Post-licensing visit·September 3, 2025

Unannounced Post Licensing visit made out to this facility on 09/03/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Joyce Mabunga, to inform her that CCL was present at this time for the post licensing visit. Current census was 4 residents. It was learned that there were (2) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (6) residents under the care of hospice at any given time. It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there were (2) residents diagnosed with dementia at this time. It was learned that there weren't any residents receiving services through home health at this time. This facility does have a bedridden fire clearance to be able to accept and retain up to (1) bedridden resident at any given time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in facility hallway, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured. Laundry room was toured at this time. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Administrator certificate, # 7026619740, for Pedro Pancho was observed to have an expiration date of 10/26/2025 and in compliance at this time. Forms and documents were being updated in order to renew this Administrator certificate at this time. Medication cabinet, located in the facility hallway cabinets, was observed to be locked and made inaccessible to the residents at this time. First aid kit, located in the kitchen area, was reviewed. This LPA observed that it did contain all of the required components at this time. Fire extinguishers (2) were located throughout this facility and observed to have been annually inspected by the local fire extinguisher company, Touch Down Fire Company, on 09/10/2024 and found to be in compliance at this time. Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted. A review of (4) facility personnel records was conducted and noted on the following LIC 859. A review of (4) facility resident records was conducted and noted on the following LIC 858. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal Rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interview