Non-compliance follow-up·October 24, 2025

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a Non-compliance inspection. Licensee Luningning Alicdan arrived at 9:05 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 the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. 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 Administrators ensuring of personal rights of residents in care and ensuring resident needs are met. The facility is being cited for not having a currently certified Administrator. As this is the third (3) time the facility is being cited (8/6/2025 & 8/22/2025) for this deficiency within one (1) year a Civil Penalty of $250.00 is being assessed. During today's inspection, LPA made the following observations: -Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. -A bottle of Povidone/Iodine was observed to be unsecured in a resident's bathroom. In addition, LPA observed that the door to the laundry room was unlocked. Within the laundry room, there were unsecured toxins. LPA further observed that the storage room in a common area was unlocked and that there were unsecured toxins in the room. These deficiencies will be cited. As this same deficiency was previously cited within the past year (4/24/2025) a Civil Penalty of $250 will be issued. -In a kitchen cabinet two (2) condiment items that were required to be refrigerated after opening, were left unrefrigerated in a kitchen cabinet. This deficiency will be cited. As this same deficiency was previously cited twice (2) times within the past year (4/24/2025 & 6/11/2025) a Civil Penalty of $250 will be issued. Continued on 809-C2... ...Continued from 809-C -In the common area, next to the storage room, a parabolic dish heater was observed to not have a protective screen to prevent the risk of burns or fire. This deficiency will be cited. The licensee unplugged and removed the heater during today's inspection so the deficiency will be cleared. -In the cabinet immediately outside of the kitchen area, across from a bathroom, food products and cleaning products were observed to be stored together. This deficiency will be cited. -In the common area, next to the storage room a cabinet with prescription items was observed to be unlocked and accessible to residents. As this same deficiency was previously cited twice (2) times within the past year (6/11/2025 & 8/22/2025) a Civil Penalty of $250 will be issued. During today's inspection, LPA reviewed four (4) residents files and two (2) staff files. LPA observed an incomplete LIC 624 Unusual Incident report in resident R4's personal records. This LIC 624 was not sent to Community Care Licensing (CCL) within the required seven (7) days from the date of the incident. Additionally, LPA observed that a required LIC 9186 Client Death Report had not be filled for resident R5. These deficiencies will be cited. As this same deficiency was previously cited within the past year (4/24/2025) a Civil Penalty of $250 will be issued. LPA observed that two (2) of two (2) staff files had all required documentation including First Aid and CPR certification and proper training documentation. 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, 811 Confidential Names, LIC 421FCs, Plan of Corrections and Appeal Rights discussed and provided to Licensee Alicdan. Signature on form confirms receipt of documents.