Follow-up·April 3, 2026

Licensing Program Analyst (LPA) Nadia Shahbazian and Licensing Program Manager (LPM) Mary Flores made an unannounced Case Management visit to clarify the physical plant of the facility. LPA and LPM met with sister Elia Caro Administrator and explained the reason for the visit. The purpose of today's visit is to clarify the use of the licensed facility rooms, census, and capacity. The building is a two story structure which is licensed as an RCFE in which cared is provided by the Franciscan Missionary Sisters of the Immaculate Conception. At 8:50am LPA, LPM and Administrator toured the physical plant of the facility and observed the following: Rooms # 101-105, 108-111, 208-215 are used for private residents. Rooms # 112-117, 201-205, 217-220 are used for sister's of the congregation which are consider residents and are currently being provided care and supervision. Rooms # 217, 218 and 220 are currently being used as staff rooms. Private signs were observed in doors or stairways leading to the areas where the sisters of the congregation reside. The signs are used to follow the Catholic church's law of privacy for the sisters. Per administrator, even though the rooms where the sister's reside are labeled as private, our department and LTCO have access to these rooms. Files are being kept for the sisters. Per administrator also the showers in different areas of the facility, mostly in rooms used for non-ambulatory residents throughout the facility are being remodeled to accommodate accessibility. Facility sketch was reviewed. Administrator informed LPA/LPM that every one living on the second floor are ambulatory. The facility is operating within capacity. Based on today's observations the Administrator will make the following changes by 4/8/26: The sister's will be added to the census of the facility. (CONTINUED ON LIC 809C) Will ensure that private signs in areas used by the sisters are updated to "Sister's area" to ensure access to CCLD, LTCO, and other agencies is clear and the public is aware that is sisters' area. Will ensure to maintain all required documents as part of resident files for the sisters that are receiving care and supervision. Will submit an updated sketch to the department, to include the rooms that will be assigned for staff, chapel in the first floor, change of use of offices, employee lounge, sister's dining area, and terrace in the second floor. Will submit a plan to the department to ensure residents are accommodated during the remodeling of the showers. No deficiencies were noted during today's visit. Exit interview conducted and a copy of the report was provided.