, 2026, at 12:30 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim met with Administrator (ADMIN) Heddymae Oyson and explained the purpose of the visit. ADMIN Oyson could not stay for the visit, and stated Staff Rosendo Carlo Ward could sign on behalf of the facility. LPA Kim conducted a health and safety check. During the visit, LPA toured the facility and observed the following: LPA observed one staff on duty and there were zero residents at the facility. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The indoor temperature measured at 77 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line (714) 646-9615 was tested and remains available. No obstacles observed in the backyard. LPA conducted interviews with two staff. LPA observed valid certificate of liability insurance effective April 2, 2026, and expires on April 2, 2027. No deficiencies were cited during the visit. An exit interview was conducted, and a copy of this report was provided to Staff Rosendo Carlo Ward.the state’s words, verbatim · CDSS document, Jul 9, 2026

Type of visit: Case Management - Health Checks

On June 15, 2026, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim met with Administrator (ADMIN) Heddymae Oyson and explained the purpose of the visit. LPA Kim conducted a health and safety check. During the visit, LPA toured the facility and observed the following: LPA observed two staff on duty providing care to four residents. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Staff stated food gets delivered one time per week. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The hot water temperature measured at 105.6 degrees F and 106.5 degrees F. The indoor temperature measured at 77 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line (714) 646-9615 was tested and remains available. No obstacles observed in the backyard. Staff #1 on LIC 500 was not cleared and not associated to the facility. Residents interviewed stated satisfaction with facility services and denied any issues with food supply or utilities. LPA conducted interviews with three residents and two staff. LPA observed valid certificate of liability insurance effective April 2, 2026, and expires on April 2, 2027. LPA spoke with residents and resident responsible parties who stated they were provided written notices that the Department is commencing proceedings to revoke the facility's license. The notice did not state the correct contact information for the Department of Social Services Community Care Licensing Division Adult Senior Care Program Orange County Regional Office address and phone number. The notice did not state to contact the department if they were to seek the license status of the facility. LPA Kim observed the facility has a notice posted to inform all residents and residents' responsible parties about the Department is commencing proceedings to revoke the facility's license. CONTINUED ON LIC809-C Deficiencies were cited during the visit per Title 22 Division 6 Chapter 8 of the California Code of Regulations. LPA observed during the visit Staff #1 (S1) was listed on the LIC500 and was present during the visit. LPA reviewed records and found that S1 did not have background clearance and association with the facility. S1 left the facility at 9:00 AM. A notice was sent out to the resident and/or resident's responsible parties did not have a statement that directs the resident or the resident’s responsible party to contact the division for information on the license status of the facility. The notice did not provide the correct information for Department of Social Services Community Care Licensing Adult Senior Care Orange County Regional Office address and office phone number. A Civil Penalty was assessed for the amount of $100 during the visit due to S1 not having criminal background clearance and not being associated with the facility. An exit interview was conducted, and a copy of this report, LIC809D, LIC421IM, and appeal rights were provided to Administrator Heddymae Oyson..the state’s words, verbatim · CDSS document, Jun 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jun 16, 2026

CRC 87355(e)(2) All individuals subject to a criminal record review... shall prior to working, residing or volunteering.,,: Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by: Based on interviews, 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 #1 (S1) 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, Jun 15, 2026

Plan of correction: Licensee stated that they will provide background clearance prior to S1 returning to the facility. Licensee stated they will send a plan for S1, and all documentation and proof that S1 has background clearance and association to CCLD via email to edward.kim@dss.ca.gov by POC due date June 16, 2026. ***Civil Penalty assessed.***

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.38(c) · Plan of correction due date: Jun 19, 2026

HSC1569.38(c) The notice provided to a resident and the resident’s responsible party, shall include the name and contact information for the local long-term care ombudsman and Community Care Licensing Division... with a statement that directs the resident or the resident's responsible party to contact the division for information on the license status of the facility... This requirement is not met as evidenced by: Based on record review, the notice sent to the residents and/or residents' responsible parties the licensee did not write the statement for information on license status and the correct contact information. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 15, 2026

Plan of correction: Licensee stated they will send a new notice to the residents and residents' responsible parties with statement that directs contact information about license status of the facility and correct information of the department and a copy to CCLD via email to edward.kim@dss.ca.gov by POC due date June 19, 2026.

Type of visit: Case Management - Health Checks

On May 21, 2026, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim was greeted and granted entry by Caregiver (CG) Yumi Lumuthang. LPA Kim spoke over the telephone with Administrator (ADMIN) Heddy Mae Oyson and explained the purpose of the visit. ADMIN Oyson stated she could not make today's visit and CG Lumuthang could sign on behalf of the facility. LPA Kim conducted a health and safety check. During the visit, LPA toured the facility and observed the following: LPA observed two staff on duty providing care to four residents. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Staff stated food gets delivered one time per week. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The hot water temperature measured at 124.8 degrees F and 125.6 degrees F. The indoor temperature measured at 76 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line (714) 646-9615 was tested and remains available. No obstacles observed in the backyard. All staff on LIC 500 are cleared and associated to the facility. Residents interviewed stated satisfaction with facility services and denied any issues with food supply or utilities. LPA conducted interviews with three residents and two staff. LPA observed valid certificate of liability insurance effective April 2, 2026, and expires on April 2, 2027. LPA spoke with residents and resident responsible parties who stated they were not provided written notice that the Department is commencing proceedings to revoke the facility's license CONTINUED ON LIC809-C While on tour of the facility, LPA Kim noticed the facility did not post a notice about the Department commencing proceedings to revoke the facility's license. The regulation states the notice needs to be in 14-point type and be posted in a conspicuous location at the facility. During the visit, the facility adjusted the hot water temperature and it was measured between 118.6 degrees F and 120.0 degrees F. Deficiencies were cited during the visit per Title 22 Division 6 Chapter 8 of the California Code of Regulations. Hot water temperature for resident bathrooms measured between 124.8 degrees F and 125.6 degrees F. The facility adjusted the hot water temperature during the visit and it measured between 118.6 degrees F and 120.0 degrees F. LPA spoke with residents and residents' responsible party who stated they were not notified about the Department commencing proceedings to revoke the facility's license. Facility did not post up a notice about the Department commencing proceedings to revoke the facility's license. The notice needs to follow the regulation of being in 14-point type and posted in a conspicuous location at the facility. A Civil Penalty was assessed during the visit for a repeat violation for resident bathrooms hot water temperature. A previous licensing report of the same violation was issued on February 17, 2026. The facility has been issued the civil penalty due to a repeating the same violation within 12 months. An exit interview was conducted, and a copy of this report, LIC809D, LIC421IM, and appeal rights were provided to Caregiver Yumi Lumuthang.the state’s words, verbatim · CDSS document, May 21, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.38(b)(1) · Plan of correction due date: May 22, 2026

