Adams Paul Inc

On 10/15/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced post licensing inspection visit. LPA met with administrator Rommel Dionson and explained the purpose of today's visit. There is one resident present and the remaining 4 are at day program. Currently there are 4 staff present in the facility and the administrator. This is a single level facility licensed for residents age range 60 and over. Approved for 6 non-ambulatory. One client is using oxygen. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on inside the facility per the administrator. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in a drawer adjacent to the kitchen sink. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator and freezer in the garage area which carries additional food supplies for resident use. Multiple bins are observed storing emergency food supplies such as canned foods and juices. This can be incorporated into facility resident meals as well. First aid kit is observed as complete with required items. Medications are observed to be locked in a credenza located outside of the kitchen. LPA observed at least two fire extinguishers in place which are currently within operating range with inspection tags of 04/17/2025, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating. Facility is equipped with fire sprinklers through out. PPE is observed to be in place and additional supplies are observed in a shed in the backyard. Laundry area is also observed as fully operational in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 10/01/2025. Water temperature was measured at 105F in both resident bathrooms observed. One is a full walk in shower room. Continued on next... 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 Page 2 LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Extra resident linen supplies are observed as in place in hallway closet and in resident room closets. Resident bathroom is observed as clean and in good worker order. Shower floors are equipped with non-skid mats. Facility does handle resident monies and is current as it is reviewed with staff. Per inspection medications and logs are observed today as current. During today's inspection, LPA reviewed 5 resident files which are current. And 4 staff files which are current. Administrator certificate is observed as current expiring on 03/02/2027. The following updated forms are requested to be submitted to CCLD by 10/22/2025 : • Copy of updated administrator certificate • Copy of facility's liability insurance • Copy of facility surety bond • Copy of current LIC610E • LIC308 Designation of responsible staff person • LIC500 Staff Schedule No citations issued. Report is reviewed with Rommel and a copy is provided on this day.

On 10/15/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Rommel Dionson and explained the purpose of today's visit. There is one resident present and the remaining 4 are at day program. Currently there are 4 staff present in the facility and the administrator. This is a single level facility licensed for residents age range 60 and over. Approved for 6 non-ambulatory. One client is using oxygen. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on inside the facility per the administrator. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in a drawer adjacent to the kitchen sink. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator and freezer in the garage area which carries additional food supplies for resident use. Multiple bins are observed storing emergency food supplies such as canned foods and juices. This can be incorporated into facility resident meals as well. First aid kit is observed as complete with required items. Medications are observed to be locked in a credenza located outside of the kitchen. LPA observed at least two fire extinguishers in place which are currently within operating range with inspection tags of 04/17/2025, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating. Facility is equipped with fire sprinklers through out. PPE is observed to be in place and additional supplies are observed in a shed in the backyard. Laundry area is also observed as fully operational in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 10/01/2025. Water temperature was measured at 105F in both resident bathrooms observed. One is a full walk in shower room. Continued on next... 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 Page 2 LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Extra resident linen supplies are observed as in place in hallway closet and in resident room closets. Resident bathroom is observed as clean and in good worker order. Shower floors are equipped with non-skid mats. Facility does handle resident monies and is current as it is reviewed with staff. Per inspection medications and logs are observed today as current. During today's inspection, LPA reviewed 5 resident files which are current. And 4 staff files which are current. Administrator certificate is observed as current expiring on 03/02/2027. The following updated forms are requested to be submitted to CCLD by 10/22/2025 : • Copy of updated administrator certificate • Copy of facility's liability insurance • Copy of facility surety bond • Copy of current LIC610E • LIC308 Designation of responsible staff person • LIC500 Staff Schedule No citations issued. Report is reviewed with Rommel and a copy is provided on this day.

LPA Jeung conducted follow-up pre-licensing inspection to confirm completion of items referenced on initial pre-licensing visit of 11/30/23. The following items are observed: 1. Emergency Disaster Plan (LIC610E) is complete and includes phone number for ambulance service and location of 2 fire extinguishers (on page 3 of LIC610E). Utility shut off locations is clearly stated. (CCR 87465 Incidental Medical and Dental Care) 2. Toilet and shower grab bars are installed in front bathroom (CCR 87303 Maintenance and Operation) 3. There is a designated area for posting information related to family councils. (HSC 1569.158) 4. Spare set of all keys for facility vehicles, facility exits, and cupboards, cabinets is available in the key cabinet in the event of an emergency. (HSC 1569.695) 5. Half bed rails are used for 4 residents, and half rail is positioned at the head of the bed. (CCR 87608 Postural Supports) As per on-site review of residents during initial pre-licensing visit by CCLD RN consultants, all are deemed appropriate for care in a RCFE, with nursing care specified in each client's Needs and Services Plan, MD approved care plans, and pending exceptions. Facility meets physical plant requirements for licensure as RCFE for 6 non-ambulatory elderly persons. Immediate licensure is recommended, pending approval of Centralized Applications Bureau.

Applicant Adams Paul Inc., represented by CEO Rosemarie Veridiano, has applied for RCFE licensure for 6 non-ambulatory elderly persons. Fire clearance has been approved. Facility is currently operated as Adams ICF/DD-N, #220000471 (effective 6/19/23 to 6/18/24), licensed by the CA Dept. of Public Health. LPA Jeung toured facility and grounds of this one level facility. Also present during this inspection are CDSS RNs Helen Shi and Paul Chua, who are present to observe residents and review their health conditions. Infection control reviews were conducted upon entry. There are 5 client bedrooms--4 private and 1 shared--2 full bathrooms, living/dining area, kitchen and garage. Facility sketch accurately reflects floor plan. There is a rear wooden deck and side ramps, and a detached storage shed in backyard where paint and extra supplies are stored. There is an adequate supply of personal protective equipment (PPE), fresh and perishable food supplies, Bedrooms are observed with required furniture. Medications are secured in medication cabinet in dining area as well as closet near front bathroom. Toxins and chemicals are stored in locked detached storage shed and locked storage room in garage. Food preparation and service items are present, as well as supply of bed and bath linens. Hot water temperature is tested at 107 degrees in shower room. Carbon monoxide detectors are present in 4 bedrooms as well as common areas. There are 2 fire extinguishers. The following items are observed and must be addressed prior to licensure: 1. Emergency Disaster Plan (LIC610E) is incomplete. Phone number for ambulance service must be included. Utility shut off locations must be corrected. Location of 2 fire extinguishers will be added to page 3 of LIC610E. (CCR 87465 Incidental Medical and Dental Care) 2. Front bathroom is not equipped with toilet grab bars. (CCR 87303 Maintenance and Operation) 3. There is no posting area designated for information related to family councils. (HSC 1569.158) Continued on page TWO 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 4. Set of all keys for facility vehicles, facility exits, and cupboards, cabinets must be made and be available in the event of an emergency. (HSC 1569.695) 5. Half bed rails are used for 4 residents, but half rail must be positioned so it is at the head of the bed, not part way down. (CCR 87608 Postural Supports) The above items must be completed prior to licensure. Applicant to notify LPA upon completion, and a follow up visit may be made. Facility phone number is verified 650/522-8108 Component III RCFE orientation is provided to RCFE administrator Rommel Dionson and Rosemarie Veridiano.

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 6 Method: Telephone call with CAB Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by correctly answering identity verification questions. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property