The Hills of Via Del Sol

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Witness 1 who reported the facility is being prepared for a new tenant and is not a facility. LPA verified there are no residents at the facility and the facility is no longer operating. An exit interview was conducted and a copy of the report left with Witness 1. Witness 1 declined to sign the report.the state’s words, verbatim · CDSS document, Jul 14, 2026

Type of visit: Case Management - Other

On July 8, 2026, at 8:30 AM, Licensing Program Analyst (LPA) Eboni Bentley conducted an announced Case Management Visit to conduct a tour of the physical plant and obtain the facility license. LPA Bentley was greeted by Licensee Maricel Nepomuceno who stated the licensee did not have access to the facility. Landlord Jonathan Mayorga arrived a short time later and granted LPA access into the interior of the facility. LPA Bentley toured the interior and exterior of the physical plant with Licensee and Landlord and observed the following: There are no residents in care. LPA observed minimal furnishings throughout the facility and resident bedrooms were empty of personal belongings. Licensee stated the facility in no longer operational and surrendered facility license to LPA. All utilities were disconnected with the exception of water that was reactivated by the Landlord as a safety precaution. On June 30, 2026, LPA requested the following records from Licensees Allen Medina and Maricel Nepomuceno with a due date of July 6, 2026. · Bank statements for March, April, May and June 2026 (outstanding) · Utilities statements for March, April, May and June 2026 (Received on July 6, 2026 via email) · Rent payments for March, April, May and June 2026 (outstanding) LPA conducted an interview with the landlord of the property, Witness #1 (W1) during the visit. W1 stated that the facility did not pay the July 2026 rent and rent payments from March-June 2026 were paid late. Licensee confirmed during the visit. CONTINUED ON LIC809-C Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A civil penalty is being assessed for a repeat violation. An exit interview was conducted with Licensee Maricel Nepomuceno and a copy of this report, LIC809D, Civil Penalty, and appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Jul 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Jul 9, 2026

87213 Finances: The licensee shall have a financial plan.. shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency... This requirement was not evidenced by: Based on interviews and record review conducted, the Licensee does not have a sufficient financial plan as they have an outstanding balance for July 2026 rent.the state’s words, verbatim · CDSS document, Jul 8, 2026

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

From the deficiency page — Deficiency type: Type A · Section cited: CCR87207 · Plan of correction due date: Jul 9, 2026

87207 False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. Based on interview and record review, the licensee made false statements on 6/30/2026 via email to LPA. Licensee stated they would provide LPA with documentation by 7/6/2026, which was not provided.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: Licensee agreed to provide LPA the written bank statements and rent records from March - July 2026 via email by POC date.

Type of visit: Case Management - Health Checks

On June 17, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for the purpose of conducting a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by Administrator (AD) Eleazar Cuyson after stating the purpose for the visit. During the inspection, LPA conducted a tour of the physical plant with AD and observed four residents in care. LPA was informed by the AD that one resident moved out on June 12, 2026 and three residents were moving out of the facility today, June 17, 2026. AD stated five out of five staff, including two administrators, submitted their resignations to the Licensee on May 29, 2026 due to non-payment of wages. Three of those staff are no longer working at the facility with two staff/administrators remaining until the final resident moves out. AD stated the facility will remain operational until fully vacant. LPA inspected the four resident bedrooms and observed one to be vacant during the visit. All common areas including the living, dining room, kitchen, and two car garage were observed to be free of any hazards, with all of the facilities utilities operational. During the visit, LPA conducted an interview with the landlord of the property, Witness #1 (W1). W1 stated rent for June 1 through June 30, 2026, in the amount of $7,000, was due on June 5, 2026. Licensee paid the full amount on June 12, 2026, however there is still an outstanding late fee due to $150. Based on the observations and information gathered during today's visit, a deficiency will be cited on the attached LIC809-D page. A civil penalty will also be assessed in the amount of $250.00 for a repeat violation, since the Licensee violated the same regulation on March 9, 2026. An exit interview was conducted with Administrator Eleazar Cuyson, a copy of this report, LIC809-D, civil penalty, and appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Jun 17, 2026

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

87213 Finances: The licensee shall have a financial plan.. shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency... This requirement was not evidenced by: Based on observation, interviews, and record review, five out of five staff did not receive pay timely on 6/7/2026, which poses and an immediate risk to persons in care. Delays in pay have resulted in staff quitting and leaving the facility.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: The Administrator stated that he will communicate with the Licensee to address pay wages. Licensee will submit a financial plan to ensure that staff receive their pay timely for next pay period and outstanding. Administrator/Licensee will submit proof to LPA by POC date.

Allegation investigated: Staff mismanaged resident's medications. Staff did not ensure resident's oxygen machine was working properly. Staff did not provide adequate food service. Staff did not ensure facility had adequate supplies. Staff does not ensure bathroom is clean and sanitized. Staff did not accord resident privacy.