1569.38 (b)(1) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party...within 10 days The department commences proceedings to... revoke the license. This requirement is not met as evidenced by Based on interviews and record review, the licensee did not comply with the section cited above. The facility did not provide a written notice to residents and resident's responsible party about Department proceeding to revoke the facility's license. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Licensee states they will inform with a written notice to all residents and resident's responsible party the Department is commencing proceedings to revoke the facility's license. Licensee will send a copy of the written notice and proof they provided written notices to the resident and resident's responsible party to CCLD via email to edward.kim@dss.ca,gov by POC due date May 22, 2026.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.38(e) · Plan of correction due date: May 22, 2026

1569.38(e) Upon providing the notice... the licensed residential care facility shall also post a written notice, in at least 14-point type, in a conspicuous location in the facility... This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above. The facility did not post a notice about the Department commencing proceedings to revoke the facility's license. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Licensee state they will post the notice and meet all the requirements for HSC 1569.38(e). They will send proof to CCLD via email to edward.kim@dss.ca.gov by POC due date May 22, 2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: May 22, 2026

87303 (e)(2) ... Faucets used by residents for personal care ... shall deliver hot water. Hot water temperature controls shall be maintained...to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above. LPA observed resident bathrooms hot water temperature measured between 124.8 degrees F and 125.6 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Deficiency cleared during the visit. Facility adjusted the water temperature for resident bathrooms that measured at 118.6 degrees F and 120.0 degrees F Civil Penalty assessed for repeat violation.

Type of visit: Case Management - Health Checks

On May 6, 2026, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim met with Administrator (ADMIN) Heddy Mae Oyson and explained the purpose of the visit. LPA Kim conducted a health and safety check. During the visit, LPA toured the facility and observed the following: LPA observed two staff on duty providing care to five residents. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Staff stated food gets delivered one time per week. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The hot water temperature measured at 113.5 degrees F. The indoor temperature measured at 76 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line (714) 646-9615 was tested and remains available. No obstacles observed in the backyard. All staff on LIC 500 are cleared and associated to the facility. Residents interviewed stated satisfaction with facility services and denied any issues with food supply or utilities. LPA conducted interviews with three residents and four staff. LPA observed valid certificate of liability insurance effective April 2, 2026, and expires on April 2, 2027. An exit interview was conducted, and a copy of this report to Administrator Heddy Mae Oyson.the state’s words, verbatim · CDSS document, May 6, 2026

Type of visit: Case Management - Health Checks

On April 22, 2026, at 9:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim met with Caregiver (CG) Juwita Elisabeth. LPA spoke with Administrator (ADMIN) Heddy Mae Oyson over the telephone and explained the purpose of the visit. ADMIN Oyson stated they could not attend today's visit and that CG Elisabeth could sign in behalf of the facility. LPA Kim conducted a health and safety check. During the visit, LPA toured the facility and observed the following: LPA observed two staff on duty providing care to five residents. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Staff stated food gets delivered one time per week. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The hot water temperature measured at 116.9 degrees F. The indoor temperature measured at 73 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line (714) 646-9615 was tested and remains available. No obstacles observed in the backyard. All staff on LIC 500 are cleared and associated to the facility. Residents interviewed stated satisfaction with facility services and denied any issues with food supply or utilities. LPA conducted interviews with two residents and two staff. LPA observed valid certificate of liability insurance effective April 2, 2026, and expires on April 2, 2027. During the visit LPA Edward Kim cleared a deficiency from an Annual Visit dated April 8, 2026, of R1's hole in their wall. The hole was patched up and good condition. An exit interview was conducted, and a copy of this report and POC Clearance letters were provided to Caregiver Juwita Elisabeth..the state’s words, verbatim · CDSS document, Apr 22, 2026

Type of visit: Required - 1 Year

On April 8, 2026, at 8:30 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator (ADMIN) Heddy Mae Oyson and explained the purpose of the visit. The facility is licensed to operate for six (6) nonambulatory residents, of 1 which may be bedridden, and has a hospice waiver for four (4) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage. LPA Kim toured inside and outside of the physical plant with ADMIN Oyson. There were no bodies of water or obstructions in the facility. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. LPA observed in resident #1’s (R1) room that there was a hole in the wall behind the reclining chair. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 109.5 degrees F. A comfortable temperature of 73 degrees F maintained in the facility. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food both were available and maintained properly. Evaluation Report Continues on LIC 809-C LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. Emergency food, emergency water, and emergency supplies are stored in the garage. A working telephone (714-646-9615) and an internet accessible device dedicated to the residents that can do video teleconference which both remain available. Last emergency drill was conducted on October 23, 2025. First aid kit is maintained and contains all the necessary elements. Fire extinguisher is mounted in the resident hall with a service date of October 23, 2025, and another fire extinguisher mounted in the kitchen with a service date of April 6, 2026. Evidence of liability insurance is effective April 2, 2026, and expires on April 2, 2027. LPA Kim conducted an audit of resident files (R1-R5), staff files (S1-S9), and medication and medication administration record. LPA observed R2 did not have a pre-appraisal needs and service plan in their file at the time of the visit. LPA Kim conducted one (1) staff interviews and three (3) resident interviews. Deficiencies were cited during the visit per Title 22 Division 6 Chapter 8 of the California Code of Regulations. LPA observed R1's room had a hole in the wall behind the recliner chair. LPA observed that R2 did not have a pre-appraisal on file. LPA observed last emergency drill was conducted on 10/23/2025. An exit interview was conducted, and a copy of this report, LIC809D, LIC811, and appeal rights were provided to Administrator Heddy Mae Oyson.the state’s words, verbatim · CDSS document, Apr 8, 2026

