Correction check·September 19, 2025

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit to amend a Plan of Correction and conduct a health and safety check for the residents on care. Additionally, LPA took this opportunity to review the clearance documents submitted to LPA and attempt clear deficiencies. LPA Lopez identified herself and was allowed entry by caregiver, Elizabeth “Beth” Lim. LPA discussed the purpose of the visit with caregiver Lim, and met with Licensee Cheryl Castro, who later arrived and joined the visit. On 09/05/24, the facility was issued 5 deficiencies regarding the medication being provided, insufficient personnel, two residents' Personal Rights, and personal accommodations. During the visit of 09/05/25, two deficiencies were cleared, one for personal rights and the second for personal accommodation deficiencies. During today’s visit, LPA amended the plan of corrections (POC) reports, LIC809-D pages, to update the accurate deficiency types. Additionally, on 09/17/2025, LPA received an email indicating that the Licensee spoke with staff regarding implementation of the MAR system, personnel requirements, personal rights to make choices of their daily lives, managing incontinence, and personal accommodations and services. LPA reviewed the POC with licensee Cheryl Castro and established that the POCs needed additional information and not merely a training document. Licensee did not agree with the jointly developed POC, but said they will be clearing the staffing schedule and the MAR POC's and submit information to LPA. The licensee also acknowledged that they have spoken with the residents regarding the same information but did not have the residents sign the form at the time. During the today's visit, the licensee requested for the residents sign the document submitted to LPA on 09/17/25. Those residents who were present, 4 residents, acknowledged and complied. The last resident was no longer living at the facility. (Continuation on LIC809-C) (Continuation of LIC809-C) As such, one deficiency was corrected and is deemed cleared. The additional two deficiencies are pending and will be sent to LPA via email per the licensee. Lastly, during the visit on 09/05/25, the facility received a POC for complaint investigation 08-AS-20250827145528, for dignity. LPA received the documentation via email on 09/17/2025. During today’s visit, LPA cleared this deficiency. No deficiencies were observed or cited during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee Cheryl Castro at the conclusion of the visit. The signature below confirms receipt of these documents.