On 06/03/2026, Licensing Program Analyst (LPA) contacted the licensee via email to deliver final findings regarding a complaint that was received on 09/19/2024. **Continued on 9099-C page Unsubstantiated Staff mismanaged resident's medications. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff did not ensure resident's oxygen machine was working properly. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff did not provide adequate food service. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff did not ensure facility had adequate supplies. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff does not ensure bathroom is clean and sanitized. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff did not accord resident privacy. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 22-AS-20240919083232

Type of visit: Case Management - Health Checks

On May 26, 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. Administrator (AD) Eleazar Cuyson was present and assisted with the inspection. During today’s visit, LPA conducted a tour of the physical plant with AD Eleazar Cuyson and observed the following: There are currently five residents and three staff present. Residents were observed in clean clothes, watching television, and some sleeping, with no concerns. Water, electricity, gas, and cable are all operational. Bathroom faucets are verified to dispense hot water between 113.2 and 115.6 degrees F. The kitchen was observed clean. All kitchen appliances were observed clean and operational. 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. Proof of Liability Insurance was provided and is effective from February 20, 2026 through February 20, 2027. No additional health or safety concerns were observed during the visit. Interviews were conducted with residents and staff. All residents stated there have been no interruption in utilities and staff are always present to assist. The Department began proceedings to revoke the license for the facility effective May 7, 2026. The facility is required to notify all residents and responsible parties in writing within 10 days regarding the commencement of revocation of the license. CONTINUE TO LIC809-C...... LPA spoke to five out of six responsible parties over the phone. The five responsible parties have not been notified of the commencement of revocation of the license. There is no notification of the proceedings to revoke the license posted at the facility for review. 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 Administrator Eleazar Cuyson, and a copy of this report, LIC809-D, and appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, May 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.38(b)(1) · Plan of correction due date: May 27, 2026

1569.38(b)(1) Posting of licensing reports A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following...: The department commences proceedings to... revoke the license of the facility... The requirement is not met as evidenced by: Five responsible parties have not been notified of the proceedings which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

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

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.38(e) · Plan of correction due date: May 27, 2026

1569.38(e) Posting of licensing reports Upon providing the notice described in subdivision (b), the licensed residential care facility shall also post a written notice, in at least 14-point type, in a conspicuous location in the facility, that may include posted... any other easily accessible location in the facility. The posting shall include all of the following information: The requirement is not met as evidenced by: LPA did not observe any posting regarding the revocation at the facility. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: AD stated the legal accusation document will be posted at the facility. AD to send photo of posting to LPA by POC due date.

Type of visit: Case Management - Health Checks

On May 14, 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. Administrator (AD) Eleazar Cuyson was present and assisted with the inspection. During today’s visit, LPA conducted a tour of the physical plant with AD Eleazar Cuyson and observed the following: There are currently five residents on census with one in the hospital and two staff present. Residents were observed in clean clothes, watching television, and some sleeping, with no concerns. Water, electricity, gas, and cable are all operational. Bathroom faucets are verified to dispense hot water between 115.6 and 117 degrees F. The kitchen was observed clean. All kitchen appliances to be clean and operational. kitchen appliances were observed clean and operational. 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. Proof of Liability Insurance was provided and is effective from February 20, 2026 through February 20, 2027. No additional health or safety concerns were observed during the visit. Interviews were conducted with residents and staff. All residents stated there have been no interruption in utilities and staff are always present to assist.Staff stated weekly pay is still being received. Based on today's observations, no 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 Eleazar Cuyson, and a copy of this report provided at exitthe state’s words, verbatim · CDSS document, May 14, 2026

Type of visit: Case Management - Health Checks

On April 27, 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. Administrator (AD) Janine Cuyson was present and assisted with the inspection. During today’s visit, LPA conducted a tour of the physical plant with AD Janine Cuyson and observed the following: There are currently five residents in care with three staff present. Residents were observed watching television and some sleeping with no concerns. Water, electricity, gas, and cable are all operational. Bathroom faucets are verified to dispense hot water between 115.6 and 118.2 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. Proof of Liability Insurance was provided and is effective from February 20, 2026 through February 20, 2027. Interviews were conducted with three residents and three staff. All staff stated they are being paid by check on a weekly basis. Residents stated there have been no interruption in utilities and staff are always present to assist. A record review of the Medication Administration Record (MAR) and audit of medications revealed four out of five residents' MARs with errors. Based on today's observations, a deficiency is being cited, as per Title 22 Division 6, Chapter 8 of the California Code of Regulations. An exit interview was conducted with Administrator Janine Cuyson, and a copy of this report provided at exit.the state’s words, verbatim · CDSS document, Apr 27, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465 · Plan of correction due date: Apr 28, 2026

87465 (a)A plan for incidental medical.. care shall be developed by ... encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for one out of five residents' medication which poses an immediate health, safety risk to persons in care. A record review of the Medication Administration Record (MAR) and audit of medications revealed four out of five residents' MARs with errors.the state’s words, verbatim · CDSS document, Apr 27, 2026

Plan of correction: Administrator stated that the med errors will be reported via the incident report for R1-R4 and will forward proof of staff training that has been scheduled to LPA by POC due date.

