The Hills of Tree Top

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez is conducting this case management visit for the purpose of a health and safety check. LPA arrived at facility and rang the doorbell, with no answer. LPA called Administrator Shaleemar Balignasay and Licensee Maricel Nepomuceno with no availability. LPA observed all window of the facility had the shades closed and some with no shades. For this visit LPA toured the outside of the exterior portion of the facility from the outside. LPA was able to verify the house was empty with minimal furnishings in the kitchen only. Resident room are empty and very minimal furnishings, none had a bed in them. LPA observed the facility to be empty and there was no indication that there were any residents. LPA observed the facility to have running water. As of today's date the facility remains empty with no residents in care and no indications that the house is used to provide care to residents. LPA observed the facility to have minimal furnishings and resident bedrooms to be empty. LPA at the time of visit did not observe any health and safety concerns in or out of the facility. LPA left a message to both the Administrator and Licensee to contact LPA when available. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. Copy of this report was left at facility mail box and will make it available to licensee.the state’s words, verbatim · CDSS document, Aug 25, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez is conducting this case management visit for the purpose of a health and safety check. LPA arrived at facility and rang the doorbell, with no answer. Shaleemar Balignasay, Administrator arrived shortly after and met with LPA. LPA observed all window of the facility had the shades closed. LPA was granted access to the facility and LPA was able to enter the facility. LPA took a tour of the physical plant of the facility. LPA observed the facility to be empty and there was no indication that there were any residents. LPA observed the utilities were still operational and minimal food supply was in pantry. LPA observed the facility to have running water. As of today's date the facility remains empty with no residents in care and no indications that the house is used to provide care to residents. LPA observed the facility to have minimal furnishings and resident bedrooms to be empty. LPA at the time of visit did not observe any health and safety concerns in or out of the facility. Licensee to contact Community Care Licensing (CCL) to inform of when they are ready to accept new residents or if there are any changes with the license. As noted Licensee will contact CCLD once residents are being admitted. In an effort to update the facility file, the Administrator is required to submit to the licensing agency a copy of the following: An updated Personnel Report (LIC 500) and Copy of Administrator Certificate. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. This report was reviewed with Administrator and a copy of was provided to the facility.the state’s words, verbatim · CDSS document, Aug 3, 2026