Type of visit: Case Management - Health Checks

On April 8, 2026, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim met with Administrator (ADMIN) Heddy Mae Oyson and explained the purpose of the visit. LPA Kim conducted a health and safety check. During the visit, LPA toured the facility and observed the following: LPA observed two staff on duty providing care to five residents. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Staff stated food gets delivered one time per week. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The indoor temperature measured at 73 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line (714) 646-9615 was tested and remains available. No obstacles observed in the backyard. All staff on LIC 500 are cleared and associated to the facility. Residents interviewed stated satisfaction with facility services and denied any issues with food supply or utilities. LPA conducted interviews with three residents and two staff. . LPA observed valid certificate of liability insurance effective April 2, 2026, and expires on April 2, 2027. An exit interview was conducted, and a copy of this report and POC Clearance letters were provided to Administrator Heddy Mae Oyson.the state’s words, verbatim · CDSS document, Apr 8, 2026

Type of visit: Case Management - Health Checks

On April 3, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purpose of conducting a Case Management - Health Checks visit. LPA introduced self, explained the reason for the visit, and was granted entry into the facility by staff. LPA Bentley spoke with Administrator (AD) Heddy Mae Oyson via telephone and explained the purpose of the visit. AD Oyson stated they could not be present during today's visit and designated Caregiver (CG) Juwit Elizabeth to sign the facility report. During today’s visit, LPA conducted a tour of the physical plant with staff and observed the following: There are currently five residents in care with three staff present. Residents were observed exercising and watching television with no concerns. Water, electricity, gas, and cable are all operational. Bathroom faucets are verified to dispense hot water between 117.6 and 119 degrees F. The kitchen was observed clean and the facility has a two day supply of perishable and seven day supply of nonperishable food items available. Emergency food and water supplies were available in the garage. Interviews were conducted with three residents and two staff. Staff stated they recently started working at the facility and there are no outstanding wages at this location. All staff on the LIC 500 are cleared and associated to the facility. Residents stated there have been no interruption in utilities, meals are served regularly, and staff are always present to assist. Liability Insurance was requested during today's visit and AD stated the facility does not currently have valid insurance. Based on today's observations, deficiencies are being cited, as per Title 22 Division 6, Chapter 8 of the California Code of Regulations. An exit interview was conducted with staff and a copy of this report provided at exit.the state’s words, verbatim · CDSS document, Apr 3, 2026

Type of visit: Case Management - Health Checks

On March 25, 2026, at 11:15 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim spoke with Administrator (ADMIN) Heddy Mae Oyson over the phone and explained the purpose of the visit. ADMIN Oyson stated they could not make it for today's visit and stated Caregiver (CG) Joey Sarmiento could sign in behalf of the facility. LPA Kim conducted a health and safety check. During the visit, LPA toured the facility and observed the following: LPA observed two staff on duty providing care to five residents. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Staff stated food gets delivered one time per week. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The indoor temperature measured at 72 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line (714) 646-9615 was tested and remains available. No obstacles observed in the backyard. All staff on LIC 500 are cleared and associated to the facility. Residents interviewed stated satisfaction with facility services and denied any issues with food supply or utilities. Facility did not notify Licensing, residents, and residents’ representatives that they received default notices of missed payments for the facility. LPA conducted interviews with three residents and two staff. The facility does not have current and valid insurance at the facility. As of today, the facility still has not provided current and valid insurance as agreed upon. Evaluation Report Continues on LIC 809-C Deficiencies were cited during the visit per Title 22 Division 6 Chapter 8 of the California Code of Regulations. The facility did not notify licensing, residents, and residents’ representatives of the default notices received. The Licensee is receiving the same citation that was issued during a previous visit conducted on March 2, 2026. The Licensee has not corrected the deficiency for not having a current and valid insurance. A Civil Penalty is being assessed for Failure to Correct/Repeat Violations for not having current and valid insurance The total amount of Civil Penalties assessed today are $900. An exit interview was conducted, and a copy of this report, LIC809D, appeal rights, and LIC 421FC were provided to Caregiver Joey Sarmiento.the state’s words, verbatim · CDSS document, Mar 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(d)(4) · Plan of correction due date: Mar 26, 2026

87211 Reporting Requirements (d) The licensee shall notify the Department... all residents, and... their representatives, in writing within two business days of any of the following... (4) The licensee receives a written notice of default of payment of rent... This requirement is not met as evidenced by: Based on Licensee interview, Licensee did not comply with the section cited above as they received notice of default on the mortgage for the facility due to being five months behind on mortgage payments and they have not provided any written notice to any resident or their family.the state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: Licensee to provide written notice to residents and their representatives of written notice they received regarding default on the mortgage for the facility and a copy of written notice to residents will be provided to LPA Edward Kim via email by POC due date March 26, 2026.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.605 · Plan of correction due date: Mar 26, 2026

Liability insurance; coverage requirements: ..all residential care facilities for the elderly.. shall maintain liability insurance covering injury to residents and guests... This requirement was not met evidenced by Based on observation, interviews, and records reviewed, the Licensee did not ensure there was RCFE liability insurance for the facility. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: Licensee stated they will provide required insurance and to provide proof to CCLD via email edward.kim@dss.ca.gov by POC due date March 26, 2026.