Type of visit: Case Management - Health Checks

On April 14, 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. Administrator (AD) Janine Cuyson was present and assisted with the inspection. During today’s visit, LPA conducted a tour of the physical plant with AD Janine Cuyson and observed the following: There are currently five residents in care with three staff present. Residents were observed watching television, some sleeping, and some eating breakfast with no concerns. Water, electricity, gas, and cable are all operational. Bathroom faucets are verified to dispense hot water between 115.6 and 118.2 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. Proof of Liability Insurance was provided and is effective from February 20, 2026 through February 20, 2027. Interviews were conducted with three residents and three staff. All staff stated they are being paid by check on a weekly basis, were last paid on April 10, 2026, and there are no outstanding wages. Residents stated there have been no interruption in utilities and staff are always present to assist. Based on today's observations, no 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 Janine Cuyson, and a copy of this report provided at exit.the state’s words, verbatim · CDSS document, Apr 14, 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. Administrator (AD) Janine Cuyson was present and assisted with the inspection. During today’s visit, LPA and AD Janine Cuyson conducted a tour of the physical plant and observed the following: There are currently five residents in care with three staff present. Residents were observed watching television and some sleeping with no concerns. Water, electricity, gas, and cable are all operational. Bathroom faucets are verified to dispense hot water between 115 and 117.6 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. Proof of Liability Insurance was provided and is effective from February 20, 2026 through February 20, 2027. Interviews were conducted with three residents and three staff. All staff stated they are being paid by check on a weekly basis, were last paid on April 1, 2026, and there are no outstanding wages. Residents stated there have been no interruption in utilities and staff are always present to assist. Based on today's observations, no 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 Janine Cuyson, 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 26, 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 spoke with Administrator (ADMIN) Janine Cuyson 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. Bathroom hot water temperature measured 111.5 degrees F to 114.0 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 (949-334-1281) 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. The Evidence of Liability Insurance is effective from February 20, 2026, and expires February 20, 2027. No deficiencies were cited during the visit per Title 22 Division 6 Chapter 8 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to Administrator Janine Cuyson.the state’s words, verbatim · CDSS document, Mar 26, 2026

Type of visit: Case Management - Health Checks

On March 16, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purpose of conducting a Case Management - Health Checks visit and requesting documentation. LPA introduced self to staff, explained the reason for the visit, and was granted entry into the facility by staff. Administrators (AD) Janine Cuyson and Eleazar Cuyson were present and assisted with the visit. During today’s visit, LPA and Janine Cuyson conducted a tour of the physical plant and observed the following: There are currently five residents in care with three staff present. Residents were observed dressed and watching Television in the living room area, with no concerns. Water, electricity, gas, and air conditioning are all operational. Bathroom faucets are verified to dispense hot water between 115 and 117 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. During the inspection, LPA observed all window screens throughout the facility in good repair. Interviews were conducted with residents and staff. Interviews were conducted with three residents and three staff. Five out of five residents stated utilities have been in working order with no interruption and there have been no shortage of staff or care provided. Three out of three staff confirmed there have been no interruptions in utilities and no staff shortages. All three staff reported that they were paid in full through February 18, 2026 and expect to receive their next paycheck on March 22, 2026 for days worked from February 19, 2026 through March 15, 2026. All staff stated they were fine with that date as the pay schedule had recently changed. Based on today's observations, no deficiencies are being cited. An exit interview was conducted with Administrator Janine Cuyson, and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 16, 2026

Type of visit: Case Management - Health Checks

On March 9, 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. Administrators (AD) Janine Cuyson and Eleazar Cuyson were present and assisted with the visit. During today’s visit, LPA and AD Janine Cuyson conducted a tour of the physical plant and observed the following: There are currently five residents in care with three staff present. Residents were observed watching television and some sleeping with no concerns. Water, electricity, gas, and air conditioning are all operational. Bathroom faucets are verified to dispense hot water between 106.4 and 108.6 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. During the inspection, LPA observed one out of four stove burners is non-operational and six window screens are in need of repair. Interviews were conducted with residents and staff. As of as of March 9, 2026, staff have not received received any pay due for February 2026. 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 Administrator Janine Cuyson, and a copy of this report, LIC809-D, and appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Mar 9, 2026

