Routine inspection·January 12, 2026

On 01/12/2026 at approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Administrator, Hezle Lomibao. The facility has an approved fire clearance for a capacity of four (4) residents, including up to three (3) non-ambulatory residents and one (1) bedridden resident. The facility also has an approved hospice waiver for up to three (3) individuals. Facility is a single-story building with 4 Resident bedrooms, 2 bathrooms, and common spaces. At approximately 10:05AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:45AM, LPA and Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked housekeeping closet in the laundry room next to garage. Water temperature measured 109.6 degrees F and 110.4 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire Extinguishers found to be last charged on 09/15/2025 at the time of visit. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a cabinet in the hallway. Continued on LIC809-C page... Continued from LIC809 page... At approximately 11:35AM, LPA reviewed 3 resident records and found 3 out of 3 residents did have current physician's reports, care plans, signed admission agreements with North Bay Regional Center, and physician's orders on file. Medication records are thorough and contained physician's orders for each resident. At approximately 12:05PM, LPA reviewed 3 staff records. 3 of 3 records did contain required documentarians. LPA was presented with proof of current CPR & 1 st Aid certification for the whole staff. Administrator Certificate is for Hezle Lomibao #6065313740 expires 06/09/2026. Facility conducted and documented a disaster drill on 12/17/2025. LPA reviewed the facility emergency disaster plan. Facility has supplies enough to operate for more than 72 hours in an emergency. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 01/25/2026: LIC 308 Designation Facility Responsibilities LIC 500 Personnel Summary LIC 9020 Register of Facility Client’s/Resident’s Copy/Proof of Updated Certificate of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit. Exit interview conducted. Copy of report provided to Administrator. Signature on form confirms receipt of documents.