Type of visit: Case Management - Health Checks

On March 16, 2026, at 10:45 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim met with Administrator (ADMIN) Heddy Mae Oyson and explained the purpose of the visit. LPA Kim conducted a health and safety check. During the visit, LPA toured the facility and observed the following: LPA observed two staff on duty providing care to five residents. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Staff stated food gets delivered one time per week. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The indoor temperature measured at 72 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line (714) 646-9615 was tested and remains available. No obstacles observed in the backyard. All staff on LIC 500 are cleared and associated to the facility. Residents interviewed stated satisfaction with facility services and denied any issues with food supply or utilities. LPA conducted interviews with three residents and one staff. The facility does not have current and valid insurance at the facility. As of today, the facility still has not provided current and valid insurance as agreed upon by due date of March 3, 2026. A Civil Penalty is being assessed for Failure to Correct/Repeat Violations for not having current and valid insurance by due date The total amount of Civil Penalties assessed today are $500. An exit interview was conducted, and a copy of this report and LIC 421FC were provided to Administrator Heddy Mae Oyson.the state’s words, verbatim · CDSS document, Mar 16, 2026

Type of visit: Case Management - Health Checks

On March 11, 2026, at 12:15 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim met with Administrator (ADMIN) Heddy Mae Oyson and explained the purpose of the visit. LPA Kim conducted a health and safety check . During the visit, LPA toured the facility and observed the following: LPA observed two staff on duty providing care to five residents. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Staff stated food gets delivered one time per week. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The hot water temperature measured at 113.1 degrees F to 115.1 degrees F. The indoor temperature measured at 75 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line (714) 646-9615 was tested and remains available. No obstacles observed in the backyard. All staff on LIC 500 are cleared and associated to the facility. Residents interviewed stated satisfaction with facility services and denied any issues with food supply or utilities. Staff stated they received a partial payment for the month of February. They have not been paid according to the payment schedule. LPA conducted interviews with two staff and two residents. The facility does not have current and valid insurance at the facility. As of today, the facility still has not provided current and valid insurance as agreed upon by due date of March 3, 2026. A deficiency was cited during the visit per Title 22 Division 6 Chapter 8 of the California Code of Regulations. Staff are not being paid for their full amount and on time for the month of February. A Civil Penalty is being assessed for Failure to Correct/Repeat Violations for not having current and valid insurance by March 3, 2026. An exit interview was conducted, and a copy of this report, LIC809D, LIC 421FC, and appeal rights were provided to Administrator Heddy Mae Oyson.the state’s words, verbatim · CDSS document, Mar 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Mar 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 ensure and provide 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 11, 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 March 12, 2026.

Type of visit: Case Management - Health Checks

On February 5, 2026, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim met with Administrator (ADMIN) Heddy Mae Oyson and explained the purpose of the visit. LPA Kim conducted a health and safety check with ADMIN Oyson. During the visit, LPA toured the facility and observed the following: LPA observed two staff on duty providing care to five residents. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Staff stated food gets delivered one time per week. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The hot water temperature measured at 113,1 degrees F to 114.7 degrees F. The indoor temperature measured at 71 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line, (714) 646-9615 was tested and remains available. The patio area fan was not operating as intended. No obstacles observed in the backyard. The grass is overgrown in the backyard and front yard. All staff on LIC 500 are cleared and associated to the facility. Staff stated they did not receive their February 28, 2026 payment. They did mention that the facility informed them that since the payment was on the weekend, they would receive payment on March 2, 2026. Evaluation Report Continues on LIC 809-C Deficiencies were cited during the visit per Title 22 Division 6 Chapter 8 of the California Code of Regulations. LPA observed the facility did not have an current and valid insurance for the facility at the time of the visit. LPA observed the patio area fan was not turning on as intended. Civil Penalties of $250 is being assessed for Failure to Correct/Repeat Violations for the patio fan and the insurance. . An exit interview was conducted, and a copy of this report, LIC809D, LIC421FC, and appeal rights were provided to Administrator Heddy Mae Oyson.the state’s words, verbatim · CDSS document, Mar 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.605 · Plan of correction due date: Mar 3, 2026

Liability insurance; coverage requirements: ..all residential care facilities for the elderly.. shall maintain liability insurance covering injury to residents and guests.. This requirement was not met evidenced by: Based on observation, interviews, and records reviewed, the Licensee did not ensure there was RCFE liability insurance for the facility. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: Licensee stated they will provide required insurance and to provide proof to CCLD via email edward.kim@dss.ca.gov by POC due date March 3, 2026. Civil Penalty assessed for repeat violation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Mar 9, 2026

87303(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 met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above. LPA observed the fan in the patio room was not operating. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: Licensee stated they will fix the fan in the patio area to be operational and send evidence of correction through email to CCLD via email to edward.kim@dss.ca.gov by POC due date March 9, 2026. Civil Penalty assessed for repeat violation.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced Case Management visit to conduct a health and safety check on the residents in care. LPA was greeted and granted entry by Staff 1 (S1). Administrator (AD), Heddy "Girlie" Mae Oyson was notified by phone that LPA was at the facility. LPA asked if the facility had current liability insurance, Administrator stated that is it being taken care of by the Licensee. The Administrator could not provide proof of liability insurance. LPA and Staff 1 toured the facility. LPA observed the See Something Say Something sign (PUB 475) posted in the dining room. LPA observed the 5 burner gas stove lights unassisted. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The kitchen is clean and organized. The fire extinguisher in the dining is room is fully charged. LPA interviewed 2 residents. Both residents reported they have no issues and are doing well. LPA interviewed Staff 1 and Staff 2. Both staff members reported they are doing well and have no issues. Both staff members are background cleared and associated to the facility. LPA observed both bathrooms are clean and operational. Hot water measured 109.2 degrees Fahrenheit in both bathrooms. LPA observed all resident rooms had the required furnishings. LPA observed all resident rooms are clean and all beds have clean linen. Smoke detectors/carbon monoxide detectors tested operational. LPA toured the backyard. LPA observed the backyard grass is overgrown. No bodies of water observed. The exit gate on the North side of the house is operational. LPA and staff toured the garage. The garage is kept locked and used for storage. Staff reported that residents do no go into the garage. No obstacles or hazards observed inside or outside of the facility. No health or safety concerns observed during the visit. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations and Health and Safety Code. A Civil Penalty of $250 is being assessed for Failure to Correct/Repeat Violation. An exit interview was conducted and a copy of this report was given to the facility along with a copy of the, LIC 421-FC, LIC 809-D and Appeal Rights.the state’s words, verbatim · CDSS document, Feb 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.605 · Plan of correction due date: Feb 27, 2026