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

87213 Finances: The licensee shall have a financial plan that....assures sufficient resources to meet operating costs for care of residents; .... financial reports as may be required ...including interim financial statements. This requirement is not evidenced by: Based on observation, interviews, and record review, staff did not receive pay timely on 3/7/2026, which poses and an immediate risk to persons in care. Pay for period 2/19-2/28/2026 is late and staff have not been paid for as of today's visit.the state’s words, verbatim · CDSS document, Mar 9, 2026

Plan of correction: Licensee will submit a financial plan to ensure that staff receive their pay timely for next pay period and ongoing. Administrator/Licensee will submit proof to LPA by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a) · Plan of correction due date: Mar 10, 2026

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 observation and interview, the licensee did not comply with the section cited above in one out of four stove burners, which poses an immediate health and safety risk to persons in care. LPA observed one out of four stove burners is on-operational and six window screens are in need of repair.the state’s words, verbatim · CDSS document, Mar 9, 2026

Plan of correction: Licensee to repair stove top burner to ensure all four burners are operational, repair/replace six window screens and will submit proof to CCLD by POC due date.

Type of visit: Case Management - Health Checks

On March 3, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purpose of conducting a Case Management - Health Checks visit and requesting documentation. LPA introduced self, explained the reason for the visit, and was granted entry into the facility by staff. Administrators (AD) Janine Cuyson and Eleazar Cuyson were present and assisted with the visit. During today’s visit, LPA and AD Janine Cuyson conducted a tour of the physical plant and observed the following: There are currently five residents in care with four staff present. Residents were observed watching television and some sleeping with no concerns. Water, electricity, gas, and air conditioning are all operational. Bathroom faucets are verified to dispense hot water between 108.2 and 111.3 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. During the inspection, LPA observed one out of four stove burners is non-operational. Interviews were conducted with staff, and it was reported that they were expecting pay on February 27, 2026, for the hours they worked from February 4, 2026 through February 22, 2026 and have not received pay as of March 3, 2026. Based on today's observations, deficiencies are being cited, as per Title 22 Division 6, Chapter 8 of the California Code of Regulations and Health and Safety Code. CIVIL PENALTIES ASSESSED. An exit interview was conducted with Administrator Janine Cuyson, and a copy of this report, LIC809-D, LIC421IMs, and appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Mar 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Mar 4, 2026

87213 Finances: The licensee shall have a financial plan that....assures sufficient resources to meet operating costs for care of residents; .... financial reports as may be required ...including interim financial statements. This requirement is not evidenced by: Based on observation, interviews, and record review, staff did not receive pay timely on 2/27/2026, which poses and an immediate risk to persons in care. Pay for period 2/4-2/18/2026 is late and staff have not been paid for as of today's visit. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Mar 3, 2026

Plan of correction: Licensee will submit a financial plan to ensure that staff receive their pay timely for next pay period and ongoing. Administrator/Licensee will submit proof to LPA by POC date. A civil penalty was previously assessed on 2/26/2026 for failure to comply with CCR 87213

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a) · Plan of correction due date: Mar 4, 2026

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 observation and interview, the licensee did not comply with the section cited above in one out of four stove burners, which poses an immediate health and safety risk to persons in care. LPA observed one out of four stove burners is still non-operational since previous visit.the state’s words, verbatim · CDSS document, Mar 3, 2026

Plan of correction: Licensee to repair stove top burner to ensure all four burners are operational and will submit proof to CCLD by POC due date. A civil penalty was previously assessed on 2/19/2026 for failure to comply with CCR 87303(a)

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced health and safety case management visit to the facility. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the visit, LPA toured the facility and observed the following: Facility is a two story home with caregivers quarters on the second floor. Facility appears clean and sanitary. There is a gated empty pool in the backyard. Water temperature measured at 108.8 degrees F. There is ample two day perishables and seven day non-perishables. LPA observed emergency food and water as well as ample hygiene supplies. Facility provided proof of liability insurance during the visit. Interviews with staff indicate payroll was late 12 days and one out of three staff state being paid full wages. All utilities are operational during today's visit. Based on observations and interviews conducted, Deficiency is 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 Finances: The licensee shall have a financial plan that....assures sufficient resources to meet operating costs for care of residents; .... financial reports as may be required ...including interim financial statements. This requirement is not evidenced by: Based on observation and interviews, staff did not receive pay timely. Payroll was 12 days late and one out of three did not receive full wages. This poses an immediate health and safety risk to persons in care. CIVIL PENALTY ASSESSEDthe state’s words, verbatim · CDSS document, Feb 26, 2026

Plan of correction: Licensee will submit a financial plan to ensure that staff receive their pay timely for next pay period and ongoing. Administrator/Licensee will submit proof to LPA by POC date.

