Non-compliance follow-up·November 6, 2025

Licensing Program Analyss (LPA) Christi Coppo arrived unannounced to conduct a Non-compliance and was greeted by licensee Luningning Alicdan. 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 on 809... 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: during LPA's last non-compliance visit at facility on 7/1/25 licensee was cited for not having a current Administrator certificate. Again the licensee was cited on 8/6/25 for not having a current Administrator certificate. As of today, she still does not have a current Administrator certificate. However, as of 11/5/25 Edward R. Alicdan is now the Administrator for the facility. Edward R. Alicdan Administrator certificate number 6039689740 expires 10/2/27. LPA discussed with licensee that she will be taking over again as Administrator once her paperwork is mailed in on 11/19/25. LPA verified all training hours current. LPA will make change of Administrator once all paperwork is submitted to CCL. As pertains to staff training: Staff all have current training. Files complete. As pertains to resident and staff records: All staff current in CPR/1st Aid. All staff have Health Screen present with TB clearance. Resident files complete. 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. LPA and caregiver reviewed Centrally Stored Medication log (CSML) and current physician's orders for R1. LPA and caregiver observed bottle of Ondansetron 4mg to be present in R1's medications but not listed on current physician's orders. LPA and caregiver observed Calcium Continued on 809C(2)... continued from 809C... Citrate-Vitamin D3 315mg-5mcg on R1's current physician's orders but not listed on the CSML, medication discontinuation not present. LPA advised if a medication is not listed on CSML but is listed on current physician's orders, a discontinuation order must be in the resident's file ( deficiency cited, see 809D ). LPA and caregiver went over PRN MAR for R2. Last date of entry on PRM MAR was 10/29/25, administered before R2 receives a bed bath. R2 receives a bed bath 2 days per week, last bath given yesterday 11/5/25. PRN entry not logged. Additionally, PRN MAR does not list any outcomes for R2 ( deficiency cited, see 809D ). As pertains to following through with TSP: licensee has followed through with TSP successfully. 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 licensee and a copy of this report was given