Liability insurance; coverage requirements: ..all residential care facilities for the elderly.. shall maintain liability insurance covering injury to residents and guests.. This requirement was not evidenced by: Based on observation, interviews, and records reviewed, the Licensee did not ensure there was RCFE liability insurance for the facility. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: Licensee agrees to have the required insurance and to provide proof to the Agency (CCL) by the POC due date.

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

On February 17, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegation listed above and to deliver the complaint findings. 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. During the course of the investigation, LPA conducted staff interviews, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, staff did not issue responsible party proper refund, the following has been concluded: It was alleged that staff did not issue responsible party proper refund for Resident #1 (R1). R1 was admitted to the facility on September 25, 2025, and passed away on October 19, 2025. LPA reviewed R1's admission agreement. LPA observed that on R1's admisson agreement, is states, "Per community policy, the admission agreement is automatically terminated on the date of the resident's death. The responsible party will not be responsible for any charges after the resident's date of death." CONTINUED ON LIC9099-C Substantiated LPA conducted an interview with R1's responsible party, Witness #1 (W1). W1 stated that R1's rent was paid in full for the month of October 2025. W1 confirmed that R1 passed away on October 19, 2025, and the facility did not issue them a refund for the remaining twelve days of October 2025, despite multiple request. LPA conducted an interview with Licensees Allen Medina and Maricel Nepomuceno. Both Licensees interviewed admitted that a refund had not been issued to W1 after R1 passed away on October 19, 2025. LPA also observed that there was an email exchange between W1 and Licensee Maricel Nepomuceno, in which Licensee Maricel Nepomuceno admitted that a refund was not issued to W1 after R1 passed away. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, staff did not issue responsible party proper refund. The preponderance of evidence standards has been met; therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D. An exit interview was conducted via telephone with Licensee Allen Medina. A copy of the report and Appeal Rights were provided to an authorized facility representative.the state’s words, verbatim · CDSS document, Feb 17, 2026 · control 22-AS-20260213100418

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Feb 24, 2026

87507 Admission Agreement: (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not evidenced by: Based on inteviews conducted and records reviewed, the Licensee's did not issue a refund to Resident #1's responsible party after his death. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 17, 2026

Plan of correction: The Licensee stated that he will issue a refund to Resident #1's resposible party for the remaining twelve days of October 2025. The Licensee agreed to provide LPA proof of the refund via email or fax by POC date.

Type of visit: Case Management - Health Checks

On February 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 staff after explaining the purpose for the visit. Licensee Allen Medina was notified via telephone but was unable to assist with the inspection. On today's visit, LPA observed five residents in care and two care giving staff present. 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 additional linens to be stored in a hallway closet. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the two 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 131.5 and 132.8 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 facility has a three day emergency food and water supply stored in the attached two car garage. 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 three staff and five residents during the visit. 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. CONTINUED ON LIC809-C However, the three staff stated that they have not been paid yet and do not know when they will be paid. Additionally, the three staff stated that they have been paid late in previous pay periods. LPA observed that the Licensee currently does not have liability insurance for the facility. 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. Mortgage 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 financial records or payroll records. The Licensee did not provide the mortgage 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 pages. An exit interview was conducted with Licensee Allen Medina via telephone. A copy of the report and Appeal Rights were provided to an authorized facility representative.the state’s words, verbatim · CDSS document, Feb 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Feb 18, 2026

87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents ...shall be.. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirment was not evidenced by: Based on observation, the Licensee did not ensure the water measured within regulatory requirements as the hot water temperature measured between 131.5 and 132.8 degrees Fahrenheit. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 17, 2026

Plan of correction: The Licensee was advised to adjust the hot water temperature to be within regulatory requirements. LPA will conduct a subsequent visit to measure the hot water temperature.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87213 · Plan of correction due date: Feb 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 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 17, 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 late pay of staff wages. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.605 · Plan of correction due date: Feb 18, 2026

§1569.605 Liability insurance; coverage requirements: ..all residential care facilities for the elderly.. shall maintain liability insurance covering injury to residents and guests.. This requirement was not evidenced by: Based on observation, interviews, and records reviewed, the Licensee did not ensure there was RCFE liability insurance for the facility. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 17, 2026

Plan of correction: The Licensee stated that he will create a written plan on how he will obtain RCFE liability insurance for the facility. 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 5, 2026, at 8:40 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim met with Administrator (ADMIN) Heddy Oyson and explained the purpose of the visit. LPA Kim conducted a health and safety check with ADMIN Oyson. During the visit, LPA toured the facility and observed the following: LPA observed two staff on duty providing care to five residents. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Staff stated food gets delivered one time per week. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. LPA observed the lock was missing from the right cabinet door under the kitchen sink. This is where cleaning supplies were stored such as a bottle of Cascade, a bottle of Great Value liquid detergent, Clorox all purpose spray bottle, Great Value dishwasher packs, and Clorox disinfecting wipes. Staff immediately placed a lock underneath kitchen sink. The cabinet is locked and secured. The hot water temperature measured at 108.1 degrees F. The indoor temperature measured at 72 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line, (714) 646-9615 was tested and remains available. The patio area fan and light were not turning on as intended. No obstacles or hazards observed in the backyard. All staff on LIC 500 are cleared and associated to the facility. Evaluation Report Continues on LIC 809-C LPA Kim reviewed and received copies of the facility staff roster, resident roster, and resident records of four (4) residents which included each resident's facesheet, admission agreement, physician report, reappraisal, and functional capabilities. LPA Kim reviewed and will receive through email the previous two months of the facility's electricity bills and payments, facility’s gas bills and payments, facility’s water bills and payments, and the facility’s waste management bills and payments. LPA conducted interviews with four staff and three residents. Deficiencies were cited during the visit per Title 22 Division 6 Chapter 8 of the California Code of Regulations. LPA observed the right cabinet door under the kitchen sink was missing a lock which had cleaning supplies inside of it such as a bottle of Cascade, a bottle of Great Value liquid detergent, Clorox all purpose spray bottle, Great Value dishwasher packs, and Clorox disinfecting wipes. During the visit, the staff installed the lock. LPA observed the patio area fan and light were not turning on as intended. An exit interview was conducted, and a copy of this report, LIC809D, and appeal rights were provided to Administrator Heddy Oyson.the state’s words, verbatim · CDSS document, Feb 5, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Feb 6, 2026