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Allen Medina and explained the reason for the visit. At this time the facility has no residents. The Administrator reported that the facility is going to be sold to a new Licensee applicant and there are no plans to have any new residents move in, until after the facility is sold. LPA and the Administrator toured the facility. The facility is a single story home with a living room, dining room, kitchen, 6 bedrooms, (1 is for staff) 2 1/2 half bathrooms and a 2 car garage. LPA verified the facility is empty and has no residents. LPA verified no one is living at the facility. The living room has a screened fireplace. There is no furniture in the living room. The bedroom furniture is in the garage. The facility has no water or electricity or food. LPA informed the Administrator the facility would have to be inspected before moving any residents in, the Administrator stated he understood. There are no staff or residents at the facility so there are no records to review. LPA informed the Administrator that as long as the facility is licensed it is subject to unannounced visits by the Agency, the Administrator stated he understood. LPA consulted with the Administrator regarding the facility requirements for moving residents in and the process of closing the facility and reporting requirements. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jul 20, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA knocked at the door, no answer. LPA called the facility phone number, the number is disconnected. LPA attempted to contact the Licensee with numbers on file, no answer. LPA left a message to call LPA. No contact made. No inspection conducted.the state’s words, verbatim · CDSS document, Jul 14, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez is conducting this case management visit for the purpose of a health and safety check. LPA arrived at facility and rang the doorbell, with no answer. Shaleemar Balignasay, Administrator arrived shortly after and met with LPA. LPA observed all window of the facility had the shades closed. LPA was granted access to the facility and LPA was able to enter the facility. LPA took a tour of the physical plant of the facility. LPA observed the facility to be empty and there was no indication that there were any residents. LPA observed the utilities were still operational and minimal food supply was in pantry. LPA observed the facility to have running water. As of today's date the facility remains empty with no residents in care and no indications that the house is used to provide care to residents. LPA observed the facility to have minimal furnishings and resident bedrooms to be empty. LPA at the time of visit did not observe any health and safety concerns in or out of the facility. Licensee to contact Community Care Licensing (CCL) to inform of when they are ready to accept new residents or if there are any changes with the license. As noted Licensee will contact CCLD once residents are being admitted. In an effort to update the facility file, the Administrator is required to submit to the licensing agency a copy of the following: An updated Personnel Report (LIC 500) and Copy of Administrator Certificate. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. This report was reviewed with Administrator and a copy of was provided to the facility.the state’s words, verbatim · CDSS document, Jul 14, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez is conducting this case management visit for the purpose of a health and safety check. LPA arrived at facility and rang the doorbell, with no answer. LPA spoke to Shaleemar Balignasay, Administrator and explained the purpose of visit. Shaleemar Balignasay, Administrator arrived shortly after and met with LPA. LPA observed all window of the facility had the shades closed. LPA was granted access to the facility and LPA was able to enter the facility. LPA took a tour of the physical plant of the facility. LPA observed the facility to be empty and there was no indication that there were any residents. LPA observed the utilities were still operational and minimal food supply was in pantry. LPA observed the facility to have running water and hot water measured 113.9 degrees Fahrenheit. As of today's date the facility remains empty with no residents in care and no indications that the house is used to provide care to residents. LPA observed the facility to have minimal furnishings and resident bedrooms to be empty. Caregiver was unsure if the facility will be occupied or renovated for now, but that is unclear for now if and when that will happen. LPA at the time of visit did not observe any health and safety concerns in or out of the facility. Licensee to contact Community Care Licensing (CCL) to inform of when they are ready to accept new residents or if there are any changes with the license. As noted Licensee will contact CCLD once residents are being admitted. In an effort to update the facility file, the Administrator is required to submit to the licensing agency a copy of the following: An updated Personnel Report (LIC 500) and Copy of Administrator Certificate. LPA requested further documentation with a due date of July 06, 2026 to be emailed or mailed to LPA Martinez. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. This report was reviewed with Administrator and a copy of was provided to the facility.the state’s words, verbatim · CDSS document, Jun 23, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit for a Health & Safety check. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. LPA observed two residents in care and one staff present. LPA observed two residents in their bedroom. LPA observed residents to be clean and in good spirit, residents were observed to have clean clothes. LPA, conducted a tour of the physical plant. LPA inspected the 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. The water and toilets in each of the resident bathrooms were operational. The hot water temperature measured 106.4 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 four burner gas stove in operation during the visit. Knives and sharps objects are kept locked in a kitchen drawer. LPA observed the facility has a three day emergency food and water supply stored in the garage. Facility has a spare refrigerator located in the garage with additional food supply. LPA verified carbon monoxide and smoke detectors were operational. Fire extinguisher was mounted on the wall of the kitchen with service date of August 13, 2025. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom hallway. Cleaning/toxic chemical are kept locked in storage, garage is used for storage. LPA toured the backyard, no bodies of water observed. There is a shaded seating area in the front yard and backyard for residents to sit. The exit gates are operational. No obstacles or hazards observed in the backyard. Staff present are background cleared and associated to the facility. No health or safety concerns were observed. LPA observed caregiver preparing lunch. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this LIC809 was provided to the facility.the state’s words, verbatim · CDSS document, Jun 2, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit for a Health & Safety check. