Routine inspection·October 2, 2025

At approximately 8:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Members, Elena Mendoza and Glyzelle Recella. Designated Representative, Bella Nachor, arrived during visit at approximately 9:15AM. Licensee, Ana Belle Bautista, arrived during visit at approximately 10:00AM and left facility around 11:15AM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents where 1 can be bedridden in Bedroom #2. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 5 residents in care and 2 staff members on-site. At approximately 9:00AM, LPA reviewed the Facility's Staff Roster and found that Staff Member 1 (S1) was not associated to the facility per regulation. Administrator provided proof of transfer paperwork submitted to Regional Office to associate S1 dated 05/23/2025. LPA to follow up on S1's association. LPA conducted a walk-though of the facility with Administrator. LPA observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 5 Resident bedrooms, a staff room, 2 1/2 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regu lations. LPA observed multiple instances of unlabeled food in facility’s fridge and freezer. LPA also identified freezer burned food and expired canned goods in facility's cabinet (deficiency cited, regulation 87555(a)). There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Fire extinguishers were last inspected November 2023 (deficiency cited, regulation 87202(a)). Smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted September 2025. Continued on LIC809C Continued from LIC809 LPA reviewed staff files and resident files. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Administrator's Certificate for Ana Belle Bautistia (7000300740) and Bella Nachor (7008140740) was current with an expiration date of 3/12/2027 and 05/27/2027. LPA discussed the following topics: Reporting Requirements PIN regarding 911 protocols PIN regarding dementia regulations LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610E) Updated Personnel Report (LIC 500) Updated Liability Insurance Active and Current Administrator Certificate Documents to be submitted to Community Care Licensing (CCL) by due date of 11/02/2025. LPA unable to complete Annual Visit. Annual Continuation Visit to be conducted at a later date. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator/Designated Representative. Signature on form confirms receipt of documents.