Willie Care Home II

Type of visit: Required - 1 Year

On 5/22/2026, LPA Grace Donato arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the Administrator, Guili Xu, and disclosed the purpose of the inspection. LPA toured the facility with the administrator. The indoor temperature reading of 73°F. Water was at 110°F. LPA inspected the kitchen and observed breakfast preparation and cooking in progress at the time. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted. LPA inspected the fire extinguisher mounted on the wall in the dining area and found it fully charged, with the last service tag dated 4/27/2026. The facility is observed to be clean, odorless, and well maintained. All passageways are unobstructed. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed to be locked. Five resident records and three staff records were reviewed. Staff have criminal record and fingerprint clearances on file. Staff have current First Aid/CPR certifications on file and updated trainings. Resident records were reviewed and were observed to be complete. All medication logs are complete and updated. No deficiencies cited today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, May 22, 2026

Type of visit: Required - 1 Year

On April 30, 2025, at 08:45 AM, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the Administrator, Guili Xu, and disclosed the purpose of the inspection. The Administrator informed the LPA that the facility had five (5) residents in care and two (2) staff members present at the time. At 9:17 AM, the LPA initiated a walk-through of the facility, accompanied by the Administrator. The indoor temperature reading of 72°F on a thermostat was observed in the hallway at the time of the visit. LPA inspected the kitchen and observed breakfast preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet under the sink containing detergents, disinfectants, cleaning supplies, knives and sharp objects. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted. LPA inspected the dining area adjacent to the kitchen. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. LPA inspected the fire extinguisher mounted on the wall in the dining area and found it fully charged, with the last service tag dated 05/01/2024. LPA advised the Administrator to have the fire extinguisher serviced as soon as possible for the year 2025. At 09:28 AM, LPA inspected the garage and observed the garage cluttered with incontinence supplies, furniture, food supplies, Christmas decorations, suitcases, several wooden doors, cabinets, wheelchairs, and mattresses. Continued on LIC809-C LPA inspected the laundry room next to the kitchen and observed a washer, a dryer there. LPA inspected the living room and observed a sofa set, chairs, recliner, coffee table, covered fireplace, small refrigerator, music system, and a television. One (1) resident was observed sitting on the recliner and watching TV. Board games, chess, puzzles, arts, coloring, bingo, and other recreational activity items for residents’ activities were also observed in the living room. The Administrator tested the smoke and carbon monoxide detector located in the living room in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit. LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. The backyard had a set of a patio table, chairs, and umbrella for resident use. No accessible bodies of water were found. LPA inspected (1) storage shed and observed wheelchairs, walkers, and furniture items in the shed. There were six (6) bedrooms and four (4) bathrooms designated for residents' use. All (6) resident rooms were single occupancy. LPA inspected all (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. Storage closets with incontinence supplies were observed in the rooms. LPA inspected four (4) full bathrooms and found them in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower bench, and non-slip mats/flooring. At 9:46 AM, the hot water temperature at the sink faucet measured 127.8°F in bathroom #1, 126.2°F in bathroom #2, and 127.8°F in bathroom #4. At 09:43 AM, the LPA inspected the storage space in the hallway closet and observed it containing linens for residents’ use and found that sliding door was dangling and the door track was broken on the bottom. LPA reviewed five (5) staff personnel records and five (5) resident records. At, 10:56 AM, The LPA observed that 4 of 5 residents did not have Safeguards for property/valuables inventory filed, dated, and signed. 1 of 5 residents had last annual Physician assessment done on 2/25/2021 and 2 of 5 residents’ assessment was done in the year 2023. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members were associated with the facility. Continued on LIC809-C At 11:38 AM, the LPA observed a locked centrally stored medication cabinet located inside in the dining area next to the kitchen. Medications were organized in separate boxes for each resident. 5 of 5 resident’s medication prescription names, prescription numbers, and date filled were not entered correctly in the Centrally Stored Medication Records (CSMR). 5 of 5 resident’s prescription medication labels were altered with the handwritten notes on it. LPA inspected the first aid kit and found it fully stocked. LPA reviewed Emergency Drill Logs and observed Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 3/25/2025. The following updated forms are requested to be submitted to CCLD by 05/07/2025: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility Certificate of Liability Insurance Administrator Certificate(s) The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, and Plans of Correction were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and provided to the Administrator, Penny Xu, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Apr 30, 2025

