197608221-2-13-2026-28-AS-DSIS-DRWQCB-20260306110250

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608221
Report Date: 02/13/2026
Date Signed: 02/13/2026 01:16:21 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2026 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260203110210

FACILITY NAME:	CHLOIE'S COTTAGE II		FACILITY NUMBER:	197608221
ADMINISTRATOR:	LINDA RENARD		FACILITY TYPE:	740
ADDRESS:	305 E. BASELINE ROAD		TELEPHONE:	(909) 592-4488
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	6	CENSUS: 5	DATE:	02/13/2026
		UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Eva Tencinco - House Manager		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with Eva Tencinco and explained the purpose of today's visit.

The investigation consisted of the following:
During initial visit 2/12/26 LPA obtained copies of Administrator certificates, copies of Resident #1’s (R1) Physician Report and CalAIM Assessment Form, conducted interviews with 3 Staff (S1-S3) and 3 Residents (R2-R4), toured facility and inspected medication, cleaning supplies and disinfectants, restrooms, laundry area and tested all exit door chimes. After visit LPA conducted interview via phone call with R1.
On 2/13/26 LPA received copies of staff trainings, restricted health care plan for R2, Admission agreement, Resident Appraisal , Consent Forms, and Emergency ID Information for R1. LPA interviewed 2 Staff via phone call (S4-S5) and delivered findings on the reported allegations.

(Continued on LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2026 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260203110210

FACILITY NAME:	CHLOIE'S COTTAGE II		FACILITY NUMBER:	197608221
ADMINISTRATOR:	LINDA RENARD		FACILITY TYPE:	740
ADDRESS:	305 E. BASELINE ROAD		TELEPHONE:	(909) 592-4488
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	6	CENSUS: 5	DATE:	02/13/2026
		UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Eva Tencinco - House Manager		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Licensee did not ensure that the Administrator or their designee was present at the facility as required.
Licensee accepted resident(s) with a higher level of care need.
Staff do not allow resident to get food when hungry.
Staff do not ensure that resident is adequately fed.
Staff retaliated against resident.
Staff are not providing adequate care and supervision to residents.
Staff do not answer facility phone.
Staff did not store hazardous items as required.
Licensee does not ensure that staff are adequately trained.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with Eva Tencinco and explained the purpose of today's visit. (there is a Continuation to this report on the attached LIC9099A as all allegations on compaint did not fit on one report

The investigation consisted of the following:

During initial visit 2/12/26 LPA obtained copies of Administrator certificates, copies of Resident #1’s (R1) Physician Report and CalAIM Assessment Form, conducted interviews with 3 Staff (S1-S3) and 3 Residents (R2-R4), toured facility and inspected medication, cleaning supplies and disinfectants, restrooms, laundry area and tested all exit door chimes. After visit LPA conducted interview via phone call with R1. On 2/13/26 LPA received copies of staff trainings, restricted health care plan for R2, Admission agreement, Resident Appraisal, Consent Forms, and Emergency ID Information for R1. LPA interviewed 2 Staff via phone call (S4-S5) and delivered findings on the reported allegations.(Continued LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 28-AS-20260203110210

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHLOIE'S COTTAGE II	FACILITY NUMBER: 197608221
	VISIT DATE: 02/13/2026

NARRATIVE

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The investigation revealed the following:
Allegation: Licensee did not ensure that the Administrator or their designee was present at the facility as required.It is alleged that Administrator Linda hasn't been in the facility for over 1.5 years and there has been no designated Administrator during Linda's absence. LPA interviewed 4 residents and 3 residents denied the above allegation and stated that the Administrators visit daily for hours at a time and when the Administrators are not present there is a live in staff (S4) that is present and is the House Manager. LPA interviewed 5 staff and each denied the allegation and stated that Administrators are present daily for a few hours at a time, are always reachable via phone/text and that the House Manager is there regularly to assist with residents or any emergencies as they are a live in staff. During LPA’s visit Administrator arrived within 15 minutes after LPA’s arrival and was present for the entire investigation.

Allegation: Licensee accepted resident(s) with a higher level of care need.It is alleged that there are residents at the facility that require higher level of care. LPA reviewed resident files there is 1 resident (R2) who is on hospice and has a G-Tube, LPA obtained a copy and reviewed R2’s hospice health care plan with no issues. The facility is approved for 3 residents under hospice care. LPA interviewed 5 staff and each denied the allegation and stated that although they have a resident on Hospice, there is a hospice nurse that visits regularly to assist resident, during visit LPA observed a hospice nurse arrive and visit/assist resident. LPA interviewed 4 Residents and 3 residents denied the allegation and stated that they believe all residents are getting proper care, nurses are seen visiting facility and assisting with residents , and don’t believe any of the residents at the facility require a higher level of care.

