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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Licensee/Administrator Azucena 'Sandy' Zipagan and Assistant Administrator (AADM) Triponia M. Tuazon. LPA stated the purpose of the visit. ADM states the facility has 6 residents. No residents were present during inspection. Licensee stated all 6 residents were at day program. LPA toured the interior and exterior of the facility with Licensee and AADM to include the kitchen, resident rooms, dining rooms, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. LPA observed the facility to be clean, safe, sanitary and in good repair. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed refrigerator temperature at 40 F and Freezer at 0 F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. Fire extinguishers were last serviced on 6/3/2025. The facility's fire sprinkler system was inspected on 10/11/2023 by a third party vendor and has a five (5) year certification letter for compliance. The facility first aid kit was reviewed. The facility emergency drill log was reviewed. The facility's last drill was conducted on 3/2/2026. The facility is conducting drills quarterly. Page 1 of 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA toured 6 resident bedrooms. All 6 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 2 bathrooms. All 2 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. Water temperature in 2 resident bathrooms measured at 124 F. Licensee had facility maintenance adjust water temperature during inspection. Licensee provided Water Log records for March 2026, documenting water temps in the facility kitchen, and resident bathrooms. Water temperatures documented were all under 120 degrees. Warning signs that water temperature may exceed 120 degree F was prominently displayed in the kitchen and resident bathrooms. LPA advised Licensee to continue to monitor and document water temperatures for the next 7 days, and submit documentation to CCL by 3/31/2026. A Technical Assistance was issued. LPA reviewed 2 resident records. LPA reviewed 2 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA reviewed 2 staff records. LPA reviewed 2 resident's P & I with AADM. No deficiencies were cited during today's visit per California Code of Regulations Title 22. A Technical Assistance was issued. An exit interview was conducted with Licensee/Administrator Azucena 'Sandy' Zipagan and Assistant Administrator (AADM) Triponia M. Tuazon and a signed copy of this report was provided. Page 2 of 2 END OF REPORT

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual inspection visit and met with Licensee/Administrator (LIC/ADM) Azucena Zipagan and assistant administrator (AADM) Triponia M. Tuazon. The facility has 6 resident and 4 staff, including LIC/ADM and AADM. All residents are currently out of the facility attending day program at the time of the visit. LPA observed the following are displayed prominently and can be easily seen; facility license, personal rights, administrator certificate and visitor hours posters were observed at the main entrance. LPA toured the exterior and interior of the facility with AADM. LPA inspected living room, kitchen, dinning area, restrooms, laundry room and garage. The facility has 4 resident bedrooms. 3 restrooms, 1 staff room. One of the staff room has been converted to a resident bedroom in June 15, 2024, the room is located at the end of the hallway towards the garage, and has it's own emergency exit door. No significant changes to the wall or layout of the facility. LPA observed medication, knives and toxic materials including but not limited to laundry detergents are in a locked cabinet not easily accessible. Non-skid mats and handle bars were observed in bathrooms. Room temperature was observed at 68 to 76 degree Farenheit (F) and water temperature in the bathroom and kitchen measured from 110 to 120 degree F. Warning signs that water temperature may exceed 120 degree F was prominently displayed. Refrigerator temperature was measured at 35 degree F, freezer temperature was measured at negative 10 degree F. LPA observed 2 days of perishable and 7 days non-perishable food. Continued on LIC 809C page 1 of 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA observed the facility is equipped with fire alarm wall system, fire sprinklers, carbon monoxide and smoke detector. The facility is inspected by Northern California Fire Protection Services annually for compliance and maintenance. Smoke alarm and carbon monoxide detector were tested and were found in good working condition. The fire extinguishers complies with the Fire Marshall's requirement. The interior hallways have working night lights. LPA toured he exterior and interior perimeter, ramps and walkways were free from any obstruction and debris. LPA reviewed 3 residents and 2 staff records. The records were complete and updated for the residents. The staff records were updated. No deficiencies and citations were issued for today's visit per California Code of Regulations Title 22. An exit interview was conducted with LIC/ADM Azucena Zipagan and signed copy of the report was provided.

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual inspection visit and met with Administrator (ADM) Azucena Zipagan. The facility has 6 resident and 3 staff including the administrator. All residents are currently out of the facility attending day program at the time of the visit. LPA observed the following are displayed prominently and can be easily seen; facility license, personal rights, administrator certificate and visitor hours posters were observed at the main entrance. LPA toured the exterior and interior of the facility with the staff (S1), Assistant Administrator (AADM) and ADM. LPA inspected living room, kitchen, dinning area, restrooms, laundry room and garage. The facility has 4 resident bedrooms, 3 restrooms, 1 staff room. LPA observed medication, knives and toxic materials including but not limited to laundry detergents are observed in a locked cabinet not easily accessible. Non-skid mats and handle bars were observed in bathrooms. Room temperature was observed at 68 to 76 degree Farenheit (F) and water temperature in the bathroom and kitchen measured from 110 to 120 degree F. Refrigerator temperature was measured at 35 degree F, freezer temperature was measured at negative 10 degree F. LPA observed food supply is ample/sufficient for 2 days of perishable and 7 days non-perishable. Continued on LIC 809C page 1 of 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 continued from page 1 LPA observed the facility is equipped with fire alarm, fire sprinklers, carbon monoxide and smoke detector. Smoke alarm and carbon monoxide detector were tested and were found in good working condition. The fire extinguishers complies with the Fire Marshall's requirement. The interior hallways have working night lights. LPA observed the outside perimeter, ramps and walkways were free from any obstruction and debris. LPA reviewed 3 residents and 2 staff records. The records were complete and updated for the residents. The staff records were updated. No deficiencies and citations were issued for today's visit per California Code of Regulations Title 22. The exit interview was conducted with ADM Azucena Zipagan and signed copy of the report were provided to ADM. Page 2 of 2 End of Report

Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Azucena (Sandy) Zipagan Administrator. LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked room. Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products and a covered trash can. Hand Washing signs posted in the bathrooms and in the kitchen. Hand sanitizer available to visitors and residents. LPA observed supply of Personal Protective Equipment (PPE). COVID 19 signs posted included Symptoms of COVID 19, It's a Two Way Street, Please Wear a Mask, Visiting Options, Guidelines for Health and Safe Life, How Can I Protect Myself, Universal Precautions and Social Distancing. LPA reviewed the facility policies and procedures to include screening, visitation, masking, isolation and disinfecting, No citations were issued per the California Code of Regulations, Title 22. LPA reviewed report with Sandy Zipagan and a copy provided.