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Facility and staff did not treat residents with dignity and respect Facility did not provide the appropriate variety of food in a timely manner Facility did not provide adequate basic services to residents.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Administrator (ADM) Guili Xu. On 1/11/2024, the Department received a complaint with the above allegations. On 1/19/2024, the Department conducted an initial investigation visit. LPA interviewed ADM, 2 staff, and residents. LPA requested Roster of residents, LIC500 Personnel Report, residents' physician reports, Appraisal Needs and Service Plan, and food menu. Continue on LIC9099-C. page 1 of 5. Unsubstantiated Facility and staff did not treat residents with dignity and respect: The Allegation is that staff did not treat resident R1 with dignity and respect when staff changed the diapers and clothing for R1. On 1/17/2024, LPA interviewed R1's family member (FM). FM stated in September 2023, a male caregiver S1 was rude and rough to R1 when changing R1's diaper and clothing. On 1/19/2024, LPA interviewed resident R1. R1 stated a female caregiver S2 treated him/her rude. LPA interviewed the other 5 residents. 3 Out of 5 residents did not have any complaint against the facility staff. LPA interviewed staff S2. S2 denied he/she was rude to resident R1. LPA interviewed ADM. ADM denied staff abused residents. On 10/17/2024, LPA interviewed Administrator (ADM). ADM stated staff S1 worked for NOC shift from Monday to Friday. ADM stated R1's family member (FM) reported to him/her that S1 was rude to R1 when changing R1's diapers and clothing even though was not intentionally. ADM stated he/she interviewed S1 and S1 denied he/she treated R1 rude and rough. ADM stated he/she decided to let S1 go within S1's first two month's working in the facility. ADM stated it was not an staff abusing resident incident. ADM stated he/she wants to maintain the quality of service to residents. ADM stated after S1's incident, he/she did not receive any report that staff treat residents rude. LPA interviewed 2 staff. Both denied they treat residents rude. LPA interviewed 5 residents. 3 Out of 5 residents stated they did not see or hear any incident that staff treat residents rude. Based on the review of the Law Enforcement Task Report dated 1/11/2024, R1 stated the facility staff were trying their best not to harm R1 when staff were working with R1. The report states R1 was not a victim of physical abuse or neglect. Continue on LIC9099-C. Page 2 of 5. Based on the interviews and records reviewed, there is no evidence to indicate that facility and staff did not treat residents with dignity and respect. Facility did not provide the appropriate variety of food in a timely manner: The allegation is that the facility did not provide appropriate variety of food in a timely manner to resident R1. R1's dinner was offered around 3:30PM to 4:30PM . Family member claimed it was too early for dinner. On 1/19/2024, LPA interviewed Administrator (ADM). ADM stated the facility breakfast is from 7:00AM to 9:00PM, lunch is from 11:00AM to 1:00PM, and dinner is from 4:00PM to 6:00PM. ADM stated after dinner, the facility staff need to clean the kitchen, help residents for showers, administer medications to residents, and prepare residents to go to sleep. ADM stated some family members might think the dinner is offered too early, but the facility staff are very busy after dinner. The dinners are scheduled from 4:00PM to 6:00PM. ADM stated resident R1 does not have teeth and R1 eats meals at bed. ADM stated the facility has some limits to offer the food for R1. ADM stated R1 does not eat the food he/she does not like. LPA interviewed resident R1. R1 stated one day, he/she was offered sandwiches for the whole day. LPA interviewed other 5 residents. 3 out of 5 residents did not have any complaint for the facility meals. On 10/17/2024, LPA interviewed ADM. ADM stated the facility offers variety of food for meals and provides the facility food menu to LPA. LPA interviewed staff S3. S3 stated he/she is a cook. S3 stated she cooks variety of food for meals. S3 stated resident R1 does not have teeth and eats meals at bed. S3 stated he/she offered different food for R1, but R1 most time refused. S3 stated one time he/she prepared a very good Thanksgiving dinner for R1, but R1 refused it. S3 stated most of time R1 accepts sandwich. S3 stated he/she provided sandwiches with different flavor to R1. S3 stated the facility breakfast is 7:00AM to 9:00AM, lunch is from 11:00AM to 1:00PM, and dinner is from 4:00PM to 6:00PM. Continue on LIC9099-C. Page 3 of 5. LPA interviewed 5 residents. 3 Out of 5 residents stated they likes the facility food and no complaint about the facility meals. During LPA's visit of the facility, LPA observed residents were served the lunches. LPA observed food supplies with a variety of vegetables, meats, protein, grains, and juice. Based on the review of the Law Enforcement Task Report dated 1/11/2024, the food offered to R1 was observed with different items and sufficient by R1. Based on the observation, interview, and records reviewed, there is no evidence to indicate the facility did not provide the appropriate variety of food in a timely manner to R1. Facility did not provide adequate basic services to residents: The allegation is that the facility did not provide basic care and service to resident R1. On 1/19/2024, LPA interviewed resident R1. R1 stated the facility staff come to check his/her condition every day, but he/she was unable to confirm how often. R1 stated the facility staff clean his/her room but was unable to confirm how often. R1 stated the facility staff check/change his/her diaper but he/she was unable to confirm how often. LPA observed R1 has a pendant call, LPA pressed the pendant call and observed staff came within 2 minutes. R1 stated he/she has bed bath every day with staff's help. R1 stated one day he/she had a deflated mattress. LPA interviewed ADM. ADM stated the staff check resident every two hours. ADM stated residents can press call button to ask for help immediately. ADM stated resident R1 had an air inflated mattress. ADM stated that day PG&E had a power outrage and was unable to inflate R1's mattress. On 10/17/2024, LPA interviewed staff S3. S3 stated staff check residents every two hours. Staff change resident diaper every two hours. Staff clean resident room every day. S3 stated for R1's deflated mattress issue, the facility staff offered to transfer R1 to a regular mattress but R1 refused. Continue on LIC9099-C. Page 4 of 5. Facility did not keep the facility clean and free of flies and other insects: The allegation is that on 7/13/2023, resident R1's room was found a lot of ants. On 1/19/2023, LPA interviewed resident R1. R1 stated he/she found ants in the room when the first day he/she moved in the facility. R1 stated staff cleaned the room and got rid of the ants immediately. R1 stated after that day, he/she did not see any ants in the room. LPA toured all 6 residents rooms. LPA did not observe any ants or other insects in all the resident rooms. LPA interviewed other 5 residents. 3 Out of 5 residents stated they do not any complaint regarding the facility environment. 3 Out of 5 residents stated there is no ant or inspects in the resident rooms. On 10/17/2024, LPA interviewed 2 staff. Both stated the facility staff clean resident room every day. LPA interviewed ADM. ADM stated R1 moved in the facility in June 2023. LPA toured the facility including 6 resident bedrooms, LPA did not observe any ant or inspect in the resident rooms or in the facility. Based on the review of the Law Enforcement Task Report dated 1/11/2024, resident R1's room was observed in sanitary condition and well maintained. R1 was observed to be in good health condition, and was not in distress or upset. There is no evidence that on 7/13/2023, R1's room had a lot of ants. Based on the interviews, observation, and record reviewed, resident R1's room was in sanitary condition and well maintained. Staff did not administer medication in a timely manner: The allegation is resident R1 was not administered medication for 4 days. On 1/19/2023, LPA interviewed resident R1. R1 stated the facility staff administer medications to him/her on time. Continue on LIC9099-C. Page 2 of 3. On 10/17/2024, LPA interviewed ADM. ADM stated the facility staff only administer doctor prescription medications or doctor order medication to residents. LPA interviewed 2 staff . Both stated they administer medications to residents based on doctor prescription or doctor order. Both stated they administer medications to residents and watch residents to finish the medications and they leave the resident room. LPA interviewed 5 residents. 3 out of 5 residents stated the staff give them medications every day. Based on the review of the Law Enforcement Task Report dated on 1/11/2024, R1 stated the facility staff are very careful with the medications he/she requires and he/she is not allowed to take any other medication that are not prescribed by doctor. Based on the interviews and record reviewed, there is no evidence to indicate Staff did not administer medication in a timely manner: The Department has investigated the above allegations. Based on the investigation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. This report was provided to review and for signature. A copy of this report was provided to ADM. Page 3 of 3. LPA interviewed 5 residents. 3 Out of 5 residents stated they don't have any complaint against the facility. Based on the review of the Law Enforcement Task Report dated 1/11/2024, R1 stated staff takes good care of him/her and staff checked him/her occasionally, and R1 was observed has call button to call for help. Based on the interview, observation, and records reviewed, there is no evidence to indicate facility did not provide adequate basic services to resident R1. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No citations noted for today’s visit. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of this report was provided to ADM. Page 5 of 5.the state’s words, verbatim · CDSS document, Oct 31, 2024 · control 26-AS-20240111153835