87309(a)...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances,... and other similar items ... are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above. LPA observed the right cabinet door under the kitchen sink was not locked with cleaning supplies. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: POC Cleared during the visit. Staff installed a lock to the cabinet door under the kitchen sink. It is now locked and secured.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Feb 19, 2026

87303(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 met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above. PA observed the fan and the light were not turning on in the patio area. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: Licensee stated they will fix the light and fan in the patio area to be functioning and send evidence of correction through email to CCLD via email to edward.kim@dss.ca.gov by POC due date February 19, 2026.

Allegation investigated: Staff did not provide authorized representative with a refund after resident passed away.

On January 15, 2026, at 8:00 AM Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA Kim spoke with Licensee (LI) Maricel Nepomuceno over the phone who stated that they could not attend today’s visit. LI Nepomuceno stated that caregiver (CG) Hannah Jose could sign on behalf of the facility. The investigation consisted of the following. LPA Kim toured the facility. LPA Kim reviewed and obtained copies of the following records for two Residents: Admission Agreement, Identification and Emergency Information, Physician's Report, Appraisal Needs and Services Plans, and other pertinent records. LPA reviewed and obtained the Personnel Record, Resident Roster, and other pertinent records. LPA Kim conducted interviews with five staff, one witness, and one resident The investigation revealed the following: Continued on LIC9099C Substantiated Allegation: Staff did not provide authorized representative with a refund after resident passed away. It is alleged the staff would refund part of the money, but the Resident #1 (R1) responsible party never received the refund. R1 moved into the facility on October 1, 2025 and passed away on October 5, 2025. The resident’s belongings were removed out of the facility in October. Based on interviews conducted, five out of five staff and one out of one witness corroborated the allegation. One out of one resident could not confirm or deny the allegation. All staff stated that R1 lived in Room 1 and passed away on October 5, 2025. All staff stated R1’s personal belongings were removed on October 6, 2025. All staff stated they heard that the facility did not provide a refund to R1 in a timely manner. S2 stated that the monthly amount for R1 was $7220. S2 stated the admission agreement stated the monthly amount for $7200 and they did not update the admission agreement for the $20 additional charge for DVR. S2 stated that the facility received and deposited a $3500 but did not deposit a check for the amount of $3720 and voided it. One witness also stated that the facility received an amount of $3500 and the facility did not deposit a check for the amount of $3720. Based on record review, the Admission Agreement dated October 1, 2025, stated R1 was admitted to the facility on October 1, 2025. The additional $20 charge for DVR was not updated on the admission agreement. A text message dated October 4, 2025, stated the DVR will be additional $20 per month. On page 5 of the Admission Agreement, stated on page 5 that the admission agreement is terminated on the date of the resident’s death and refund schedule will be prorated The admission agreement stated the responsible party will not be responsible for any charges after the resident’s date of death. A text message dated on October 6, 2025, at 12:39 PM stated that R1’s belongings were picked up and any remaining items will be removed that same day. A text message dated on October 13, 2025, at 2:39 PM, shows a check dated October 2, 2025, for the amount of $3720 marked “Void.” Based on observation, LPA verified that R1 no longer resides at the facility via the Resident Roster dated December 10, 2025. R1 passed away on October 5, 2025, and all of their belongings were removed from Room 1. Continued on LIC9099C Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff did not provide authorized representative with a refund after resident passed away is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. A deficiency is being cited on the attached LIC9099D. A civil penalty was assessed for a repeated deficiency. Exit interview was conducted, and a copy of the report, LIC9099D, LIC811s, a civil penalty, and the appeal rights were provided to Caregiver Hannah Jose and a copy of the report will be mailed to the corporate address.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 22-AS-20260109143610

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Jan 23, 2026

1569.652(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual... within 15 days. This requirement is not met as evidenced by Based on record review, interview, and observation, the licensee did not comply with the section cited above. A refund was not issued to R1’s responsible party who paid for the month of October. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Licensee states they will pay a refund of $2335.48 to R1’s Responsible Party who paid the October payment and will send proof of payment to CCLD via email to Edward.kim@dss.ca.gov by POC due date January 23, 2026. A Civil Penalty was assessed for a repeated violation for deficiency on HSC 1569.652(c) within the year.

Allegation investigated: Staff did not provide authorized representative with a refund after resident passed away.

