Inspection visit

Routine inspection (multi-day)April 8, 2025

ABOVE & BEYOND RCFE, INC.License 01920111913 citations on this visit

13 citations recorded

Inspector’s narrative

What the inspector wrote

On this day, 4/08/25, at 11:45 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on 3/28/25. LPA met with staff, Larry Poblete, Evangelien Porter and Gerald Cayle Garcia, and informed the reason for visit. LPA called and spoke over the phone with Leticia Velasco, licensee, who arrived at around 12:25 pm. Max Neri, administrator (ADM) arrived at around 1:00 pm. Disaster drill record on file was dated 1/10/25. There's no record as proof drills were conducted on previous quarters. LPA reviewed 5 staff and 5 residents' files. Residents medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. LPA observed the following: -at 12:20 pm, staff (S2) does have LIC501 Personnel Record, LIC503 Health Screening, TB test and 40 hours required training on file. -at 12:35 pm, staff (S4) is not associated to this facility. Does not have LIC503 Health Screening, TB test, required 40 hours training and first aid certificate on file. -at 12:40 pm, staff (S5) does not have LIC503 Health Screening, TB test, required 40 hours training and first aid certificate on file. .......continued on 809C -at 1:05 pm, resident's (R1) LIC602A indicated ambulatory but resident has major neurocognitive disorder. LIC625 on file is over a year old. -at 1:17 pm, resident's (R2) LIC602A on file dated 2023 indicated bedridden but R2 was observed able to ambulate using walker. LIC602A indicated major neurocognitive disorder. LIC625 is over a year old. -at 1:25 pm, resident's (R3) LIC625 Appraisal/Needs Services Plan not properly filled-up - incomplete; page 2 blank; page 3 no care plan. No doctor's order on file for half bed rails. -at 1:40 pm, resident's (R4) LIC602A is over a year old; does not have Pre-Admission Appraisal and LIC625 Appraisal/Needs and Services Plan. Half bed rails does not have doctor's order on file. -at 2:10 pm, resident's (R5) 2 medications received by the facility not properly recorded on LIC622. Administrator to submit current/updated copies of the following documents by April 22, 2025: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610D Emergency Disaster Plan (9 pages). 4. $3M Liability Insurance certificate Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with ADM. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

Citations

13 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87463(i)Type B
Hold reappraisal meeting on changes
Based on records review, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: R1 and R2's LIC625 over a year old; R3's LIC625 not properly filled-up.
87411(c)(1)Type B
First aid training requirements
Based on record review, the licensee did not comply with the section cited above in S4 and S5 not having first aid certificate on file which pose a potential safety and/or personal rights risks to persons in care.
87411(f)Type B
Health screening and fitness requirements
Based on records review, the licensee did not comply with the section cited above in S2, S4 and S5 not having TB test on file which pose a potential health and/or personal rights risks to persons in care.
1569.625(b)(1)Type B
Based on records review, the licensee did not comply with the section cited above in S2, S4 and S5 not having the 40 hours required training on file which pose a potential health, safety and/or personal rights risk to persons in care.
1569.695(c)Type B
Based on records review, the licensee did not comply with the section cited above in not having records showing drills were conducted on previous quarters which pose a potential safety and/or personal rights risks to persons in care.
87355(e)(3)Type B
Request a transfer of criminal record clearance
Based on record review, the licensee did not comply with the section cited above in S4 not associated which poses a potential safety and/or personal rights risks to persons in care.
87412(a)Type B
Maintain required personnel records for staff
Based on record review, the licensee did not comply with the section cited above in S2 does not having LIC501 Personnel Record on file which poses a potential safety and/or personal rights risks to persons in care.
87412(a)(11)Type B
Include required health screening documents
Based on records review, the licensee did not comply with the section cited above in S2, S4 and S5 not having LIC503 on file which pose a potential health and/or personal rights risks to persons in care.
87456(a)(2)Type B
Perform a pre-admission resident appraisal
Based on record review, the licensee did not comply with the section cited above in R4 not having Pre-Admission Appraisal which poses a potential health, safety and/or personal rights risks to persons in care.
87457(c)Type B
Complete admission suitability appraisal
Based on record review, the licensee did not comply with the section cited above in R4 not having LIC625 Appraisal/Needs and Services Plan which poses a potential health, safety and/or personal rights risks to persons in care.
87458(c)(5)Type B
Based on records review, , the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: R1's LIC602A indicated ambulatory but resident has major neurocognitive disorder. R2's LIC602A indicated bedridden but R2 was observed able to ambulate using walker.
87506(a)Type B
Maintain separate complete record for each resident
Based on record review, the licensee did not comply with the section cited above in R5’s 2 medications received by the facility not properly recorded on LIC622 which posed a potential personal rights risk to persons in care.
87608(a)(3)Type B
Maintain physician order documentation in resident record
Based on records review, the licensee did not comply with the section cited above in R3 and R4’s half bed rails not having doctor's order on file which pose a potential safety and/or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the April 8, 2025 inspection of ABOVE & BEYOND RCFE, INC.?

This was an other inspection of ABOVE & BEYOND RCFE, INC. on April 8, 2025. 13 citations were issued: 13 Type B.

Were any citations issued to ABOVE & BEYOND RCFE, INC. on April 8, 2025?

Yes, 13 citations were issued (0 Type A, 13 Type B). The first citation was for: "Based on records review, the licensee did not comply with the section cited above in the following which pose a potenti..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated July 13, 2026. If you believe any information is inaccurate, report it here.

Routine inspection (multi-day)·April 8, 2025