Facility Evaluation Report

While investigating a complaint (Control # 15-AS-20211105095643), Licensing Program Analyst (LPA) Delmundo requested for resident’s (R1) documents to be submitted by 11/12/21. LPA did not receive the requested documents. On 8/14/24, LPA called and requested again for the documents and licensee stated R1’s documents were already in the attic and if she cannot find them in her computer, she will not get to the attic to retrieve the documents. On August 27, 2024, LPA called and left an urgent message on licensee’s voicemail and requested to submit the documents by August 30, 2024. Licensee did not submit the documents. LPA reviewed the documents that were received via fax by the Department's Regional Office for October 2021, November 2021 and December 2021 and didn’t observe any documents for R1 from the facility.

On this day, 5/13/25, LPA learned that the staff (S1) is not fingerprinted. LPA asked S1 who stated she started working Monday, May 5, 2025.

The above were discussed with Carmen Nica, licensee, and John Nica, administrator (ADM).

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil penalty is assessed for S1 who is not fingerprinted and will continue for $100.00/day until corrected. Failure to submit proof of correction by plan of correction due date for the other deficiency may also result in civil penalty.

Deficiencies and plan and proof of corrections were discussed. Exit interview conducted. Appeal Rights, LIC421BG Civil Penalty, LIC9098 Proof of Correction form and copy if this report provided to ADM.