Health inspection·December 2, 2025

F 0844 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. Based on interview and record review, the facility failed to notify the required State Agency (SA) within ten (10) days when there was a Change in Administrator (CHOA) on 11/13/2023. This failure had the potential for the facility information to not be up to date and had the potential for the old Administrator (ADM) to receive communication from the SA that was intended for the current ADM. Findings: During a concurrent interview and record review on 12/2/2025 at 12:33 p.m. with the Director of Nursing (DON), the facility's organizational chart, undated was reviewed. The organizational chart indicated that ADM 1 was the administrator. The DON stated ADM 1 had been the ADM since she assumed position as the DON in May 2025. The DON stated she was aware he was the ADM two years ago when she was a Licensed Nurse (LN) at a sister facility.During an interview on 12/2/2025 at 12:51 p.m. with the Medical Records Director (MRD), the MRD stated she had worked at the facility for 3 years. The MRD stated ADM 1 had been at the facility as the ADM for over 2 years. The MRD stated staff were notified of the change of administrator (CHOA) during a meeting and ADM 1 was introduced to staff. The MRD stated she was not sure what reporting requirements were for a CHOA.During an interview on 12/2/2025 at 1 p.m. with the Social Services Director (SSD), the SSD stated she had worked at the facility for 5 years. The SSD stated there had been three ADM changes since she worked at the facility. The SSD stated ADM 1 was the third ADM change. The SSD stated the ADM 1 started working at the facility in 2023 but was unsure of the exact month. The SSD stated she was not aware if a CHOA report was made to the SA.During an interview on 12/2/2025 at 1:10 p.m. with ADM 1, ADM 1 stated he assumed the role of ADM for the facility on 11/13/2023. ADM 1 stated ADM 2 was the previous administrator and had left the facility before he assumed the role of ADM. ADM 1 stated he was aware that the State of California required facilities to report administrative changes to the SA. ADM 1 stated the [NAME] President of Operations (VPO) was responsible for reporting the change. ADM 1 stated, since becoming the ADM, he had communicated and represented the facility with the SA on many occasions, during surveys and inspections. ADM 1 stated he was responsible for regulatory reporting.During a review of the facility document titled, Offer Letter, the document indicated that ADM 1 was hired on 11/13/2023.During a review of the facility document titled, Letter of Resignation (LR), dated 9/6/2023, the document indicated ADM 2 had sent a formal resignation to the VPO effective 9/15/2023.During a review of the facility document titled, Applicant Individual Information (HS215A) form (HS), dated 12/30/2023, the document indicated, .A. Applicant Facility Information. 1. Facility Name: {named organization} dba (doing business as) {named 3 different facilities} . The document indicated ADM 1 completed and signed the HS on the 12/30/2023. The document had no certified receipt or stamped date indicating the document was received by the SA.During a phone interview on 12/10/2025 at 8:50 a.m. with ADM 1, ADM 1 stated the HS was submitted to the SA via postal service mail carrier. ADM 1 stated he did not have proof the form was mailed to the SA. ADM 1 stated he never verified with the SA if he was listed as the ADM on record. ADM 1 stated he did not know Page 1 of 2 055935 055935 12/02/2025 Ceres Postacute Care 1711 Richland Avenue Ceres, CA 95307

F 0844 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few how to verify if he was the ADM on record. ADM 1 stated the facility had been waiting for electronic mail (e-mail) from the SA to confirm the ADM on record had been updated. ADM 1 stated he was unsure when he first learned he was not the ADM on record and would have to refer back to when he got an e-mail from the SA. ADM 1 was unable to provide evidence of the correspondence between the facility and the SA on the CHOA for the facility. ADM 1 stated the facility had no policy and procedure for CHOA. ADM 1 stated the facility had no policy and procedure for reporting to the Regulatory Authority.During a phone interview on 12/10/2025 at 9:05 a.m. with the VPO, the VPO stated she was responsible for notifying the SA of the CHOA. The VPO stated the ADM was responsible for ensuring the facility was in compliance with the SA at all times. The VPO stated an appointment letter along with the HS was sent to the SA. The VPO was unable to provide proof of the mailed documents. The VPO stated when documents were mailed to the SA, the facility would receive a notification back in the form of a letter stating whether the application had been accepted or not. The VPO was unable to provide the letter stating whether the application had been accepted or not.During a record review of the Electronic Licensing Management System (ELMS) for the SA Licensing and Certification (L&C), under the Facility - Related Entity Tab dated 12/11/25, the ELMS indicated the ADM on record was, ADM 2 . role status: Active.start date-7/12/2022 and no end date.During a record review of the ELMS program under the Facility- Applications Tab, dated 12/11/25, the ELMS indicated the prior application for CHOA for the facility was on 4/22/2022 with Application ID: 2966790 and the status: application approved. The ELMS indicated the most recent application for CHOA for the facility was on 12/3/2025, Application ID: 4411485, and status: pending assignment. The ELMS indicated there was no application for CHOA for the facility between 4/22/2022 and 12/3/2025. The ELMS indicated there were no additional pending CHOA applications for the facility.During a review of California Code of Regulations Title. 22, S 72211 - Report of Changes (CCR), dated as 11/28/25 Register 2025, No. 48, reviewed on 12/12/2025, found at https://govt.westlaw.com/calregs/Document/IB8E826655B6111EC9451000D3A7C4BC3?viewType=FullText&originationCo the CCR indicated, .(b) When a change of administrator occurs, the Department shall be notified within 10 days in writing by the licensee. Such writing shall include the name and license number of the new administrator. 055935 Page 2 of 2