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. LPA met with administrator Shaleemar Balignasay. On today's visit, LPA observed four residents in care and two staff present. LPA observed two residents in the living room and two residents in their bedroom. LPA observed residents to be clean and in good spirit, residents were observed to have clean clothes. LPA, conducted a tour of the physical plant. LPA inspected the 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. The water and toilets in each of the resident bathrooms were operational. The hot water temperature measured 109.4 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 four burner gas stove in operation during the visit. Knives and sharps objects are kept locked in a kitchen drawer. LPA observed staff prepping for lunch in the kitchen. LPA observed the facility has a three day emergency food and water supply stored in the garage. Facility has a spare refrigerator located in the garage with additional food supply. LPA verified carbon monoxide and smoke detectors were operational. Fire extinguisher was mounted on the wall of the kitchen with service date of August 13, 2025. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom hallway. Cleaning/toxic chemical are kept locked in storage, garage is used for Continued on LIC809-C storage. LPA toured the backyard, no bodies of water observed. There is a shaded seating area in the front yard and backyard for residents to sit. The exit gates are operational. No obstacles or hazards observed in the backyard. At time of visit LPA observed residents having lunch. All staff present are background cleared and associated to the facility. No health or safety concerns were observed. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. This report was reviewed with Administrator and a copy of this LIC809 was provided to the facility.the state’s words, verbatim · CDSS document, May 19, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit for a Health & Safety check. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. LPA spoke with administrator Shaleemar Balignasay over the phone. On today's visit, LPA observed four residents in care and two staff present. LPA observed three residents in the living room doing activities and one resident in their bedroom. LPA observed residents to be in clean clothes. LPA, conducted a tour of the physical plant. LPA observe staff having activities with the residents in the living room. LPA inspected the 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. The water and toilets in each of the resident bathrooms were operational. The hot water temperature measured 114.9 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 four burner gas stove in operation during the visit. Knives and sharps objects are kept locked in a kitchen drawer. LPA observed the facility has a three day emergency food and water supply stored in the garage. Facility has a spare refrigerator located in the garage with additional food supply. LPA verified carbon monoxide and smoke detectors were operational. Fire extinguisher was mounted on the wall of the kitchen with service date of August 13, 2025. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom hallway. Cleaning/toxic chemical are kept locked in storage, garage is used for Continued on LIC809-C storage. LPA toured the backyard, no bodies of water observed. There is a shaded seating area in the front yard and backyard for residents to sit. The exit gates are operational. No obstacles or hazards observed in the backyard. At time of visit LPA observed residents having lunch. All staff present are background cleared and associated to the facility. No health or safety concerns were observed. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. This report was reviewed with Administrator and a copy of this LIC809 was provided to the facility.the state’s words, verbatim · CDSS document, May 4, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit for a Health & Safety check. LPA was greeted and granted entry into the facility by staff. LPA observed four residents in care and two staff present. LPA observed residents to be in clean clothes. LPA, conducted a tour of the physical plant. LPA observe 3 residents having lunch and 1 resident in the living room. LPA inspected the 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. The water and toilets in each of the resident bathrooms were operational. The hot water temperature measured 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 four burner gas stove in operation during the visit. Knives and sharps objects are kept locked in a kitchen drawer. LPA observed the facility has a three day emergency food and water supply stored in the garage. Facility has a spare refrigerator located in the garage with additional food supply. LPA verified carbon monoxide and smoke detectors were operational. Fire extinguisher was mounted on the wall of the kitchen with service date of August 13, 2025. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom hallway. Cleaning/toxic chemical are kept locked in storage, garage is used for storage. LPA toured the backyard, there is a shaded seating area in the front yard and backyard for residents to sit. The exit gates are operational. No obstacles or hazards observed in the backyard. All staff present are background cleared and associated to the facility. No health or safety concerns were observed. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. This report was reviewed with Administrator and a copy of this LIC809 was provided to the facility.the state’s words, verbatim · CDSS document, Apr 21, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit for a Health & Safety check. Administrator Shaleemar Balignasay was present during the visit and assisted with the inspection. LPA observed three residents in the living room watching a TV and one resident in their bedroom. LPA observed residents to be in clean clothes. LPA, conducted a tour of the physical plant. LPA inspected the 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. The water and toilets in bathrooms were operational. The hot water temperature measured 115.8 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 four burner gas stove in operation during the visit. Knives and sharps objects are kept locked in a kitchen drawer. LPA observed the facility has a three day emergency food and water supply stored in the garage. Facility has a spare refrigerator located in the garage with additional food supply. LPA additionally conducted interviews. Staff interview stated that 2 of 2 employees received their pay but they still are owed from previous pay periods. LPA verified carbon monoxide and smoke detectors were operational. Fire extinguisher was mounted on the wall of the kitchen with service date of August 13, 2025. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom hallway. LPA reviewed medication and observed medication was labeled and stored inaccessible Continued on LIC809-C to residents in care. LPA observed the first aid kit, and a first aid manual. Cleaning/toxins chemical are kept locked in the garage and the garage is used for storage, a washer and a dryer located in garage. LPA toured the backyard, no bodies of water observed. There is a shaded seating area in the front yard and backyard for residents to sit. The exit gates are operational. No obstacles or hazards observed in the backyard. All staff present are background cleared and associated to the facility. The exit gates are operational. No obstacles or hazards observed in the backyard. All staff present are background cleared and associated to the facility. No health and safety concerns noted. Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC809-D for deficiencies. Civil penalty is assessed. This report was reviewed with facility representative and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.the state’s words, verbatim · CDSS document, Apr 7, 2026

