Non-compliance follow-up·June 11, 2025

At approximately 9:20 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a Non-compliance inspection and was greeted by Staff Member Laurel Roque. Administrator Luningning Alicdan arrived at 9:50 AM. 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 Continued on 809-C... ...Continued from 809 · 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. Today, LPA conducted the Non-Compliance inspection. Licensee found to be in compliance as pertains to responding to and participating with the Technical Support Program. LPA reviewed records pertaining to compliance with areas including staff training records, maintaining staff and resident records, and pre-pouring of medication. LPA conducted interviews and made observations pertaining to Admin's ensuring of personal rights of residents in care and ensuring resident needs are met. During the Inspection LPA observed a medication cabinet in common area, next to the storage room, to be unlocked. This deficiency will be cited. This deficiency was previously cited on 4/24/2025. A Civil Penalty is being assessed for $250.00 for this repeat violation. During records review. LPA observed the following: -Residents R2, R3 and R5 did not have a current Appraisals/Needs & Service Plans on file. This deficiency will be cited. This deficiency was previously cited on 4/24/2025. A Civil Penalty is being assessed for $250.00 for this repeat violation. -LPA further observed that staff members S1, S2, S3 and S4 did not have required number of training hours on file. This deficiency will be cited. This deficiency was previously cited on 4/24/2025. A Civil Penalty is being assessed for $250.00 for this repeat violation. -LPA observed that staff members S2 and S4 did not have current First Aid certification on file. This deficiency will be cited. Continued on 809-C2... ...Continued from 809-C Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809Ds, LIC 421FCs, Plan of Corrections and Appeal Rights discussed and provided to Licensee/Administrator Alicdan. Signature on form confirms receipt of documents.