Allegation: Staff do not allow resident to get food when hungry.It is alleged that staff will not allow R1 to enter the kitchen and get a yogurt or snack out of the refrigerator when R1 is hungry and will harass and ask R1 what they are doing when in the kitchen. During visit LPA observed R1 enter the living room and kitchen area freely, staff were assisting other residents, said good morning to R1 and R1 proceeded to enter kitchen, grab a snack from the refrigerator and take it to their room with no interference or harassment from staff. LPA interviewed 4 residents and 3 residents denied the allegation and stated that they are able to get snacks freely if they wish, however, due to their diasability they prefer to ask staff to get them their food/snacks. LPA interviewed 5 staff and each denied the allegation and stated that residents are free to get their own food/snacks, however, due to a majority of the residents disabilities the staff assist with this ADL. Staff stated that there is only one resident that is able to do this independently and that is R1 and they have never harassed or tried to prevent R1 from getting their food/snack from the kitchen. (continued on LIC9099-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 28-AS-20260203110210

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHLOIE'S COTTAGE II	FACILITY NUMBER: 197608221
	VISIT DATE: 02/13/2026

NARRATIVE

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Allegation: Staff do not ensure that resident is adequately fed.
It is alleged that R1 has a health condition that effects their appetite and is not being adequately fed. LPA interviewed 4 residents and each denied the allegation. Interview with R1 revealed that they are provided meals, however, they feel that other residents are not being adequately fed because of meals being pureed or yogurt. LPA interviewed 5 staff and each denied the allegation and stated that they provide 3 meals and snacks to the residents, some residents are on a pureed food diet along with/or ensure due to their disability, staff stated if residents do not like what the meal is they are provided with alternative meals of their choice. LPA inspected food supply and there was a sufficient amount of food available to meet the needs of the residents.

Allegation: Staff retaliated against resident.

It is alleged that S4 and S5 started retaliating against R1 after Administrator Linda spoke to them of concerns brought to Linda’s attention. LPA interviewed 4 residents and 3 residents denied the allegation and stated that staff have never made them feel threatened or retaliated against and have never seen this happen to other residents. LPA interviewed 5 staff and each denied the allegation and stated they have never threatened or retaliated against a resident and have never witnessed another staff do this.

Allegation: Staff are not providing adequate care and supervision to residents.

It is alleged that staff put the residents to bed right after they have dinner and then for the most part don't supervise them during the overnight hours. LPA interviewed 4 residents and 3 residents denied the allegation and stated that there is always someone at the facility even in the night hours to assist with their needs, and stated that there are 2 live in staff that are always available at night. LPA interviewed 5 staff and each denied the allegation and stated that there is always a staff available to meet the needs, there are 2 live in staff that are readily available to assist with there residents. LPA conducted file review for all residents and there was nothing noted within the resident files that indicate they have wandering behaviors at night.

Allegation: Staff do not answer facility phone.

It is alleged that staff do not answer the phone from 7 pm until the morning. LPA interviewed 4 residents and each denied the allegation and stated that they have never heard there phone ringing at night and staff not answer. LPA interviewed 5 staff and each denied the allegation and stated that they always answer the phone unless they are busy with a resident and cannot get to the phone in time, but the facility phone is never ignored intentionally. S5 stated that sometimes if they see that it is a spam call they will not answer, LPA advised staff that all calls must be answered if they are available to answer the phone in the case that it can be licensing or another important call. (continued on LIC9099-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 9

Control Number 28-AS-20260203110210

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHLOIE'S COTTAGE II	FACILITY NUMBER: 197608221
	VISIT DATE: 02/13/2026

NARRATIVE

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Allegation: Staff did not store hazardous items as required.
It is alleged that knives were accessible to the residents, and that toxic cleaning supplies were left accessible to residents. LPA toured facility, inspected knife drawer and hazardous items/cleaning supply closet and both were locked securely during visit. LPA interviewed 4 residents and 3 out of 4 residents denied the allegation and stated that they have never seen any hazardous items to be left unattended or accessible. Interview with R3 reveled that they enjoy using nail polish and sometimes use nail polish remover and staff are always present to assist and they lock up the items when not in use.

Allegation: Licensee does not ensure that staff are adequately trained.
It is alleged that staff do not have proper training to meet the needs of residents such as resident that have a G-Tube. LPA conducted file review and observed that R2 has a hospice care plan for G-Tube assistance that states only a nurse or qualified professional shall assist with g-tube, however, for feeding purposes trained staff are able to feed ensure through G-tube. LPA interviewed 4 residents and 3 residents denied the allegation and stated that they feel confident that the staff are well trained to meet their needs. LPA interviewed 5 staff and each denied the allegation and stated that only the nurses assist with the G-tube when cleaning, disinfecting and have been instructed if any pain or redness occurs to call hospice or take resident to the hospital, staff stated they have been trained to be able to assist with feeding through G-tube for R1 if needed, however, R1 is now able to eat on a pureed diet and no longer needs to be fed through the g-tube. During visit LPA observed staff prepare a pureed meal for R1 and R1 was eating it with no issues.