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

87213 The licensee shall have a financial plan that [...] assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency. This requirement is not evidenced by: Based on interviews, the Licensee did not ensure employees have received their backpay from previous pay periods. This poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: The Administrator/Licensee to submit a financial plan to ensure that staff receive their pay that is due, and for pay periods moving forward. the finacial plan shall be submitted via email or fax by POC date. This area was cited on 3/11/26. Due to deficiencies not corrected facility is receiving civil penalty.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit for a Health & Safety check. Administrator Shaleemar Balignasay was present during the visit and assisted with the inspection. LPA observed three residents in the living room watching a TV and one resident in their bedroom. LPA observed residents to be in clean clothes. LPA, conducted a tour of the physical plant. LPA inspected the 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. The water and toilets in bathrooms were operational. The hot water temperature measured 113.1 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 four burner gas stove in operation during the visit. Knives and sharps objects are kept locked in a kitchen drawer. LPA observed the facility has a three day emergency food and water supply stored in the garage. Facility has a spare refrigerator located in the garage with additional food supply. LPA additionally conducted interviews. Staff interview stated that 2 of 2 employees received their pay but they still are owed from previous pay periods. LPA verified carbon monoxide and smoke detectors were operational. Fire extinguisher was mounted on the wall of the kitchen with service date of April 9, 2025. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom hallway. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA observed the first aid kit, and a first aid manual. Cleaning/toxins chemical are kept locked in the garage and the garage is used for storage, a washer and a dryer located in garage. LPA toured the Continued on LIC809-C backyard, no bodies of water observed. There is a shaded seating area in the front yard and backyard for residents to sit. The exit gates are operational. No obstacles or hazards observed in the backyard. All staff present are background cleared and associated to the facility. The exit gates are operational. No obstacles or hazards observed in the backyard. All staff present are background cleared and associated to the facility. No health and safety concerns noted. Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC809-D for deficiencies. Civil penalty is assessed. This report was reviewed with facility representative and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.the state’s words, verbatim · CDSS document, Apr 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Apr 3, 2026

87213 The licensee shall have a financial plan that [...] assures sufficient resources to meet operating costs for care of residents; 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 is not evidenced by: Based on interviews, the Licensee did not ensure employees have received their full pay. This poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Apr 2, 2026

Plan of correction: The Administrator/Licensee to submit a financial plan to ensure that staff receive their pay that is due, and for pay periods moving forward. the finacial plan shall be submitted via email or fax by POC date. This area was cited on 3/11/26. Due to deficiencies not corrected facility is receiving civil penalty.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit for a Health & Safety check. Administrator Shaleemar Balignasay was present during the visit and assisted with the inspection. On today's visit, LPA observed four residents in care and two staff present. LPA observed two residents in the living room watching a TV and two residents having breakfast. LPA observed residents to be in clean clothes. LPA, conducted a tour of the physical plant. LPA inspected the 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. The water and toilets in each of the resident bathrooms were operational. The hot water temperature measured 109.7 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 four burner gas stove in operation during the visit. Knives and sharps objects are kept locked in a kitchen drawer. LPA observed the facility has a three day emergency food and water supply stored in the garage. Facility has a spare refrigerator located in the garage with additional food supply. LPA additionally conducted interviews. Staff interview stated that 1 od 2 employees received their pay and 1 of 2 employees has not received their pay. LPA verified carbon monoxide and smoke detectors were operational. Fire extinguisher was mounted on the wall of the kitchen with service date of April 9, 2025. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom Continued on LIC809-C hallway. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA observed the first aid kit, and a first aid manual. Cleaning/toxins chemical are kept locked in the garage and the garage is used for storage, a washer and a dryer located in garage. LPA toured the backyard, no bodies of water observed. There is a shaded seating area in the front yard and backyard for residents to sit. The exit gates are operational. No obstacles or hazards observed in the backyard. All staff present are background cleared and associated to the facility. No health or safety concerns were observed., washer was in use and there was a dryer. LPA toured the backyard, no bodies of water observed. There is a shaded seating area in the front yard and backyard for residents to sit. The exit gates are operational. No obstacles or hazards observed in the backyard. All staff present are background cleared and associated to the facility. Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC809-D for deficiencies. Civil penalty is assessed. This report was reviewed with facility representative and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.the state’s words, verbatim · CDSS document, Mar 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Mar 26, 2026

