Follow-up on corrections·January 15, 2026

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced Case Management visit to address deficiencies related to the failure to correct cited deficiencies. LPA was greeted by Kevin Ortiz, Lead Caregiver and discussed the purpose of the visit. On December 2, 2025, Licensing Program Analyst (LPA) Gabriela Castro conducted an Annual Inspection and cited deficiencies with a Plan of Correction (POC) due by December 23, 2025. As of the date of the follow-up visit, the deficiencies remained uncorrected. The following deficiencies were cited: CCR-87411(f)- A report shall be made of each screening signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. Plan of Correction The licensee agrees to ensure all staff obtain TB tests and physical examinations. Proof of completed TB tests and physical exams for all staff will be submitted by the POC date. (continued on 809C) HSC -1569.625(b)(2)- (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. Plan of Correction Licensee is to ensure annual training requirements are met annually. Licensee will update training requirements and send proof by POC date. CCR-87411(c)(1) -(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. Plan of Correction Licensee to ensure staff receive first aid training as per regulation. Licensee to submit proof of first aid training for staff by POC date. CCR-87465(e) -(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. Plan of Correction Licensee to obtain a physician’s order for Imodium and Claritin (allergy medication) or discontinue medications and submit by POC due date. Licensee to continue to review PRN policy with residents’ families. CCR-87633(a)(1)- (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department. Plan of Correction Licensee to ensure they are following their approved hospice waiver. Licensee to submit a request for a hospice waiver increase. (continued on 809C) CCR-87463(a)- (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. Plan of Correction Licensee to ensure they are updating appraisals as frequently as necessary or once every twelve months. Licensee to submit updated re-appraisals by POC date. CCR-87458(c)(1)(A) - (c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. Plan of Correction Licensee is to ensure compliance on Communicable Tuberculosis examinations prior to acceptance of a resident. Licensee is to submit proof of TB text by POC date. An exit interview was conducted with Kevin Ortiz, Lead Caregiver. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.