Correction check·July 23, 2025

Licensing Program Analyst (LPA) Cynthia Tamayo made an unannounced POC visit to the facility to verify correction of citations issued on 6/30/2025. An extension for POCs was requested and granted with a new POC due date of 7/18/2025. LPA Tamayo met with facility staff Isikeli Tuikenatabua (S2) and explained the purpose of the visit. Administrator, Cleopatra Gardiner, was contacted via phone call and informed she will return to the facility "early next week". Upon arrival, LPA Tamayo observed three staff members (S2-S4) present and working. The current census is 12. An extention was granted for 6 out of 6 POC's dated 6/30/2025. POC verification for 4 out of 6 POCs dated 6/30/2025 has not been received by the Regio nal Office as of today, 7/23/25, the POC's are overdue. A civil penalty for failure to correct applied due to outstanding plan of correction regarding water temperature regulations, staff training, and administrator oversight. S2 stated they call Administrator when they have updates or questions but there has not been an administrator on site for a while. It is unclear how long the administrator has been off site due to inconsistent responses, but it may be two to three months since the Administrator has last been at the facility. On 7/1/25, LPA emailed S1 POC's dated 6/30/25 and requested a S1 contact LPA, but LPA has not received a response. LPA observed toxins including cleaning products such as Clorox and Lysol sprays were kept locked and inaccessible to residents. [continued on 809-C] Staff submitted SIR for medication error and completed medication administration training on 7/18/25. POC clearance letter generated. Facility also submitted Death Report for Cal Susimmout was received. POC clearance letter generated. S2 stated a maintenance person came and replaced the water heaters. LPA measured the water temperature in the resident bathrooms and the temperature measured 115.7 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA measure d the water temperature in kitchen faucet, temperature measured at 91.97 degrees F which do es not meet s the 105-120 degree Fahrenheit regulation. Per staff statement, staff training on Storage Space and Access has not been conducted and will be competed upon Administrator's return. S2 stated meal times are 8:00AM-9:00AM for breakfast, 12:00-1:00 PM for Lunch and 4:30PM-5:30PM for Dinner each day. The following documentation was requested to be submitted to the department: -LIC 500 (April-July 2025) A technical advisory/ violation was provided for sections 87218, 87415, 87705, and 87706. Per the California Code of Regulations, Title 22, The following deficiencies are cited during today's inspection. Immediate civil penalties will be issued due to failing to correct citations and failing to complete the plans of correction identified in the previous licensing report. Appeal rights and a copy of LIC 809 and LIC 809-C left at the facility.