87213 The licensee shall have a financial plan that [...] assures sufficient resources to meet operating costs for care of residents; 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 is not evidenced by: Based on interviews, the Licensee did not ensure employees are receiving their paychecks timely. One staff interviews conducted confirmed that they have not been paid. This poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: The Administrator/Licensee to submit a financial plan to ensure that staff receive their pay that is due, and for pay periods moving forward. the finacial plan shall be submitted via email or fax by POC date. This area was cited on 3/11/26. Due to deficiencies not corrected facility is receiving civil penalty.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit for a Health & Safety check. LPA was greeted and granted entry into the facility by staff. LPA met with administrator Shaleemar Balignasay. LPA observed four residents in care and two staff present. LPA observed residents to be in clean clothes. LPA, conducted a tour of the physical plant. LPA observe staff having activities with the residents in the living room. LPA inspected the 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. The water and toilets in each of the resident bathrooms were operational. The hot water temperature measured 107. 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 four burner gas stove in operation during the visit. Knives and sharps objects are kept locked in a kitchen drawer. LPA observed the facility has a three day emergency food and water supply stored in the garage. Facility has a spare refrigerator located in the garage with additional food supply. LPA verified carbon monoxide and smoke detectors were operational. Fire extinguisher was mounted on the wall of the kitchen with service date of April 9, 2025. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom hallway. Cleaning/toxic chemical are kept locked in storage, garage is used for storage. LPA toured the backyard, there is a shaded seating area in the front yard and backyard for residents to sit. The exit gates are operational. No obstacles or hazards observed in the backyard. All staff present are background cleared and associated to the facility. No health or safety concerns were observed. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. This report was reviewed with Administrator and a copy of this LIC809 was provided to the facility.the state’s words, verbatim · CDSS document, Mar 18, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit for a Health & Safety check. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator Shaleemar Balignasay was present during the visit and assisted with the inspection. On today's visit, LPA observed four residents in care and two staff present. LPA observed three residents in the living room watching a movie and one resident in their bedroom. LPA observed residents to be in clean clothes. LPA, conducted a tour of the physical plant. LPA inspected the 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. The water and toilets in each of the resident bathrooms were operational. The hot water temperature measured 113.1 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 four burner gas stove in operation during the visit. Knives and sharps objects are kept locked in a kitchen drawer. LPA observed the facility has a three day emergency food and water supply stored in the garage. Facility has a spare refrigerator located in the garage with additional food supply. LPA additionally conducted interviews. Staff interview stated that 1 od 2 employees received partial pay and 1 of 2 employees has not received their pay. LPA verified carbon monoxide and smoke detectors were operational. Fire extinguisher was mounted on the wall of the kitchen with service date of April 9, 2025. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom hallway. LPA reviewed medication and observed medication was labeled and stored Continued on LIC809-C inaccessible to residents in care. LPA observed the first aid kit, and a first aid manual. Cleaning/toxic chemical are kept locked in storage, garage is used for storage, washer was in use and there was a dryer. LPA toured the backyard, no bodies of water observed. There is a shaded seating area in the front yard and backyard for residents to sit. The exit gates are operational. No obstacles or hazards observed in the backyard. All staff present are background cleared and associated to the facility. No health or safety concerns were observed. Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC809-D for deficiencies. Civil penalty is assessed. This report was reviewed with facility representative and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.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 The licensee shall have a financial plan that [...] assures sufficient resources to meet operating costs for care of residents; 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 is not evidenced by: Based on observation and interviews, the Licensee did not ensure employees are receiving their paychecks timely. Two staff interviews conducted confirmed that they have not been paid or receive partial pay. This poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: The Administrator/Licensee to submit a financial plan to ensure that staff receive their pay that is due, and for pay periods moving forward. the finacial plan shall be submitted via email or fax by POC date. This area was cited on 2/26/26. Due to deficiencies not corrected facility is receiving civil penalty.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.605 · Plan of correction due date: Mar 12, 2026

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests...This requirement is not met as evidenced by: Based on observation and interviews the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA was informed Licensee currently does not have liability insurance for the facility.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: The Adminstrator/Licensee to provide LPA proof of liability insurance for the facility via email or fax by POC date. This area was cited on 2/26/26. Due to deficiencies not corrected facility is receiving civil penalty.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit for a Health & Safety check. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. LPA met with administrator Shaleemar Balignasay. On today's visit, LPA observed four residents in care and two staff present. LPA observed two residents in the living room watching a movie and two residents in their bedroom. LPA observed residents to be in clean clothes. LPA, conducted a tour of the physical plant. LPA observe staff having activities with the residents in the living room. LPA inspected the 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. The water and toilets in each of the resident bathrooms were operational. The hot water temperature measured 116.8 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 four burner gas stove in operation during the visit. Knives and sharps objects are kept locked in a kitchen drawer. LPA observed the facility has a three day emergency food and water supply stored in the garage. Facility has a spare refrigerator located in the garage with additional food supply. LPA additionally conducted interviews. LPA verified carbon monoxide and smoke detectors were operational. Fire extinguisher was mounted on the wall of the kitchen with service date of April 9, 2025. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom hallway. Cleaning/toxic chemical are kept locked in Continued on LIC809-C storage, garage is used for storage. LPA toured the backyard, no bodies of water observed. There is a shaded seating area in the front yard and backyard for residents to sit. The exit gates are operational. No obstacles or hazards observed in the backyard. All staff present are background cleared and associated to the facility. No health or safety concerns were observed. LPA was shown and given information for payment to liability insurance and Administrator will submit insurance policy copy to LPA for verification. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. This report was reviewed with Administrator and a copy of this LIC809 was provided to the facility.the state’s words, verbatim · CDSS document, Mar 4, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced health and safety case management visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA toured the facility and observed the following: Facility is a one story home that appears clean, safe and sanitary. There are four residents present. LPA observed the residents relaxing in the living room. Residents verbalized satisfaction with facility services. LPA observed ample two day perishables and seven day non-perishables as well as ample emergency food and water. Utilities are operational and staff deny any interruption in services. LPA observed ample linens and hygiene supplies. Water temperature measured between 111.5 and 114.8 degrees F in facility restrooms. Smoke detectors are operational. Fire extinguishers are fully charged. LPA observed secured toxins and sharps as well as a first aid kit. Facility staff deny wages are owed at this time but confirm payroll was delayed 10 days. Facility does not have current liability insurance. No health or safety concerns noted during today's visit. Based on observations and interviews conducted, Deficiencies are being cited, as per Title 22 Division 6, Chapter 8 of the California Code of Regulations. An exit interview was conducted with Administrator and a copy of this report as well as appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 26, 2026

