Non-compliance follow-up·July 1, 2025

Licensing Program Analyss (LPA) Christi Coppo arrived unannounced to conduct a Non-compliance and was greeted by caregiver. On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as: · Administrator Duties and Plan of Operation · Staff Training · Resident and staff records · Resident Care and Personal Rights · Insufficient Staffing · Failure to clear deficiencies timely · Medication Management · Failure to follow through with TSP Licensee was to ensure the following: · Follow through with responding to and participating with the Technical Support Program · Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication. · Ensuring personal rights of residents in care and ensuring resident needs are met. Continued from 809,,, Today, LPA toured facility and found it to be clean and at a comfortable temperature. As pertains to Administrator duties and qualifications: on 6/19/25 LPA Frank notified Administrator Luninging Alicdan of the following: They said your application to recertify your Administrators certificate was missing hours. They said they tried to contact you several times with no response. As such the application has been closed. Please contact them immediately as your facilities currently don’t have a certified Administrator. As of today, CCL has not received a response from Administrator and their certificate is still expired. With LPA present Admin called Admin cert unit but was unable to reach an agent. Admin explained she owed $10 and sent that $10 on 6/24/25, but has yet to hear anything else ( deficiency cited, see 800D ). As pertains to staff training: S2 and S3 do not have the required number of hours of training completed ( deficiency cited, see 809D ). As pertains to resident and staff records: All staff current in CPR/1st Aid. All staff have Health Screen present with TB clearance. All required resident documentation present. As pertains to Resident Care and Personal Rights: LPA visited room #4 and found it to be clean and free from incontinence odors. LPA visited all rooms of residents and found them to be free of incontinence odors as well. Facility overall free from incontinence odors. As pertains to inadequate staffing: LPA reviewed Guardian roster and found all active employees associated to the facility. LPA reviewed LIC500 and found at least 2 people on shift for day shift, evening shift, and NOC shift. As pertains to failure to clear deficiencies timely: Licensee has not had any outstanding deficiencies to clear in a timely manner, so licensee found to be in compliance with clearing deficiencies timely. As pertains to medication management: LPA did spot check of medication and verified that facility is no longer pre-pouring medications. As pertains to following through with TSP: licensee has followed through with TSP. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given .