Type of visit: Case Management - Health Checks

On February 19, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purpose of conducting a Case Management - Health Checks visit and to request documentation. LPA introduced self to staff, explained the reason for the visit, and was granted entry into the facility. Administrator (AD) Eleazar Cuyson was present to assist with the visit. During today’s visit, LPA and AD conducted a tour of the physical plant and observed the following: There are currently five (5) residents in care with three (3) staff present. Residents were observed dressed and well groomed. Water, electricity, gas, and air conditioning were all operational. Bathroom faucets were verified to dispense hot water between 110.4 and 116 degrees F. The kitchen was observed and there is an adequate supply of perishable and non-perishable food items. One out of four stove burners was non-operational. LPA conducted interviews with five (5) residents and three (3) staff. The following documentation was requested from the facility Administrator: - Payroll records for February 2026 - Grocery receipts for February 2026 - Utility bills (water, gas, cable, and electricity) for February 2026 - Proof of rent payment for February 2026 - Proof of Liability Insurance The facility does not have current Liability Insurance. Deficiencies are being cited, as per Title 22 Division 6, Chapter 8 of the California Code of Regulations and Health & Safety Code. CIVIL PENALTY ASSESSED. An exit interview was conducted with Administrator Eleazar Cuyson, and a copy of this report, LIC809-Ds, LIC421FC, and appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Feb 19, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Feb 20, 2026

87213 Finances: The licensee shall have a financial plan that....assures sufficient resources to meet operating costs for care of residents; .... financial reports as may be required ...ncluding interim financial statements. This requirement is not evidenced by: Based on observation, interviews, and record review, staff did not receive pay timely and the Licensee failed to provide the documents requested by CCLD that were due by 3 PM on February 6, 2026. This poses an immediate health and safety risk to persons in care. Staff stated they were due pay on 2/13/2026 and have not received pay as of today's visit.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: Licensee will submit a financial plan to ensure that staff receive their pay timely for next pay period and ongoing. Administrator/Licensee will submit proof to CCLD via email or fax by POC date. A deficiency was previously cited on 11/4/2025 for failure to comply with CCR 87213. CIVIL PENALTY ASSESSED.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.605 · Plan of correction due date: Feb 20, 2026

1569.605 Liability insurance; coverage requirements: On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a ... the licensee or its employees. This requirement is not evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above, which poses an immediate health, safety, and personal rights risk to persons in care. Administrator stated the facility does not have current liability insurance.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: Administrator/Licensee will submit proof of liability insurance for the facility to CCLD via email or fax by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Feb 20, 2026

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 observation and interview, the licensee did not comply with the section cited above in one out of four stove burners, which poses an immediatel health and safety risk to persons in care. Staff stated one out of four stove burners has been non-operational for the past three days and Licensee was notified.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: Licensee to repair stove top burner to ensure all four burners are operational and will submit proof to CCLD by POC due date.

Type of visit: Case Management - Other

On February 5, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purpose of conducting a case management visit and requesting records. LPA introduced self to staff, explained the reason for the visit, and was granted entry into the facility by Administrator (AD) Janine Cuyson. During today’s visit, LPA and AD conducted a tour of the physical plant and observed the following: There are currently five (5) residents in care with three (3) staff present. Water, electricity, gas, and air conditioning are in operation. Bathroom faucets are verified to dispense hot water at 107.6 F. Perishable and non-perishable food supply observed adequately stocked and emergency food and water supplies are available. LPA conducted interviews with five (5) resident and three (3) staff. The following documentation was requested from facility staff: - Payroll records for December 2025, January & February 2026 - Grocery receipts for December 2025, January & February 2026 - Utility bills (water, gas and electricity) for December 2025, January & February 2026 - Proof of rent payments for December 2025, January & February 2026 (provided) - Proof of Liability Insurance - Resident Records: Emergency Face Sheets, Admissions Agreements, Physician's Reports, Appraisals, and Hospice Records An exit interview was conducted and a copy of this report was provided to Administrator Janine Cuyson and Eleazar Cuyson.the state’s words, verbatim · CDSS document, Feb 5, 2026

Type of visit: Case Management - Health Checks

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a case management/health check visit. LPA was greeted and granted entry by the facility caregiving staff after stating the purpose of the visit. Administrator Janine Cuyson was present on the premises and assisted with the visit. During the visit, LPA was able to verify that utilities were currently active. Room temperature was measured at 71.4F. Electricity and cable service are on. Water temperature was measured at 110F. Per facility staff interviewed, the weekly grocery run was conducted earlier on the day. Adequate supply of perishable and non-perishable food items observed in the refrigerator, freezer and pantry. There are adequate cleaning and laundry supplies stored in the garage, along with incontinence supplies in large quantity. LPA conducted two staff interviews during the visit. Two out of two interviews indicated that the next pay day was January 9, 2026 and confirmed that wages for the previous pay period had been paid with a few days' delay. There is already one active deficiency per Section 87213 of the California Code of Regulations so no additional deficiencies were cited today. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 8, 2026