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

87213 The licensee shall have a financial plan that [...] assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records...This req is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure employees are receiving their paychecks timely. Two staff interviews conducted confirmed payroll was 10 days late. This poses an immediate health and safety risk for persons in care. CIVIL PENALTY ASSESSEDthe state’s words, verbatim · CDSS document, Feb 26, 2026

Plan of correction: The Administrator/Licensee to submit a financial plan to ensure that staff receive their pay that is due, and for pay periods moving forward. The financial plan shall be submitted via email or fax by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR1569.605 · Plan of correction due date: Feb 27, 2026

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests...This requirement is not met as evidenced by: Based on interviews conducted, the licensee did not comply with the section cited above. Licensee currently does not have liability insurance for the facility. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Feb 26, 2026

Plan of correction: Licensee to obtain liability insurance and forward proof to LPA by POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit for a Health & Safety check. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator Shaleemar Balignasay was present during the visit and assisted with the inspection. On today's visit, LPA observed four residents in care and two staff present. LPA observed two residents in the living room watching a movie and two residents in their bedroom. LPA observed residents to be in clean clothes. LPA, conducted a tour of the physical plant. LPA inspected the 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. The water and toilets in each of the resident bathrooms were operational. The hot water temperature measured 113.1 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 four burner gas stove in operation during the visit. Knives and sharps objects are kept locked in a kitchen drawer. LPA observed the facility has a three day emergency food and water supply stored in the garage. Facility has a spare refrigerator located in the garage with additional food supply. LPA additionally conducted interviews. Staff interview stated that they have not received their pay and they were told they would get paid this week or next pay period. LPA verified carbon monoxide and smoke detectors were operational. Fire extinguisher was mounted on the wall of the kitchen with service date of April 9, 2025. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom hallway. LPA reviewed medication and observed medication was labeled and stored Continued on LIC809-C. inaccessible to residents in care. LPA observed the first aid kit, and a first aid manual. Cleaning/toxic chemical are kept locked in storage, garage is used for storage, washer was in use and there was a dryer. LPA toured the backyard, no bodies of water observed. There is a shaded seating area in the front yard and backyard for residents to sit. The exit gates are operational. No obstacles or hazards observed in the backyard. All staff present are background cleared and associated to the facility. No health or safety concerns were observed. Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC809-D for deficiencies. An immediate civil penalty is assessed. This report was reviewed with facility representative and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.the state’s words, verbatim · CDSS document, Feb 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87213 · Plan of correction due date: Feb 18, 2026

87213 The licensee shall have a financial plan that [...] assures sufficient resources to meet operating costs for care of residents; 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 is not evidenced by: Based on observation and interviews, the Licensee did not ensure employees are receiving their paychecks timely. Two staff interviews conducted confirmed that they have not been paid. This poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Feb 17, 2026

Plan of correction: The Administrator/Licensee to submit a financial plan to ensure that staff receive their pay that is due, and for pay periods moving forward. the finacial plan shall be submitted via email or fax by POC date. This area was cited on 1/8/26. Due to deficiencies not corrected facility is receiving civil penalty.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.605 · Plan of correction due date: Feb 18, 2026

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests...This requirement is not met as evidenced by: Based on observation and interviews the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA was informed Licensee currently does not have liability insurance for the facility.the state’s words, verbatim · CDSS document, Feb 17, 2026

