Non-compliance follow-up·April 23, 2026

A Non-Compliance Conference (NCC) was conducted today on April 23, 2026, via Microsoft Teams with the Sacramento South Regional Office. Present in the meeting were Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Liza King, LPM Lisa Rios, Licensing Program Analyst (LPA) Michael Bilger, LPA Charlie Yang, and LPA Albert Johnson. Also present were Ombudsman Kathryn Thomas. Licensee and designees Richie Almendrala and Maria Almendrala were present during this meeting. The non-compliance conference process was explained during this meeting to include the administrative process. Since 4-23-2025 and within this yearly time period, Licensee has received a total of four A citations and one B citation. The regulated areas of which the citations occurred were Admission agreements, care and supervision, prohibited health conditions, observation of the resident, and administrator qualifications Citations issued by the Department include: {Cont. on 809C} 7-17-2025: Type B - Section 87507(5)(c) Admissions Agreement. The facility was found to be deficient as evidenced by review of the resident records that upon notice of death to a resident this facility has still not issued a refund for the pre-paid basic services fees. 10-10-2025: Type A – Section 87615(a)(1) Prohibited Health Conditions. This facility was found to be deficient as evidenced by the retention of a resident diagnosed with a Stage IV pressure ulcer. 10-10-2025: Type A - Section 87466 Observation of The Resident. This facility was found to be deficient as evidenced by repeated visits to the local medical facility for a resident exhibiting the same medical issues eventually resulting in more serious health conditions. 3-19-2026: Type A – Health and Safety Code 1569.39(b) Assistance with accessing home health or hospice services; receipt of medical services. Licensee did not ensure appropriate and timely medical intervention for R1’s wounds leading to a worsening condition including severe sepsis. 3-19-2026: Type A – Section 87405(d)(1) Administrator-Qualifications and Duties. Licensee and designee did not ensure an appropriate exception request necessary for proper care and supervision of R1’s wound. {Cont. on 809C} Topics discussed during today’s Non-Compliance Conference were: · Care and Supervision · Client Records – proper maintenance of various documentation · Administrator qualifications and duties · Prohibited Health Conditions · Emergency protocols and when to call 9-1-1 The Licensee has agreed to the following for purposes of reaching substantial compliance : · Facility program administrator will ensure compliance plan is being followed · Licensee will ensure facility program administrator is physically present at facility for a minimum of 20 hours per week · Licensee to send copy of a current skin check lists by end of day 4-24-2026. {Cont. on 809C} · Ensure all staff including Administrator and Licensee are in compliance with required training: Observing and reporting changes in residents’ conditions, restricted and prohibited health conditions, various stages of wound care, Emergency protocols/calling 9-1-1, Training to be conducted initially by 5-23-2026, then every three months thereafter, and evaluated by LPA during visits and inspections. · Daily documentation of residents’ conditions including but not limited to: Participation in Activity of Daily Living (ADL) functioning, various changes in conditions including those warranting exceptions, waivers, or 9-1-1 calls · Monthly audits of residents’ skin/body check forms to ensure accuracy · Maintenance of other documentation including but not limited to: Care notes, needs and services plans (updated yearly or sooner if significant changes occur), physician’s reports, medication log sheets, and incident reports · Submit an updated LIC 500 to include Administrator days and hours scheduled. Submit by end of day 4-24-2026. · Submit an updated LIC 308 by end of day 4-24-2026. For best practices and consistency purposes in regards to maintaining compliance, the above implementations are to also be included at licensee’s additional facilities: ST Mary’s Home #502701255 and ST. Stephen’s Home #502700261. {Cont. on 809C} In addition, at this meeting the notified Licensee/Administrator was advised future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and further potential administrative action . Community Care Licensing Department (CCLD) will do the following: · Quarterly visits to ensure above compliance plan and other Title 22 and Health and Safety code requirements. Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager. Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted with Licensee and a copy of this report and supplemental LIC 9111 was provided via email with request to return with signature no later than 4-24-2026.