Correction check·January 21, 2026

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced Plan of Correction (POC) Case Management visit to address deficiencies related to the facility’s failure to correct previously cited deficiencies. LPA was greeted by Kevin Baas, Lead Caregiver and discussed the purpose of the visit. LPA spoke with Licensee Toby Miclat via phone in detail. On January 15, 2026, LPA conducted a Case Management visit to follow up on deficiencies cited during the Annual Inspection, for which a Plan of Correction (POC) was due by December 23, 2025. During that visit, the deficiencies remained uncorrected, and the deficiencies were re-issued with a new POC due date of January 16, 2026. As of the date of this follow-up visit, the deficiencies remained uncorrected. The following deficiencies were cited: CCR 87411(f)- licensure. 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. (continued on 809C) 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. ( POC Corrected ) 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 . CCR87411(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. (continued on 809C) CCR87465(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. CCR87633(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. CCR87463(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. (Continued on 809C) CCR87458(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. Civil penalties will be issued during today’s visit for the assessed dates of January 17 through January 20, 2026. Failure to correct the deficiencies may result in additional civil penalties. An exit interview was conducted with Kevin Baas, Lead Caregiver. Civil penalties were provided for the assessed period of January 17 through January 20, 2026, please refer to LIC 421. A copy of this report along with appeal rights were provided.