Plan of correction: The Adminstrator/Licensee to provide LPA proof of liability insurance for the facility via email or fax by POC date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management visit for a Health & Safety check. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Shaleemar Balignasay was present during the visit and assisted with the inspection. On today's visit, LPA observed five residents in care and two staff present. LPA observed two residents in the living room watching a movie and three residents sleeping in their bedroom. LPA observed residents to be in clean clothes. LPA, accompanied by the administrator, 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. The water and toilets in each of the resident bathrooms were operational. The hot water temperature measured 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 four burner gas stove in operation during the visit. Knives and sharps objects are kept locked in a kitchen drawer. LPA observed the facility has a three day emergency food and water supply stored in the garage. Facility has a spare refrigerator located in the refrigerator with additional food supply. LPA additionally conducted interviews. Staff interview stated that they had received their back pay for December and received partial payment for January and or pay was not Continued on LIC809-C. paid accurately. LPA reviewed residents records and obtained copies of pertinent documents. LPA verified carbon monoxide and smoke detectors were operational. Fire extinguisher was mounted on the wall of the kitchen with service date of April 9, 2025. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom hallway. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA observed the first aid kit, and a first aid manual. Cleaning/toxic chemical are kept locked in storage, garage is used for storage, washer was in use and there was a dryer. LPA toured the backyard, no bodies of water observed. There is a shaded seating area in the front yard and backyard for residents to sit. The exit gates are operational. No obstacles or hazards observed in the backyard. All staff present (2), Administrator/caregiver and 1 caregivers, are background cleared and associated to the facility. No health or safety concerns were observed. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. This report was reviewed with Administrator and a copy of this LIC809 was provided to the facility.the state’s words, verbatim · CDSS document, Feb 4, 2026

Type of visit: Case Management - Health Checks

On January 8, 2026, Licensing Program Analyst (LPA) Garlli Tat made an unannounced case management visit for a Health & Safety check. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Shaleemar Balignasay was present during the visit and assisted with the inspection. On today's visit, LPA observed five residents in care and two staff present. LPA observed residents sleeping in their respective rooms and having lunch in the kitchen. LPA observed residents to be in clean clothes. LPA, accompanied by the administrator, 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. The water and toilets in each of the resident bathrooms were operational. The hot water temperature measured 114.0 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 four burner gas stove lights unassisted. LPA observed the facility has a three day emergency food and water supply stored in the garage. No health or safety concerns were observed. LPA additionally conducted interviews with two staff and one resident. Per staff interviewed, it was reported that they only received partial pay for the pay period between December 1 - 15, 2025. It was also reported that payments have also been delayed. LPA obtained the Identification and Emergency Information sheet for each resident. Continued on LIC 809-C. Based on the observations made during today's visit, one deficiency is being cited per Title 22 of California Code of Regulations. An exit interview was conducted with administrator Shaleemar Balignasay and a copy of the report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jan 8, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87213 · Plan of correction due date: Jan 16, 2026

87213 The licensee shall have a financial plan that [...] assures sufficient resources to meet operating costs for care of residents; 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 is not evidenced by: Based on observation and interviews, the Licensee did not ensure employees are receiving their full paychecks timely. Two staff interviews conducted confirmed that they have not been paid in full for December 2025. This poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Jan 8, 2026

