Follow-up·March 24, 2026

On 03/24/2025 at PM, 3:10 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct a Case Management visit. LPA met with Administrator (ADM) Divina Fernandez, and explained the purpose of the visit. While LPA was at the facility for another visit, LPA observed the following: LPA observed R1 down the street from the facility and R1 entering the facility couple minutes later. During the visit, LPA reviewed R1's physician report dated 05/29/2025 that indicated that R1 is able to leave the facility unsupervised. LPA observed incident report that indicated R2 had a unwitnessed fall on 10/12/2025. During the visit, LPA reviewed documents including but not limited to Medroom Daily Communication Log, After-Visit Summary, Email Correspondence, and facility's care plan. Documents revealed that R2 had multiple falls. During the visit, LPA verified that the facility was following their care plan which was to provide 1:1 care to R2. LPA observed a portable safety barrier blocking the front, side, and back exit doors. Interview with ADM revealed that the barriers are there temporarily while the facility is working on their gates outside. LPA observed the facility is currently repainting the walls all around the facility and LPA was not notified. LPA and ADM discussed that any construction being done needs to be reported to the Department. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.