Type of visit: Case Management - Legal/Non-compliance

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a case management visit following up on the non-compliance conference that took place on July 30, 2025. LPA was greeted and granted entry after introducing himself and stating the purpose of the visit. Administrator Janine Cuyson was notified via telephone and arrived later to assist with the visit. During the present visit, LPA accompanied by staff conducted a tour of the physical plant and observed the following: There are currently 5 residents in care along with two staff members present. Utilities are confirmed to be running, electricity and air conditioning are in operation. Bathroom faucets are verified to dispense hot water at 108F. Food supplies are verified to be present in sufficient quantities. Emergency food and water supplies are present. Cleaning and laundry supplies are present as well. LPA conducted two staff interviews and attempted multiple resident interviews. Additionally, LPA requested the following documentation from facility staff: - Payroll records for August, September, and October, 2025, (provided during the visit) - Grocery receipts for August, September, and October, 2025 (provided during the visit) - Utility bills (water, gas and electricity) or August, September, and October, 2025 (provided during the visit), - Proof of rent payments for August, September, and October, 2025 (provided). CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 Per a review of the utility bills provided, no payments were made towards the amount due for electricity service to the facility in either September or October, resulting in a past due balance of $3,154.59. Additionally, no payment was made towards the natural gas bill issued in October 2025 as a November 1. The account is also flagged as being "Cash Only" which indicates a history of missed or returned payments. One work wage payment to a staff member also shows as having been returned before being successfully paid out in the following days. Type B deficiency cited. Based on the observation and records reviewed during the present visit, one type B deficiency is being cited during the present visit. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.the state’s words, verbatim · CDSS document, Nov 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87213 · Plan of correction due date: Nov 21, 2025

Per CCR 87213 on Finances: "The licensee shall have a financial plan(...) that assures sufficient resources to meet operating costs for care of residents". This requirement is not met as evidenced by: Based on the review of utilities requested during the present visit, multiple occurrences of missed payments were recorded for the electricity and natural gas bills in September and October 2025. This constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: Licensee will provide proof of payment bringing utility accounts current to licensing staff before the plan of corrections due date.

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility administrator/caregiver Eleazar Cuyson after stating the purpose of the visit. There are currently four residents in care, three of which are receiving hospice care at this time. LPA observed residents relaxing in their respective bedrooms or in the facility's common living areas. LPA accompanied by facility staff toured the physical plant. The facility is a two-story house with an attached garage, with four private bedrooms, one shared bedroom. There are are one shared and one en-suite bathrooms on the premises. The upstairs portion of the house is strictly for staff use and verified not to house any residents during the visit. Bedrooms appear clean and sanitary. One resident receiving hospice care is observed to have a bed equipped with full-length bed rails. Hospice plan of care reviewed. All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary and are equipped with grab bars and slip mats. Hot water temperature measured at 111.9F. LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items, cleaning supplies and the medication central storage are verified to be secure. The fire extinguisher present is charged with up-to-date maintenance tag. Carbon monoxide and smoke detectors were found to be present and operational. CONTINUED ON FORM LIC809-C CONTINUED FROM LIC809 The garage is secured and used for the storage of supplies and food as well as the laundry area. Emergency food and water supplies verified to be present. All utilities (gas, water, electricity, internet and cable) are verified to be operational during the visit. Fresh groceries are also present. LPA and facility staff toured the outside of the facility. LPA observed a shaded outdoor seating area with furniture for resident use. The identified routes of egress are free of clutter and obstructions. There are self-latching gates on both sides of the premises. The swimming pool present in the backyard has been emptied due to lack of maintenance in the context of an ongoing dispute with the facility's landlord. It is adequately fenced and treated to avoid pests. Egress alarms are in use on exit doors, however facility does not utilize locked perimeters or delayed egress. LPA reviewed four resident records which included all necessary components. LPA reviewed resident medication records and prescription orders for two out of four residents with no discrepancies observed. LPA reviewed staff records for two staff members present during the visit. CPR training, initial and annual training reviewed for 2024 and 2025. Disaster drills are conducted and documented, however the most recent quarterly drill was not conducted as scheduled due to one staff member undergoing medical treatment. Consultation provided. Staff members are verified to be background cleared and associated to the licensed location. Based on the observation conducted during the present visit, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jul 7, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility is in financial distress. Facility did not meet the reporting requirements.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit to conclude and deliver the findings into the above allegations. LPA was greeted and granted entry by Administrator Eli Cuyson after stating the purpose of the visit. Chief Officer of Operations/Co-Founder Maricel Nepomuceno was also advised by telelphone approximately 10:13am. During today's visit, LPA observed four residents in care and two staff on duty. On April 10, 2025, the Department received the complaint. During the initial investigation visit conducted on April 17, 2025, two staff and five residents were present. LPA accompanied by Admin Cuyson, conducted a tour of the physical plant. LPA observed the utilities were operating, indoor temperature was within range, facility maintained ample food/emergency/hygiene supplies, dual functioning smoke/carbon monoxide detectors were operational, facility landline was tested and remains available. The annual licensing fee is current and facility maintains a valid lability insurance policy. LPA observed one meal service at 12:21pm. Substantiated Residents were served meatballs with veggies, orange, and a blueberry muffin during the initial visit. Hot water temperature measured at 114.4 and 106.5 degrees Fahrenheit. During the course of the investigation, LPA interviewed four staff and five residents and obtained the following documentation: Resident Rosters dated January 29, 2025 and July 2, 2025, Personnel Reports dated January 23, 2025 and July 2, 2025, Certificate of Liability Insurance, Face Sheets, Physician's Reports, Admission Agreements of five residents, bank statements, time sheet/pays tubs, utilities billing statement, Supplemental Financial Information (LIC401a), Montlhy Operating Statement (LIC401), Balance Sheet Supplemental Schedule (LIC403a), and Balance Sheet (LIC403). The investigation revealed the following: Regarding the allegation, Facility is in financial distress, based on two out of four staff interviews and correspondence obtained obtained during the investigation, the licensee has been unable to provide timely payments of the rent as required by the leasing agreement signed with the owner of the property in which the facility operates. As of this subsequent visit, licensee is seven months delinquent on lease payments from January 2025-July 2025. On May 2, 2025, an unlawful detainer was served by the landlord to the licensee, confirming that the situation was still ongoing. Evidence corroborates financial issues experienced by the licensee. Regarding the allegation, Facility did not meet the reporting requirements, neither the initial financial issues nor the issuance of an unlawful detainer were reported to the Department by facility staff. Reporting requirements were therefore not met. Therefore, based on interviews and record review, the preponderance of evidence standard has been met, and the allegations are deemed SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099D as per the Title 22, Division 6, Chapter 8. Chief Officer of Operations/Co-Founder Maricel Nepomuceno arrived approximately 1:55pm for the exit interview in which the exit interview was conducted, and a copy of this report including the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 22-AS-20250410152406