Plan of correction: The Licensee will create a financial plan to ensure staff receive their pay for the previous pay period and pay periods moving forward. The Licensee that will provide CCLD with the financial plan via email or fax by the POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez is conducting this case management visit for the purpose of a health and safety check. Five (5) residents currently reside at this location and hospice services are being provided to three (3) residents at this time. LPA arrived at facility was greeted at the door by caregiver and granted entry. Upon entry LPA observed there was three residents in living room watching TV, one caregiver in living room with residents, one caregiver in kitchen doing meal preparation with one resident in the kitchen, and one resident in their bedroom. During the case management visit LPA took a tour of the inside of the facility, restrooms and common areas. LPA observed the kitchen is clean and organized. LPA observed that the meal prepared appeared of good quality and storage areas organized. LPA inspected food supply adequate amount was observed to be within regulations. The facility has a two-day supply of perishables, and seven-day supply of non-perishable food is available as required by regulations. Knives and sharps objects are kept locked in a kitchen drawer. LPA observed the fire extinguisher charged and mounted in the wall in the kitchen with service date of April 9, 2025. LPA inspected that medication is centrally stored in a safe locked storage closet located in the bedroom hallway of the facility. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA observed all resident rooms had the required furnishings. LPA observed all resident rooms are clean and organized. The facility stays at a comfortable temperature. LPA observed bathroom was clean and operational. LPA measured the hot water temperature which measured 117.8 Fahrenheit Degrees. LPA inspected the garage; door is kept locked. LPA observed the following an emergency food supply and water, there is a spare refrigerator with additional Continued on LIC809-C food supply, cleaning/toxic chemical are kept locked in storage, garage is used for storage, washer and dryer noted to be clean and operational. Smoke detectors/carbon monoxide detectors tested and found to be operational. LPA toured the backyard, no bodies of water observed. There is a shaded seating area in the front yard and backyard for residents to sit. The exit gate is operational. No obstacles or hazards observed in the backyard. All staff present (2), Administrator/caregiver and 1 caregiver, are background cleared and associated to the facility. LPA obtained copies of required documentation requested. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. This report was reviewed with Administrator and a copy of this LIC809 was provided to the facility.the state’s words, verbatim · CDSS document, Nov 3, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to conduct a health and safety check of the residents at the facility. LPA was greeted and granted entry by staff. LPA met with Shaleemar Balingnasay, Administrator and explained the reason for the visit. LPA and staff toured the facility. LPA observed all resident rooms had the required furnishings. LPA observed all resident rooms are clean and organized. LPA observed all resident bathrooms (3) are clean and operational. Hot water measured 109.2 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen, Knives and sharp objects are kept locked in a kitchen drawer. The fire extinguisher in the kitchen is fully charged. Medications are kept locked in a hallway cabinet. LPA observed the first aid kit and a first aid manual. The garage is kept locked and used for storage. LPA observed a emergency supply of food and water in the garage. Smoke detectors/carbon monoxide detectors tested operational. LPA and Administrator toured the backyard. No bodies of water observed. There is a shaded seating area for residents to sit in the front and backyard. There is an exit gate on each side of the backyard. The backyard connects to the front porch with a walkway. No obstacles or hazards observed in the backyard. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jun 26, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by staff. LPA met with Shaleemar Balingnasay, Administrator explained the nature of the visit. There are five (5) residents at the facility and there is two (2) residents receiving hospice services currently. LPA accompanied with Administrator began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in a spare refrigerator in the garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom hallway. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA observed the first aid kit and a first aid manual. LPA inspected the facility bathrooms (3) and LPA measured the hot water temperature which measured 109.2 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and locked storage cabinet in the garage. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all Continued on LIC809-C required components. Storage space is provided for residents in their bedroom. Smoke detectors/carbon monoxide detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there are shaded seating areas for residents’ enjoyment in the front yard as well as the backyard of the facility. LPA observed a fire extinguisher with service date of April 9, 2025, charged and mounted in the kitchen. Fire drills are conducted every three months, LPA verified fire drill logs are kept and last drill was conducted April 8, 2025. LPA began review of records. LPA reviewed three resident records. All the required documentation was present and current in the residents’ files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. LPA as a reminder provided annual fee dues information. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 26, 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: Prelicensing

Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted and granted entry. LPA met with Maricel Nepomuceno, applicant and Bryant So, Administrator. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (5) capacity, (0) ambulatory, (4) non-ambulatory, and (1) bedridden resident was submitted to CCL on 12/11/23. Structure: The facility is a one story house with an attached garage with 5 resident bedrooms, 1 staff bedroom, 2 full bathrooms, 1 half bathroom a living rooms, a dining room, and a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a back yard with exit walkways on both sides of the house with covered seating for the residents. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms will accommodate 5 residents with all bedrooms being private having one resident per room. Bedrooms Staff: Bedroom #1 is designated bedroom for live-in staff. Bathrooms: Facility has 2 full bathrooms and 1 half bathroom. All bathrooms have a working toilet, wash basin, walk in shower. Linens & Hygiene Supplies: Adequate supply of linen in hallway storage. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week. Food Service: Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen with extra Continued on LIC809-C food supplies stored in the spare refrigerator in the garage. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested, and found operational. Fire extinguishers mounted in kitchen dated 2/15/24. Appliances: Gas four burner stove, single oven, 2 refrigerator (kitchen and garage), microwave, dishwasher, washer, and dryer are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked underneath kitchen sink and garage. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 112.4 Fahrenheit degrees in facility bathrooms. Medications, First-Aid Kit & Book: Medication and First Aid kit are stored in bedroom storage cabinets locked inaccessible to residents in care. Resident & Staff Files: Resident records will be kept locked in a locked cabinet located in the office space and staff records are kept with medication storage. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation. Fire clearance: Was approved on 06/5/24. Resident bedroom #5 approved for 1 bedridden resident. Component III: Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities. The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued. Exit interview was conducted with applicant and a copy of this report was left with at the facility.the state’s words, verbatim · CDSS document, Jul 23, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 5 Census (if any clients in care): 5 COMP II Participants: So, Bryant; Nepomuceno, Maricel - Administrator/Licensee Interview Method: Telephone interview On 06/11/2024, 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 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, Jun 11, 2024