Norcal Care Home Ii

On 08/28/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Israel Wei and explained the purpose of today's inspection. There is currently one resident in the facility and one staff person being the administrator. This is a GGRC vendorized facility supporting GGRC seniors. This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. No residents on hospice or receiving oxygen. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. Cameras are observed to be posted around the outside perimeter of the facility but no cameras are inside according to the administrator Israel. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in in kitchen drawer adjacent to the stove. 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. First aid kit is observed as complete with required items. Medications are observed to be locked in the office area in a lockable storage area. LPA observed that there are two fire extinguishers in place inspected on 05/12/2025, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central HVAC. Facility is not equipped with fire sprinklers. PPE is observed to be in place in the central hallway outside of a resident room. Laundry area is observed as fully operational in the garage. Continued on next page... 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 Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 06/23/2024 which was an earthquake drill where all clients participated in. Water temperature is being tracked via logs observed posted on the refrigerator in the kitchen. Water temperature was measured at 110F on this day. Cleaning supplies are observed to be locked in beneath the kitchen sink and additional toxins and cleaning supplies are observed to be locked in the garage. Fire panel is in the garage with and inspection date tagged as 06/09/2025. Fire pull stations are observed by the front door of the facility and the rear door of the facility. LPA observed all client rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. Extra resident linen supplies are observed as in place in each clients room stored in appropriate areas. There are two client full bathrooms observed which are in good repair. Shower floors are equipped with non-skid mats. Residents primarily use the larger full bath with walk in shower. P&I monies are inspected and accurate to the ledger reviewed. Medications and logs are observed today as current. During today's inspection LPA reviewed 4 client files which are current and three staff files which are current. Administrator certificate current reflecting expiration date of June 29, 2027. No citations issued on this day. Report is reviewed with Israel and a copy is provided on this day.

On 08/23/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Israel Wei and explained the purpose of today's inspection. There are currently no residents in the facility as they are all at day program. This is a GGRC vendorized facility. This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. No residents on hospice or receiving oxygen. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. Cameras are observed to be posted around the outside perimeter of the facility but no cameras are inside according to the administrator Israel. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in in kitchen drawer adjacent to the stove. 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. First aid kit is observed as complete with required items. Medications are observed to be locked in the office area in a lockable storage area. LPA observed that there are two fire extinguishers in place inspected on 05/13/2024, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central HVAC. Facility is not equipped with fire sprinklers. PPE is observed to be in place in the garage and in a central hallway outside of a resident room. 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 06/23/2024 which was an earthquake drill where all clients participated in. Water temperature is being tracked via logs observed posted on the refrigerator in the kitchen. Water temperature was measured at 110F. Cleaning supplies are observed to be locked in beneath the kitchen sink and additional toxins and cleaning supplies are observed to be locked in the garage. Fire panel is in the garage with and inspection date tagged as 06/09/2023. 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 client rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. Extra resident linen supplies are observed as in place in each clients room stored in appropriate areas. There are two client full bathrooms observed which are in good repair. Shower floors are equipped with non-skid mats. P&I monies are inspected and accurate to the ledger reviewed. Medications and logs are observed today as current. During today's inspection LPA reviewed 4 client files which are current and staff files which are current. The following updated forms are requested to be submitted to CCLD by 08/30/2024 : • Copy of updated administrator certificates as there are more than one administrator • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC400 Affidavit Regarding Client/Resident Cash Resources • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease No citations issued on this day. Report is reviewed with Israel and a copy is provided on this day.

On August 5, 2022, Licensing Program Analysts (LPA) Komal Charitra and Kevin Varilla conducted an unannounced annual infection control inspection. Upon arrival LPA observed the COVID-19 signage posted on the front entrance. LPAs met with House Manager, Israel Wei and Licensee/Administrator, Fatollah Ghlichloo joined shortly thereafter. LPAs explained the purpose of the visit. LPAs were screened at entry point and House Manager was able to provide screening log documentation for staff, residents, and visitors. LPAs toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 4 bedrooms and 2 full bathrooms. All bedrooms were observed to be private resident rooms. During the visit, LPAs observed both bathrooms to be observed with liquid soap, paper towels, hand washing signs, non-skid mats, and a trash can with a lid. During the visit, all staff were observed with a face mask. LPAs toured the living room and dining room and it was clear and odor-free. The living room was clear from any tripping hazards. COVID-19 signs were observed to be posted throughout the facility. A comfortable temperature is maintained and lighting is sufficient for comfort. Living room and outdoor space is spacious for daily resident activities. LPAs observed the locked medication cabinet in the office room. LPAs toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps and toxins were stored appropriately and inaccessible to residents. Freezer temperature was measured at -20 degrees F and refrigerator was measured at 40 degrees F in both the kitchen and garage. Washer and dryer was observed to be in good working condition. First aid kit was observed to be completed. 30-day PPE supply was present. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies, PPE bin set up outside resident rooms, and face coverings. LPA requests the following forms to be sent to CCLD by 8/12/22: LIC309 Administrative Organization LIC308 Designation of Administrative Responsibility LIC500 Personnel Report LIC400 Resident Cash Resources LIC610E Emergency Disaster Plan No citations issued during this visit. Report is reviewed with Administrator/Licensee and House Manager and a copy is provided.