Follow-up on corrections·September 30, 2025

On 9/30/25, Licensing Program Analysts (LPAs) Cynthia Tamayo and Pang Lee made an unannounced visit to this facility to follow up on a case management deficiency from a previous complaint visit and quarterly visit, and POC follow up. LPA's identified themselves upon arrival, stated the purpose of the visit, and asked to meet with the administrator Alita Waqalala (S3) but they were not available. LPA's requested to speak with Licensee and S4 contacted them. LPAs met with Staff Merelisoni Mataitoga (S4) and Nawavoli Ratusione (S4) and explained the purpose of this visit. The purpose of this visit was to conduct a quarterly visit to follow up on items outlined during the Non-compliance meeting held on 0 1/30/2025 , which included the requirement for increased monitoring and to follow-up on areas of concern originally identified during the meeting as below. · Basic Services (care/supervision/elopement) · Administrator qualifications/duties and accountability/new potential administrator · Reporting requirements · Incidental Medical and Dental Care Services (resident not receiving medication as prescribed) · Fire clearance (adhering to fire clearance/submitted facility sketch) · Limitations capacity and ambulatory status (non-ambulatory resident cannot reside in an ambulatory room) · Plan of corrections (POCs) submitted in a timely manner Continued on 809-C · Background/fingerprint clearance (volunteers) This visit is also to follow-up on POC that was due to the department on 09/24/2025. This facility is licensed as a Residential Care Facility for the Elderly and is approved to serve a maximum of 10 residents. This facility is approved for 2 ambulatory residents in bedroom #5 only and 8 non-ambulatory residents. During the visit, LPAs conducted an inspection of the physical plant, including but not limited to the common areas, kitchen, dining area, resident bedrooms, bathrooms, laundry room, and outdoor courtyards. The facility was observed to be clean and in good repair and not free of odor. LPAs observed that the previously broken windows had been repaired and were in good condition. The exit gate was also observed to be functioning properly, with a one-way mechanism that does not prevent residents from exiting the facility. In resident bedroom #2, LPAs observed that the room was unoccupied and had a noticeable incontinence odor. On resident bed B, LPAs observed that an incontinence pad with visible urine had not been disposed of. According to Staff #1, the room had not been cleaned all day, as they believed it was locked. All residents bedrooms were properly furnished with appropriate bedding and adequate lighting. The layout of the facility was consistent with the original facility sketch that had been approved during the licensure process. In the resident bathroom, the hot water temperature was measured at 105.8 degrees Fahrenheit, which falls within the required regulatory range of 105 to 120 degrees Fahrenheit. Smoke and carbon monoxide detectors were tested and found to be functioning and in compliance with fire safety regulations. The fire extinguisher was located in the kitchen and had last been serviced on 01/22/2025. LPA also observed that the facility had a public telephone located in the common area. The thermostat was functioning properly and registered at 69 degrees Fahrenheit at the time of inspection. Toxic cleaning supplies were observed to be stored in storage cabinet and securely locked and inaccessible to residents. Sharp kitchen knives were locked in kitchen cabinets and were not accessible to residents. The medication storage area was reviewed and found to be locked and secure. All records reviewed were found to be complete and accurate. The first aid kit was checked and contained all required supplies. LPAs also verified the food supply, confirming that the facility maintained at least a two day supply of perishable food items and a seven-day supply of nonperishable items, in accordance with Title 22 regulations. LPAs observed a new freezer was placed in the kitchen to store additional food. Both residents’ and staff files were reviewed during the visit and were found to contain all required documentation. It is noted that on January 30, 2025, during a non-compliance meeting, the Licensee, Mark Labella, declined the referral to participate in the Technical Support Program (TSP). Despite the program being recommended as a resource to support compliance, the Licensee refused the referral at that time. The recommendation for TSP participation was reiterated; however, the Licensee again declined to participate. Continued 809-C During today’s visit, LPAs also followed up on the prior deficiencies and plan of corrections that were due on 09/24/2025 from a prior case management visit conducted on 09/23/2025. Based upon this inspection, LPAs observed the following: 1. The deficiency cited under Title 22 Regulation 87303(a) has been cleared. The license did comply with the terms of the POC-by-POC due date. A POC letter was generated and provided to the licensee. 2. The deficiency cited under Title 22 Regulation 87555(b)(26) has been cleared. The license comply with the terms of the POC-by-POC due date. A POC letter was not generated and provided to the licensee. 3. The deficiency cited under Title 22 Regulation 87468.1(a)(6) has been cleared. The license comply with the terms of the POC-by-POC due date. A POC letter was not generated and provided to the licensee. The following deficiencies were observe by LPA Tamayo: On 8/28/25, 9/4/25, and 9/8/25 food items in the pantry were locked with a magnetic lock, staff immediately unlocked on 9/8/2025. On 9/30/25, the lock mechanism was not activated but has not been installed. On 8/28/25, 9/4/25, and 9/8/25, eggs were stored in the pantry area however they should be refrigerated as indicated in the box. Staff immediately disposed on eggs and placed an order for fresh eggs. On 9/4/25, LPA Tamayo observed the MARS was not completed from 8/31/25-9/4/25. staff and resident interviewees confirm medications were given, however not documented accordingly. LPA's talked to staff regrading disposing of spare windows and broken chairs in the backyard area. As a result of this case management visit the facility is not in full compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with S4 and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.