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87213 · Plan of correction due date: Jul 15, 2025

87213 Finances “The licensee shall have a financial plan (…) that assures sufficient resources to meeting operating costs of residents.” This requirement was not met as evidenced by: Based on interviews and record review, licensee had been unable to cover operating costs related to the delinquency of rental dues owed for the period of January 2025 to July 2025, which poses a potential risk to the health, safety, and/or personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: Licensee stated a resolution was in motion regarding the delinquent payments and proof of lump sum payments made to the landlord will be submitted to LPA via email by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(d) · Plan of correction due date: Jul 9, 2025

87211 Reporting Requirements (d) “The licensee shall notify the Department in writing within two business days of any of the following specified events, or knowledge thereof: (…) (2) An unlawful detainer action is initiated against the licensee. (…) (4) The licensee receives a written notice of default payment of rent. This requirement was not met as evidenced by: Based on interviews and record review, no written reports of past due rent or of an unlawful detainer were provided to the Department which poses a potential health, safety, and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: Licensee stated an Acknowledgement of Understanding indicating that they have reviewed the reporting requirements and intend to adhere will be submited to LPA via email by POC due date.

Type of visit: Case Management - Health Checks

On June 20, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced Case Management visit for a Health and Safety check. LPA was greeted and granted entry into the facility by Administrator (AD) Eleazar Cuyson who assisted LPA with the inspection. On today's visit, LPA observed four residents in care and two care giving staff present. LPA observed residents relaxing in the living room and in their respective bedrooms. LPA observed residents to be in clean clothes. LPA, accompanied by the AD, conducted a tour of the physical plant. LPA inspected the four resident bedrooms and observed them to be free of hazards. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed the lights in each of the resident bedrooms to be operational. LPA inspected the two shared resident bathrooms and observed them to be clean. The water in each of the resident bathrooms were operational. Hot water temperature measured between 111.5 to 111.9 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 facility has a three day emergency food and water supply stored in the attached two car garage. LPA observed the facility has additional hygiene supplies stored in the garage. No health or safety concerns were observed. LPA additionally conducted interviews with staff and residents. Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Eleazar Cuyson and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 20, 2025

Type of visit: Office

On today's date, Licensing Program Managers (LPM) Alisa Ortiz and Licensing Program Analysts (LPAs) Michael Tea and Brandon Lopez met with Licensee Allen Medina, Maricel Nepomuceno, and Keak Vongphakdy on this day for the purpose of discussing financial operations and distress and reporting requirements. The following was discussed: 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

Allegation investigated: Facility did not refund resident's monthly fees after resident's death.

