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Type of visit: Required - 1 Year

On 01/12/2026 at approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Administrator, Hezle Lomibao. The facility has an approved fire clearance for a capacity of four (4) residents, including up to three (3) non-ambulatory residents and one (1) bedridden resident. The facility also has an approved hospice waiver for up to three (3) individuals. Facility is a single-story building with 4 Resident bedrooms, 2 bathrooms, and common spaces. At approximately 10:05AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:45AM, LPA and Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked housekeeping closet in the laundry room next to garage. Water temperature measured 109.6 degrees F and 110.4 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire Extinguishers found to be last charged on 09/15/2025 at the time of visit. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a cabinet in the hallway. Continued on LIC809-C page... Continued from LIC809 page... At approximately 11:35AM, LPA reviewed 3 resident records and found 3 out of 3 residents did have current physician's reports, care plans, signed admission agreements with North Bay Regional Center, and physician's orders on file. Medication records are thorough and contained physician's orders for each resident. At approximately 12:05PM, LPA reviewed 3 staff records. 3 of 3 records did contain required documentarians. LPA was presented with proof of current CPR & 1st Aid certification for the whole staff. Administrator Certificate is for Hezle Lomibao #6065313740 expires 06/09/2026. Facility conducted and documented a disaster drill on 12/17/2025. LPA reviewed the facility emergency disaster plan. Facility has supplies enough to operate for more than 72 hours in an emergency. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 01/25/2026: LIC 308 Designation Facility Responsibilities LIC 500 Personnel Summary LIC 9020 Register of Facility Client’s/Resident’s Copy/Proof of Updated Certificate of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit. Exit interview conducted. Copy of report provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 12, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA)’s Shannan Hansen & Ethel Contreras arrived unannounced to conduct a required Annual inspection and was greeted by LVN Daryl C. Licensee, Melissa Lipardo arrived later for Administrator who was unable to attend. Facility has 4 residents with a fire clearance for 4 Non Ambulatory of which 1 may be bedridden (RM 3). Facility has a Hospice Waiver for three although does not have any residents/clients currently on hospice. There is 1 resident/client with a diagnosis of dementia. At approximately 11:35 am LPA’s and staff toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. At aprox 11:41am LPA’s observed kitchen cabinet containing cleaning supplies and sharp knives unlocked, although staff was present in dining room. All bedrooms were equipped with lighting/lamp, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required slip resistant mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 114.9 to 119.8 degrees F, within the allowable range of 105 to 120 degrees F. Facility understands that resident’s beds must be outfitted with mattress pads as required by Title 22 Regulations # 87307. Fire extinguishers were last charged 9/5/2024. Smoke/Carbon Monoxide combination detectors located throughout the facility are connected to ADT and tested monthly on log. Exit doors have an auditory alert system that was functional at time of inspection. Facility’s last quarterly disaster drill was conducted on 2/1/2025. Licensee indicated facility is purchasing backup generator for use during a power outage. At approximately 12:30 pm on 2/13/2025 LPA’s conducted a review of four resident files and learned that 4 of 4 residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A). Continued on 809C... Continued from 809... At approximately 1:00 pm on 2/13/2025 LPA conducted a review of five out of seventeen staff files and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements are current and LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed, although there was a discrepancy with some 1st Aid. (TA). At approximately 12:45 pm LPA’s and LVN conducted a spot check of medication and medication records. No discrepancies observed. Medication is centrally stored in a locked closet in the hallway. P&I monies documented, secured and not commingled. Hezle Lomiboa Administrator Certificate 6065313735 expires 6/9/2025. All fees are current. LPA’s and Licensee discussed facility's Infection Control Plan and Emergency Disaster plan. Exit interview conducted & copy of report left No deficiencies cited during today's inspection LPA Hansen has requested the following documents updated and submitted to CCL by 2/27/2025. LIC500- Personnel Report LIC308- Designation of Responsibility (if changes) LIC400 Cash Resources LIC402 Surety Bond LIC9020 Register of Facility Residents Emergency Disaster Plan (if changed) Copy of Current Liability Insurancethe state’s words, verbatim · CDSS document, Feb 13, 2025

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Faciltiy failed to seek timely medical attention for resident

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint findings regarding the allegation listed above and was welcomed by staff/LVN Daryl Convento who contacted by phone Licensee and authorized staff to sign for today’s visit. Facility failed to seek timely medical attention for resident – Reporting party alleges client (C1) had a seizure and facility staff neglected to take C1 to emergency room for check up and treatment. Documents obtained revealed C1 moved to facility 10/14/2022. Interview with staff (S1) informed C1 has a history of seizures although has not had one since 12/2022. One morning during the middle of the week at the end of August 2024. C1 was getting ready for the day and came into the kitchen and informed S1 they believed they may have fallen down and possibly had a seizure. S1 assessed C1 who was walking normal and not complaining of any pain or show any signs of having a seizure. C1 proceeded to, hurry to get ready to leave for the day as usual and was gone in approximately 30 minutes. Continue on LIC9099-C Unsubstantiated Continue from LIC9099- During LPA visit, while interviewing Licensee, C1 interjected stating that they fell in their room recently while getting ready for the day but didn’t get hurt and S1 assessed them. Previous Incident reports obtained revealed the facility had submitted 2 reports for C1 when they first moved in for seizures and went to the ER for treatment. Although reporting party alleges facility failed to seek timely medical attention for resident, investigation revealed client has not had a seizure in almost 2 years and went to their day program immediately after incident. Therefore, the allegation is Unsubstantiated. Although the allegation above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, Sep 24, 2024 · control 21-AS-20240911154125

Type of visit: Required - 1 Year

01/23/2023 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Daryl Convento, LVN lead staff Gemma Posadas and explained the purpose of the visit. Administrator Michael Mephleib was unavailable for the visit. LPA Knight and staff toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared. The facility has a hospice waiver for 3 residents. Bedding, linens, and towels for residents were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the residents. Medication is locked in a cabinet. The facility was observed to be at a comfortable temperature. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean, in good repair and contained necessary grab bars and non-slip floors. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational. No pools/bodies of water are on premises. No firearms are on premises. LPA requested the following documents to be sent to CCL Santa Rosa office: LIC 500- Personnel Report Most up-to-date Liability insurance In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was provided to Daryl Convento,LVN.the state’s words, verbatim · CDSS document, Jan 23, 2024