Based on statements and interviews conducted with staff/residents, review of resident files, facility file records, and LPA observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2026 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260203110210

FACILITY NAME:	CHLOIE'S COTTAGE II		FACILITY NUMBER:	197608221
ADMINISTRATOR:	LINDA RENARD		FACILITY TYPE:	740
ADDRESS:	305 E. BASELINE ROAD		TELEPHONE:	(909) 592-4488
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	6	CENSUS: 5	DATE:	02/13/2026
		UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Eva Tencinco - House Manager		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Resident developed an infection while in care due to staff neglect.
Staff do not ensure that residents' diapering needs are met.
Licensee did not complete an individual written admission agreement upon acceptance of resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with Eva Tencinco and explained the purpose of today's visit. (this report is incontiuation to the LIC9099 as all allegations did not fit on one report)

The investigation consisted of the following:

During initial visit 2/12/26 LPA obtained copies of Administrator certificates, copies of Resident #1’s (R1) Physician Report and CalAIM Assessment Form, conducted interviews with 3 Staff (S1-S3) and 3 Residents (R2-R4), toured facility and inspected medication, cleaning supplies and disinfectants, restrooms, laundry area and tested all exit door chimes. After visit LPA conducted interview via phone call with R1. On 2/13/26 LPA received copies of staff trainings, restricted health care plan for R2, Admission agreement, Resident Appraisal, Consent Forms, and Emergency ID Information for R1. LPA interviewed 2 Staff via phone call (S4-S5) and delivered findings on the reported allegations. (Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 28-AS-20260203110210

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHLOIE'S COTTAGE II	FACILITY NUMBER: 197608221
	VISIT DATE: 02/13/2026

NARRATIVE

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The investigation revealed the following:
Allegation: Resident developed an infection while in care due to staff neglect.It is alleged that a resident has developed a very bad skin infection because staff do not change their diapers at night. LPA interviewed 4 residents and 3 residents denied the allegation and stated that they have never had an infection, and that they are changed at night around 9-10pm (before bed) and if a change is needed throughout the night they can ask a staff to assist with no issues. LPA interviewed 5 staff and each denied the allegation and stated that diapers are changed regularly and they have never seen a resident have an infection due to lack of proper diaper changes.

Allegation: Staff do not ensure that residents' diapering needs are met.It is alleged that staff leave residents in wet diapers all night. LPA interviewed 4 residents and 3 residents (all that require incontinence care) denied the allegation and stated that they are changed at night around 9-10pm (before bed) and if a change is needed throughout the night they can ask a staff to assist with no issues. LPA interviewed 5 staff and each denied the allegation, interviews with S2-S3 revealed that they are the morning staff that conducts the first morning rounds for residents and have never observed a resident to be neglected by night staff in this way, interview with night staff S4-S5 stated that they conducted rounds regular at night and have never left a resident with soiled diapers at night or day.

Allegation: Licensee did not complete an individual written admission agreement upon acceptance of resident.It is alleged that R1 has never been provided/signed an Admission Agreement since moving in. Per interview with S1 it was confirmed that R1 moved in late in the evening on 1/24/26, due to how late the resident arrived the admission paperwork was not completed that night, S1 stated that they spoke with R1 and their mom the next day on 1/25/26 and spoke to them about the facility and went over the admission agreement and informed them both that the admission agreement needed to be reviewed and signed. LPA obtained proof of several attempts made via text and email to the resident and their mom to sign the admission agreement as early as 1/29/26, however, both parties avoided signing the agreement until 2/6/26 when S1 was finally able to sit with R1 and obtain the signatures on the agreement. Per file review R1 is self-responsible and can make their own financial decisions, there is no POA assigned for R1.

Based on statements and interviews conducted with staff/residents, review of resident files, facility file records, and LPA observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 28-AS-20260203110210

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHLOIE'S COTTAGE II	FACILITY NUMBER: 197608221
	VISIT DATE: 02/13/2026

NARRATIVE

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The investigation revealed the following:
Allegation: Facility is in disrepair.
It is alleged that the facility washing machine is in disrepair/leaks water, the toilet in the second bathroom also leaks water, and there is black mold in the master bathroom. LPA toured facility, toilets were tested and there were no leaks observed, there was no indication of mold in both facility bathrooms and nor in the resident bedrooms. Staff were doing laundry and there were no signs of leaks, however, there was a chuck observed on floor near washer, chuck was dry and staff stated they place one there as when clothing sometimes falls on the floor when switching to the dryer, they rather the clean clothes fall on the clean dry chuck than the floor. Interviews with 6 staff and 2 residents revealed that there was a leak in the bathroom, the toilet would overflow and leak; and there was mold observed in the bathroom that R2 resides in. S1 provided photo of mold dated 1/22/26 and request for repairs dated 1/22/26. Both the leak and mold on ceiling of bathroom have since been repaired and there have been no further issues.

Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Exit interview held, a copy of this report and appeal rights were provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 28-AS-20260203110210

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHLOIE'S COTTAGE II	FACILITY NUMBER: 197608221
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/13/2026 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	LPA toured facility, tested toilets and washer and there were no signs of leaks. LPA toured restrooms and residnet rooms, checked for signs of mold and did not observe any. POC is cleared and the clearance letter will be emailed to Administrator at a later date.
	8 9 10 11 12 13 14	Per interviews with 6 staff and 2 residents revealed that there was a leak in the bathroom, the toilet would overflow and leak; and there was mold observed in the bathroom that R2 resides in.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026

LIC9099 (FAS) - (06/04)

Page: 9 of 9