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of delivering the findings into the above allegation. LPA was greeted and granted entry by Administrator (Admin) Eleazar Cuyson after stating the purpose of the visit. During the course of the investigation, LPA interviewed two staff and obtained pertinent records pertaining to Resident #1 (R1) such as the Resident Roster, Personnel Report Summary, Face Sheet, Physician's Report, Admission Agreement, Personal Rights of Residents, a photograph of the check, and the Death Report. The investigation revealed the following: It is alleged that the facility did not refund the resident's monthly fees after the resident's death. Per page 4 of the admission agreement signed and dated on March 24, 2024, the contract indicates that the "admission agreement is automatically terminated on the date of the resident's death." R1 passed away on January 9, 2025 per Death Report dated January 11, 2025. Substantiated Based on the interviews conducted on April 17 & 18, 2025, two out of the two staff corroborated with the allegation indicating an oversight. A photograph of the check dated April 17, 2025 intended to be issued and mailed out to R1's representative was provided to LPA via text message during the visit at 3:49pm. Based on the interviews and record review, it is determined that R1's representative was not reimbursed timely upon R1's death for January 10-31, 2025, therefore, the preponderance of evidence standard has been met and is deemed substantiated. See the attached LIC9099-D. An exit interview was conducted with Chief Executive Officer Allen Medina and Director of Business/Attorney Keack Vongphakdy, and a copy of this report including the LIC811 and the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 22-AS-20250416120858

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(5)(A) · Plan of correction due date: Apr 30, 2025

87507 Admission Agreements (5) Refund conditions. (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652. This requirement was not met as evidenced by: Based on interviews and record review, facility did not issue a refund after R1's passing for 1/10-31/25 in which poses a personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2025

Plan of correction: Licensee to provide proof that the amount issued was withdrawn and to submit an Acknowledgement of Understanding of the said deficiency to LPA via email by POC due date.

Type of visit: Case Management - Other

On 12/23/2024, LPA Mason arrived at the facility for the purpose of conducting a case management visit. LPA was greeted and granted entry by facility staff. LPA met with Eleazar Cuyson, Administrator and explained the purpose of the visit. On 12/13/2024 the Department received notification that the facility is delinquent in their lease payments. The facility stated they attempted payment on the first of the month but the transaction was unable to be processed. On 12/17/2024, the Department contacted the facility requesting proof of payment. The facility stated they received the communication, but have not provided proof to the Department yet.The facility stated they made the payment on 12/21/2024. LPA advised the facility that they would be issuing a Technical Violation and urged the facility to provide the Department with proof of the lease payment as soon as possible. Based on today's Case Management visit, a technical violation is being issued. The LPA reviewed the report with the facility and provided a copy of the LIC809 and LIC9102 to the facility.the state’s words, verbatim · CDSS document, Dec 23, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Licensee Maricel Nepomuceno. Administrator Eleazar Cuyson was present as well. An initial application to operate a Residential Care Facility for the Elderly was received by Community Care Licensing on 01/12/2024 for a capacity of six non-ambulatory residents. Upon entry, facility appears clean and sanitary. Facility has all required postings at entrance. Administrator Eleazar Cuyson has an administrator certificate expiring on 05/27/2026. This pre-licensing is a change of ownership with five residents present during today's visit. LPA Lyman along with Licensee/ Administrator toured the facility at 12:14 PM and observed the following: Structure: Facility is a two story, 4 bedroom, 2 bathroom house on first floor and two bedrooms, living area and two baths on the second floor. There is an attached garage and a white exterior. Second story is reserved for staff. The outside exit gates are closed, self latching, and unlocked. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be single and double occupancy and housed on the first floor only. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Auditory exit alarms are operational. Linens & Hygiene Supplies: Facility has ample bedding and towels in supply. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Emergency Phone Numbers and Exit Plan: Posted in the entrance of the facility. Food Service: Facility has 2 day perishables as well as 7 day non-perishables. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguisher is fully charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility has multiple secured areas for toxins and sharps. Water Temperature: Tested and recorded between 110.6 and 111.3 degrees F. in facility bathrooms. Emergency Supplies: LPA observed ample emergency food and water as well as a posted emergency disaster plan. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. CONTINUED ON LIC 809C DATED 07/22/2024. LPA observed a first aid manual. Medication is stored in a locked cabinet. Facility uses a medication administration record. Resident & Staff File: Records are stored in a secured file cabinet in the kitchen. Reading Material, Games, and Equipment: LPA observed an activity schedule with activities such as games, music therapy and exercise. Backyard: LPA observed a clean backyard with ample shaded seating for residents. Facility has a secured empty pool with a 55 inch fence around it Fire Clearance: Approved for six non-ambulatory residents on 06/19/2024. Component III waived due to multiple facilities in Orange County. Facility is ready to be licensed. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 22, 2024