Allegation investigated: Medication is accessible to residents. Hazardous chemicals are accessible to resident.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator, Guili "Penny" Xu and stated the purpose of today’s visit. On 7/27/2023, the Department received a complaint with the above allegations. On 8/1/2023, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 2. Substantiated Page 2 of 2. Medication is accessible to residents. It was alleged medication was left in the refrigerator unlocked and accessible to residents. During visit on 8/1/2023, LPA observed medication for R1 unlocked and accessible in the fridge located in the office. The medications were not locked into the fridge and the fridge did not have locking capabilities. The fridge was located in the office and the office door was not locked. LPA observed 1 resident walking around the facility. Hazardous chemicals are accessible to resident. It was alleged chemicals is unlocked and accessible to residents. During visit on 8/1/2023, LPA observed laundry detergent on the dryer machine, which was located in the office. The office door was not locked, and the laundry detergent was not locked and accessible to residents. LPA observed Clorox Disinfecting wipes in the living room, unlocked and accessible to residents. LPA observed 1 resident walking around the facility. Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator and a copy of the report was provided. Appeal Rights was provided. Page 2 of 3. Staff does not ensure that residents are adequately fed. It was alleged residents were only served breakfast and dinner. On 8/1/2023, the Department interviewed 2 staff (S1-S2). Two of two staff stated the residents are adequately fed and staff will always ask their preference for food. S1 and S2 stated R1 will only have two meal, breakfast, and dinner, per the resident’s preference. On 8/1/2023, the Department interviewed 5 residents (R1-R5). One resident was not available for interview. One out of 4 residents stated the facility staff provide 3 meals and snacks when residents are hungry. During visit on 8/1/2023, LPA observed 2 days of perishable foods and 7 days of perishable foods. LPA observed resident were served breakfast which included waffle, egg, toast, coffee, juice and yogurt parfait with fresh bananas and strawberries. LPA observed residents were served lunch which included spaghetti with meatballs, garlic bread, cantaloupe, juice and pound cake. Based on receipts for groceries purchased from 06/01/2023- 07/19/2023, the facility staff are provided quantity and quality of food to feed the residents at the facility at least 7 days to include 3 meals and snacks each day. Staff does not serve a variety of foods. It was alleged residents only served Filipino food at the facility. On 8/1/2023, the Department interviewed 2 staff (S1-S2). One of two staff stated they serve a variety of food, which includes Filipino food and Chinese food. S1 stated the staff will ask the residents how they want the food prepared and they will change the type of protein each day such as one day will be a chicken entrée and the next day will be a pork entrée. S1 stated each meal is served with vegetables, fruit, and yogurt. S2 stated the staff will always make Filipino food and the resident will eat what they are being served. Page 3 of 3. On 8/1/2023, the Department interviewed 3 residents (R1-R3). Three out of three residents stated the facility staff provide 3 meals and snacks when residents are hungry. R2 stated the variety of food is okay but would like something different. During visit on 8/1/2023, LPA observed resident were served breakfast which included waffle, egg, toast, coffee, juice and yogurt parfait with fresh bananas and strawberries. LPA observed residents were served lunch which included spaghetti with meatballs, garlic bread, cantaloupe, juice, and pound cake. Based on the interviews conducted with residents and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Guili "Penny" Xu and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 28, 2024 · control 26-AS-20230727120329

