Non-compliance follow-up·January 13, 2026

At approximately 8:55 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a Non-compliance inspection. Licensee Luningning Alicdan arrived at 9:10 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. During today's physical plant 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. -LPA observed that a storage room in a common area was unlocked and that there were unsecured toxins and insulin hypodermic needles in the room. This deficiency will be cited. As this same deficiency was previously cited within the past year (4/24/2025 & 10/24/2025) a Civil Penalty of $250 will be issued. -An over the counter (OTC) medication was observed to be unsecured in a resident's room. During file review LPA observed that the resident (R3) was not allowed to administer their own prescription or PRN (pro re nata) medications. This deficiency will be cited. As this same deficiency was previously cited within the past year a Civil Penalty of $250 will be issued. During today's inspection, LPA reviewed three (3) residents files and two (2) staff files. During file review, LPA observed the following: -One (1) of three (3) residents' files (for resident R1) was observed not to contain any emergency contact information. This deficiency will be cited. -One (1) of three (3) residents' files (for resident R2) was observed not to contain an LIC 603 Preplacement Appraisal. This deficiency will be cited. Continued on 809-C2... ...Continued from 809-C -One (1) of three (3) residents' files (for resident R3) was observed not to have a licensed medical professional's order or prescription for a PRN (pro re nata) medication. Resident R3 is not allowed to administer their own prescription or PRN medications. This Deficiency will be cited. -One (1) of two (2) staff files was observed not to contain a Medical Assessment or proof of a negative tuberculosis test. This Deficiency will be cited. 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 Caregiver Nicadao Wilhelfortes . Signature on form confirms receipt of documents.