On January 5, 2026, at 8:30 AM Licensing Program Analyst (LPA) Edward Kim conducted an unannounced initial complaint visit at the facility. LPA Kim met with Administrator (ADMIN) Joanna Gomez and explained the purpose of the visit. During today's visit, LPA Kim conducted a tour of the indoor and outdoor physical plant with ADMIN Gomez, and no concerns were observed. LPA Kim reviewed and obtained copies of the following records for Resident #1 (R1): Admission Agreement, Identification and Emergency Information, Physician's Report, Appraisal Needs and Services Plans, and other pertinent records. LPA reviewed and obtained the Personnel Record, Resident Roster, and other pertinent records. LPA Kim also conducted three (3) staff interview. The investigation revealed the following: Continued on LIC9099C Substantiated Allegation: Staff did not provide authorized representative with a refund after resident passed away. It is alleged the facility agreed to pay a refund, but the facility has not paid a refund for R1's responsible party after R1's death on September 25, 2025, and the removal of R1 personal belongings. Based on interviews conducted, three out of three staff corroborated the allegation. All staff stated that R1 lived in Room 3 and passed away on September 25, 2025. S1 stated R1’s personal belongings were removed on September 25, 2025. S2 and S3 stated that R1’s personal belongings were removed on September 26, 2025. S1 stated they were informed that a refund was not provided and then proceeded to let their supervisor know the situation. S2 and S3 both stated they heard that the facility did not provide a refund to R1. Based on record review, the Admission Agreement dated May 27, 2025, stated R1 was admitted to the facility on May 27, 2025. On page 5 of the Admission Agreement, it stated that anything after 14 days is refundable and will be based on a prorated amount. It is also stated on page 5 that the admission agreement is terminated on the date of the resident’s death and refund schedule remains as mentioned in the admission agreement. The admission agreement stated the responsible party will not be responsible for any charges after the resident’s date of death. The visitor’s log dated on September 25, 2025, lists three visitors on the day R1 passed. There are no future dates of anyone visiting for R1 to pick up their belongings on September 26, 2025, or any future date. An incident report dated October 3, 2025, stated that family and hospice were present at the time R1 passed away. Based on observation, LPA verified that R1 no longer resides at the facility and all of their belongings were removed. Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff did not provide authorized representative with a refund after resident passed away is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. A deficiency is being cited on the attached LIC9099D. Exit interview was conducted, and a copy of the report, LIC9099D, LIC811, and the appeal rights were provided to Administrator Joanna Gomez.the state’s words, verbatim · CDSS document, Jan 5, 2026 · control 22-AS-20251229115133

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Jan 14, 2026

1569.652(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual... within 15 days. This requirement is not met as evidenced by Based on record review, interview, and observation, the licensee did not comply with the section cited above. A refund was not issued to R1’s responsible party who paid for the month of September. This poses a potential health and safety risk to persons in care. ***This is an amended report***the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: Licensee states they will pay a refund of $1116.67 to R1’s Responsible Party who paid the September payment and the licensee will send proof of payment to CCLD via email to Edward.kim@dss.ca.gov by POC due date January 14, 2026.

Type of visit: Case Management - Other

On January 5, 2026, at 1:00 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim met with Administrator (ADMIN) Joanna Gomez and explained the purpose of the visit. LPA Kim conducted a health and safety check with ADMIN Gomez. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The hot water temperature measured between 109.6 degrees F and 111.5 degrees F. The indoor temperature measured at 72 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line, (714) 646-9615 was tested and remains available. LPA observed two staff on duty providing care to four residents. LPA Kim reviewed and received copies of the facility staff roster and resident roster. LPA Kim reviewed and received through email the previous three months of the facility's electricity bills and payments, facility’s gas bills and payments, facility’s water bills and payments, and the facility’s waste management bills and payments. LPA conducted three staff interviews. An exit interview was conducted, and a copy of this report was provided to Administrator Joanna Gomez.the state’s words, verbatim · CDSS document, Jan 5, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Jenifer Tirre conducted a case management visit for the purpose of conducting a health and safety check. LPA Tirre was greeted and granted entry into the facility by staff and explained the reason for the visit. Upon entry to facility, staff contacted Administrator Joanna Gomez and LPA Tirre spoke to Administrator over the phone regarding requested documents. Administrator Gomez, stated they were unable to come down to facility but would send representative to help with visit. LPA Tirre requested documents which Administrator Gomez provided via email. LPA confirmed received requested documents in six emails. During the inspection, LPA toured and inspected the facility with Licensee/ Owner Allen Medina. LPA Tirre observed no health and safety issues. The facility is in good repair. LPA Tirre observed property utilities are working, such as electricity, gas stove and water. LPA Tirre observed facility had adequate supply of two day perishable and seven day non-perishable food supply.. LPA observed facility to have a comfortable temperature of 75 degrees. LPA conducted health and safety checks on residents in care and observed no health or safety concerns. Based on the observations made during today’s inspection, no deficiencies are being cited at this time. An exit interview was conducted with Licensee/ Owner Allen Medina, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 3, 2025

Allegation investigated: Facility did not issue a refund

On June 18, 2025, at 9:20 AM Licensing Program Analyst (LPA) Edward Kim conducted an unannounced initial complaint visit at the facility. LPA Kim met with Administrator (ADMIN) Joanna Gomez and explained the purpose of the visit. During today's visit, LPA Kim conducted a tour of the indoor and outdoor physical plant with ADMIN Gomez, and no concerns were observed. LPA Kim reviewed and obtained copies of the following records: Resident/Staff Rosters, Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, and other pertinent records for one (1) resident as well as the Personnel Report, Health Screening, training, and other pertinent records for two (2) staff. LPA Kim also conducted three (3) staff interviews. Continued on LIC9099C Substantiated Allegation: Facility did not issue a refund It is alleged that a Resident #1 (R1) has not received a refund for over $1000 after moving out. R1 had notified facility 30 days and did not receive the refund to this date. Based on observation, LPA verified that R1 no longer resides at the facility via the Resident Roster dated June 16, 2025. R1 moved out on May 24, 2025. Based on record review, the Admission Agreement dated April 12, 2025, states “the total monthly rate will be prorated/refunded upon the resident’s admission or departure from the facility during the month provided the resident has given an appropriate 30-day notice in writing to vacate.” LPA Kim conducted three staff interviews. One out of the three staff interviews confirmed that the refund was not issued to the resident while a second staff confirmed receiving a text notification that R1 would move out on May 24, 2025. Per review of the billing invoice shows the resident paid for the month of May, but an invoice for the refund was not issued, which corroborates the allegation. Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility did not issue a refund is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. A deficiency is being cited on the attached LIC9099D. Exit interview was conducted, and a copy of the report, LIC9099D, LIC811, and the appeal rights were provided to Administrator Joanna Gomez Allegation: Facility staff are unable to communicate with residents due to language barrier. It is alleged a staff member does not speak English and are unable to communicate or understand resident. Based on observations, LPA Kim observed staff speak English to the residents. When any resident requested water or going to the bathroom, staff promptly responded in English and assisted each of the residents. Based on interviews conducted, three out of three staff and two out of six residents denied the allegation. Four out of six residents could not confirm or deny the allegation because they were not available to be interviewed at the time of visit. S1 stated all nighttime staff speak English and communicate with residents in English. S3 stated they understand and respond to the resident’s needs accordingly. All residents stated that all staff for all shifts speak English, and the staff understands and helps with all their needs. Therefore, based on interviews and observation, LPA did not find sufficient evidence to support the allegation, Facility staff are unable to communicate with residents due to language barrier. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted and a copy of the report including the LIC811 were provided to Administrator Joanna Gomez.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 22-AS-20250616162420

