Pacific Care Home

On 12/10/2025, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator Moddie Andaya and explained the purpose of today’s visit. Currently there are 6 residents and 3 staff present including the administrator. This is a single level facility with 6 bedrooms for residents. The facility is licensed for age 60 and over. All may be Non-Ambulatory residents; Hospice waiver granted for 3 residents. Currently there is only 2 resident on hospice. LPA Vado toured the facility both inside and outside with Moddie. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. The facility shares frozen goods with their sister facility located next door. Those supplies are observed to be in place. Canned food supplies are primarily observed as stored in a hallway pantry and is observed as in place. Knives are locked in the kitchen in a drawer next to the stove. Toxic chemicals are stored in the garage. Cleaning supplies and laundry soaps are also locked in the garage. PPE and incontinence supplies are observed to be in place in case of any use. Medications are locked in the kitchen in a large cabinet. Each resident room is observed to contain the required furniture as outlined in regulations. Facility has functioning smoke detectors and carbon monoxide detectors through out the facility. 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 The facility is equipped with private half baths in each resident room and a common full bathroom for bathing. All are observed in good working order for resident use. Water temperature is tested at 120F in resident bathrooms. Kitchen sink is measured at 130F but is labeled as delivering hot water considered over 120F. There are two fire extinguishers in the facility that is observed with inspection tags of 11/07/2025. LPA observed resident linen supplies and incidentals also store in a hallway closet. There is one main full bath that residents use. Shower room floor is equipped with a non-skid mats when in use. Based on review of all resident files, and medications all items are current and logged accurately. Last fire/disaster drill was conducted on 12/05/2025 per records reviewed. This poses a health and safety risk to residents in care. Administrator certificates are observed to be current and posted in the facility for Rafael Jison is current expiring 03/27/2026. LPA received the following updated items during today's vist: • Copy of updated administrator certificate • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule No citations issued.

On 01/09/2024, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator Moddie Andaya and explained the purpose of today’s visit. Currently there are 5 residents and 3 staff present including the administrator. This is a single level facility with 6 bedrooms for residents. The facility is licensed for age 60 and over; All may be Non-Ambulatory residents; Hospice waiver granted for 3 residents. Currently there is only 1 resident on hospice. LPA Vado toured the facility both inside and outside with Maria. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. There are refrigerators with freezers located in the garage and kitchen. Canned food supplies are primarily observed as stored in the garage. Knives are locked in the kitchen in a drawer next to the stove. Toxic chemicals are stored in the garage. Cleaning supplies and laundry soaps are also locked in the garage. PPE and incontinence supplies are observed to be in place in case of any use. Medications are locked in the kitchen in a large cabinet. Each resident room is observed to contain the required furniture as outlined in regulations. Facility has functioning smoke detectors and carbon monoxide detectors through out the facility. The facility is equipped with private half baths in each resident room and a common full bathroom for bathing. All are observed in good working order for resident use. Water temperature is tested at 120F. There are two fire extinguishers in the facility that is observed with inspection tags of 11/18/2024. 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 LPA observed resident linen supplies and incidentals also store in a hallway closet. Shower room floor is equipped with a non-skid mats when in use. Based on review of all resident files, and medications all items are current and logged accurately. Last fire/disaster drill was conducted on 02/24/2024 per records reviewed. This poses a health and safety risk to residents in care. Administrator certificates are observed to be current and posted in the facility. The following updated forms are requested to be submitted to CCLD by 01/16/2025 : • Copy of updated administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease Type B citation is issued during today's inspection visit. Report is reviewed with the administrator and a copy is provided.