Non-compliance follow-up·February 11, 2026

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Non-compliance and was greeted by Administrator Edward Alicdan Jr. LPA is conducting Non-compliance in conjunction with annual inspection. All deficiencies cited will be cited on the annual inspection, except for deficiency cited for inadequate staffing, citation issued on this report. 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,,, As pertains to Administrator duties and qualifications: 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. As pertains to staff training: Staff all have current training. Files complete. As pertains to resident and staff records: Resident (R1) did not have TB clearance on file. Deficiency cited on annual inspection. 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: Per Admin, only himself and one other caregiver have been on shift for about 2 or 3 weeks while licensee has been on of the country. However, per the NCC compliance plan all shifts must be covered by at least two [2] staff. LPA spoke to licensee over telephone while out of the country. Licensee indicated to LPA that the requirement for two [2] staff per shift is no longer needed as resident care needs have changed. However, during inspection LPA did not observe any paperwork indicating any change in resident care needs ( deficiency cited, see 809D ). 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. LPA and caregiver reviewed Centrally Stored Medication log (CSML) and current physician's orders for R1. LPA and caregiver observed errors present on CSML. Deficiency cited on annual inspection. Additionally, LPA and caregiver observed pre-poured medications in kitchen drawer. Deficiency cited on annual inspection. LPA and caregiver went over PRN MAR for R2. PRN MAR complete, including today's entry. 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 Administrator and a copy of this report was given.