Correction check·August 15, 2025

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced Plan of Correction (POC) inspection. LPA was greeted and granted entry by Staff Dory Lacwasan. and the purpose of the inspection was discussed. Administrator (AD) Cherry Aguila was contacted by phone and arrived at approximately 3:00 p.m. LPA is following up regarding deficiencies previously cited on June 20, 2025, during facility's annual/required inspection. Deficiency 1569.625(b)(1) was cited due to one of two staff records not containing documentation consisting of completed 20 hour required staff training. Deficiency 1569.69(a)(2) was cited due to two of two staff files not including documentation of completed 10 hours of initial training, consisting of 6 hours of hands-on shadowing training, and 4 hours of other training or instruction. Deficiency 1569.695(c) was cited due to emergency drills not being conducted. Deficiency 87307(a) was cited due to staff residing at the facility and spending the night on the living room couch. Deficiency 87307(a)(2)(C) was cited due to a bathroom located within a resident's bedroom being used as the staff bathroom. AD provided LPA with completed 20 hours, including six hours specific to dementia care, four hours specific to postural supports, restricted health conditions, and hospice care for staff via email on August 15, 2025. On the same email, AD provided documentation of completed 10 hours of initial training, consisting of 6 hours of hands-on shadowing training, and 4 hours of other training instruction. On July 7, 2025, AD provided LPA with documentation for disaster drill held on July 2, 2025, it included the date, the type of emergency covered by the drill, and the names of staff participating in the drill via email. (Cont. LIC809-C) During today’s visit, LPA observed facility to be at maximum capacity with four of four facility bedrooms currently occupied by residents. In the hallway storage, LPA observed the same dresser and personal items, including clothing and hygiene items previously observed during annual visit on June 20, 2025. Staff Lacwasan confirmed they continue residing at the facility and sleeping on the couch; a Deficiency was cited on today’s date. LPA also observed staff continue to use the master bedroom bathroom located within a resident's bedroom as the staff bathroom; a Deficiency was cited on today’s date. Three of five deficiencies previously cited have been cleared. Based on observations made during today’s inspection, deficiencies are being re-cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.