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Sep 29, 2024

87465(h)(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation, Licensee did not ensure medication in the fridge were locked that is not accessible to residents in care which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 28, 2024

Plan of correction: Administrator submitted a written Plan of Correction to LPA Rai during investigation and LPA Rai cleared the deficiency during today's visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 29, 2024

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation, Licensee did not ensure laundry detergents and Clorox Disinfecting wipes were stored where inaccessible to residents which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 28, 2024

Plan of correction: Administrator submit a written Plan of Correction to LPA Rai during investigation and LPA Rai cleared the deficiency during today's visit.

Type of visit: POC

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation and clear the deficiencies issued during today's visit. LPA Rai met with the Administrator, Guili "Penny" Xu and stated the purpose of today’s visit. During today's visit, LPA Rai cleared two deficiencies issued during today's visit. During the investigation, Licensee provided a written plan of action to ensure medications and toxic chemicals such as a laundry detergents and disinfecting wipes were stored inaccessible to residents in care. During today's visit, LPA observed the medications and toxic chemicals such as a laundry detergents and disinfecting wipes were stored inaccessible to residents in care. LPA Rai provided Licensee Letter of Deficiency Citations Cleared for deficiencies issued during today's visit. Exit interview conducted with Administrator, Guili "Penny" Xu and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 28, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Steve Chang Mita Partoza conducted an unannounced annual inspection visit, and met with Administrator (ADM) Guili Xu. License, personal rights posters and Administrator Certificate were observed at the entrance. LPAs reviewed 3 residents files and 3 staff files.. LPA toured the facility inside out with ADM. Living room, kitchen, dinning room and four restrooms were inspected. Six single resident bedrooms, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 71 degree F, and hot water temperature was at 119 degree F in facility. Six residents (R1 - R6) and two staff (S1, S2) were interviewed. Fire extinguisher was serviced on 4/24/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. Annual inspection will be continued at a later date. Exit interview was conducted with ADM. This report was provided to ADM for signature.the state’s words, verbatim · CDSS document, Jan 19, 2024