Follow-up·December 29, 2025

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced case management visit. LPA was greeted by staff and the reason for the visit was explained. Administrator Ralph Estanislao was advised telephonically but was not able to attend. The purpose of the visit was to follow up on items addressed during the Noncompliance Conference (NCC) meeting held on October 1, 2025. The facility is licensed to serve age range 60 and over, six (6) non-ambulatory of which one (1) may be bedridden. Hospice waiver for two (2). The facility is operating within the scope of their license with five (5) non-ambulatory residents, one (1) of which is under the age of 60 and two (2) residents are on hospice. The facility is a single-story home located in a residential area of Glendora. The home consists of a kitchen, living room, dining area, two (2) bathrooms, four (4) resident bedrooms, an attached garage, front and backyards. Upon arrival LPA observed a port-a-potty in the driveway and visible construction in the backyard. LPA asked administrator about the construction. The administrator indicated the property owner was building an addition. Staff indicated construction workers use a gate located on the side of the house to access the construction area. Construction crew does not come in the house and does not have contact with residents. LPA did not observe any construction tools or construction debris that may pose a health and safety risk to residents in care. Staff stated if residents want to go outside, they go to the front yard. CCL was not notified prior to construction. Deficiency cited. continued on LIC 809C continued from LIC 809 LPA toured facility interior and interior was observed to be clean and free of debris and obstructions. Water temperature was checked in both resident bathrooms and tested at 109.7°F and 109.4°F, which is within the required 105°F-120°F. LPA observed four (4) out five (5) residents to have bedrails. Only one (1) of the four (4) residents had physician’s orders for bedrails in the residents’ files. Deficiency cited. Penalty assessed for repeat violation. LPA reviewed five (5) resident files. Three (3) out of five (5) resident files did not contain record of TB clearance. Deficiency cited. LPA reviewed three (3) staff files. S2 file did not contain a completed Health Screening and did not have TB clearance on file. Deficiency cited. LPA reviewed MAR log. Medications are documented properly and given as prescribed. LPA reviewed log for emergency drills. Last fire/earthquake drill was conducted 12/14/25. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D. Civil penalties issued for repeat violation within 12 months. Exit interview held and a copy of the report along with appeal rights were provided to Caregiver Noel Navarro.