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Jul 2, 2025

1569.652(c)A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual... within 15 days. This requirement is not met as evidenced by: Based on observations record review, and interviews, facility did not issue a refund of $1174.19 to the resident which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: Licensee states they will send a refund to R1 for $1174.19 and send proof of copy to CCLD via email to Edward.kim@dss.ca.gov by POC due date July 2, 2025.

Type of visit: Case Management - Health Checks

On June 16, 2025, at 2:30 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim met with Administrator (ADMIN) Joanna Gomez and LPA explained the purpose of the visit. LPA Kim conducted a health and safety check with ADMIN Gomez. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The hot water temperature measured between 105.0 degrees F and 105.9 degrees F. The indoor temperature measured at 78 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line, (714) 646-9615 was tested and remains available. LPA observed three staff on duty providing care to six residents. LPA Kim reviewed and received copies of the facility staff roster and resident roster. LPA Kim reviewed and received through email the previous six months of the facility's electricity bills and payments, facility’s gas bills and payments, facility’s water bills and payments, and the facility’s waste management bills and payments. LPA conducted four staff interviews. No deficiencies were cited during the visit. An exit interview was conducted, and a copy of this report was provided to Administrator Joanna Gomez.the state’s words, verbatim · CDSS document, Jun 16, 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: o Licensee's responsibilities of facility oversight o Licensee's requirement to maintain control of facility and property o Licensee’s responsibility to maintain financially solvent o Licensee’s responsibility to communicate with the Department o Report of suspected dissolution of partnership The following was agreed upon during today's meeting: · Licensees has clarified the dissolution of partnership is not related to license but rather a separate business deal. The dissolution of partnership will not impact Licensees facilities. · The Licensees has reported they are in communication with landlords for property’s leased and will maintain a valid lease and control of property. · The Licensees will maintain payment of all facility bills and ensure sufficient staffing to meet resident’s needs. The Licensee will communicate any health and safety concerns related to the 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. · Current lease agreements with letters from landlords voiding any outstanding evictions or unlaw 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: Required - 1 Year

On April 7, 2025, at 12:15 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Yolinda Demate. Administrator (AD) Maricel Nepomuceno stated over the phone they could not make today's visit and LPA Kim explained the purpose of the visit. AD Nepomuceno stated that CG Kristyn Carteciano could sign the report in behalf of the facility. The facility is licensed to operate for six (6) nonambulatory residents, of 1 which may be bedridden, and has a hospice waiver for four (4) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage. LPA Kim toured inside and outside of the physical plant with CG Carteciano. There were no bodies of water or obstructions in the facility. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 109.5 degrees F. A comfortable temperature of 74 degrees maintained in the facility. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food both were available and maintained properly. LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. Emergency food, emergency water, and emergency supplies are stored in the garage. A working telephone (714-646-9615) and an internet accessible device dedicated to the residents that can do video teleconference which both remain available. Last emergency drill was conducted on January 13, 2025. First aid kit is maintained and contains all the necessary elements. Evidence of liability insurance is effective February 6, 2025, and expires on February 6, 2026. LPA Kim conducted an audit of resident files (R1-R4), staff files (S1-S6), and medication and medication administration record that were all in order and complete. LPA Kim conducted two (2) staff interviews and two (2) resident interviews. No deficiencies were cited during this inspection visit. An exit interview was conducted, and a copy of this report was provided to Caregiver Kristyn Carteciano.the state’s words, verbatim · CDSS document, Apr 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Administrator Assistant (ADA) Kristyn Carteciano. Carteciano notified facility Administrator (AD) Jeffrey Bencito about the visit. AD arrived shortly after. For today’s visit, LPA observed a total of 5 residents in care and 2 staff members on duty. LPA observed the Administrator's Certificate for facility AD Jeffrey Bencito which expires on 05/10/2025. LPA Ramirez toured the interior and exterior portions of the facility with AD Bencito. The facility is a single level structure and is licensed for 6 non-ambulatory residents, of which 5 may be on hospice and 1 bedridden. For this visit, there are a total of 5 residents in care. There are a total of 6 bedrooms, of which 5 are private resident bedrooms, and 1 private bedroom for staff. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 3 restrooms of which 1 is for staff and 2 are for residents. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 113.3-115.8 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and one was located by the kitchen, one by the laundry room and one by the residents bedroom hallway. CONTINUED ON LIC809-C.. LPA Ramirez observed the emergency disaster and evacuation plan, which is posted by dining area. Facility had back-up emergency food and water supply, located in the garage. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care. For the exterior portion, LPA Ramirez observed patio furniture, and the grounds were free of any hazards. There is 1 gate in the backyard, which both is self-closing and self-latching. No bodies of water were observed. LPA reviewed five resident files and two staff files. LPA interviewed residents and staff present. For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Bencito. A copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Apr 15, 2024