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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701384
Report Date: 06/04/2026
Date Signed: 06/04/2026 02:17:37 PM

Document Has Been Signed on 06/04/2026 02:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HEARTED CARE ASSISTED LIVING FACILITYFACILITY NUMBER:
342701384
ADMINISTRATOR/
DIRECTOR:		BETELIHEM AYLEMFACILITY TYPE:
740
ADDRESS:6053 36TH AVENUETELEPHONE:
(916) 519-0139
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY: 5CENSUS: 1DATE:
06/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:01 AM
MET WITH:Lucia Ramirez and Betelihem Aylem TIME VISIT/
INSPECTION COMPLETED:
02:32 PM
NARRATIVE
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On 06/04/2026, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with care staff Lucia Rameriz and explained the purpose of the visit. Care staff then called and notified the Administrator Betelihem Aylem that CCLD was present in the facility. A brief interview was done with the Administrator Aylem via telephone. The Administrator Certificate # is 6070008740 and will expire on 08/31/2026. The current census is 1 with 1 facility staff. Approximately 3 hours later the Administrator Aylem arrived and joined the visit

This facility is a single story building licensed to serve two (2) ambulatory and three (3) non-ambulatory residents and is also granted for hospice care for two residents. LPA Lee and care staff Rameriz inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 103.3 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. The smoke and carbon monoxide detectors are in compliance with fire safety.

The fire extinguisher is located in dining room and was purchased on 03/30/2026. It was observed and learned that the facility did not have an operable telephone on the premises. According to care staff Lucia, she was informed by the Administrator that AT&T was scheduled to visit the facility today to install telephone service.

CONTINUED LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 14
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/04/2026 02:17 PM - It Cannot Be Edited


Created By: Pang Lee On 06/04/2026 at 10:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HEARTED CARE ASSISTED LIVING FACILITY
FACILITY NUMBER: 342701384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87311
Telephones
All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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It was observed and learned that the facility did not have an operable telephone on the premises. According to care staff Lucia, she was informed by the Administrator that AT&T was scheduled to visit the facility today to install telephone service, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2026
Plan of Correction
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Per Administrator, ATT is scuduled to install a telephone today. Administrator will provided LPA Lee proof of installation and the facility contact number for LPA Lee to call to confirm by end of day 06/05/2026 end of day 5:00 PM along with a statement of acknowledgement of understanding and reviewing the regulation cited.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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During today's visit, a review of facility records revealed that two care staff members were not associated with the facility. S1, who was working during today's visit, was found to be fingerprint cleared; however, S1 has not yet been associated with the facility and needs be associated prior to providing care and supervision services. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2026
Plan of Correction
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Administrator stated that she will have both staff S1 and S2 associated to the faciity by end of day 06/05/2026 end of day With a statement of acknowledgement of understanding and reviewing the regulation cited.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2026 02:17 PM - It Cannot Be Edited


Created By: Pang Lee On 06/04/2026 at 10:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HEARTED CARE ASSISTED LIVING FACILITY
FACILITY NUMBER: 342701384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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It was observed that the facility does not have the PUB 475 complaint poster posted in the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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Administrator stated that she will have the PUB 475 posted in the facility and provided pictures of the poster posted by end of day 06/18/2026 by 5:00 PM with a statement of acknowledgement of understanding and reviewing the regulation cited.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2026 02:17 PM - It Cannot Be Edited


Created By: Pang Lee On 06/04/2026 at 10:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HEARTED CARE ASSISTED LIVING FACILITY
FACILITY NUMBER: 342701384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review of 2 staff files, 1 out of 2 of the files did not have CPR/First Aid training. During today's visit, staff on duty Lucia Ramirez did not have CPR/First aid training in her file. Per staff she did complete the training but does not have it in her file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2026
Plan of Correction
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Per Administrator, S1 does have CPR/First aid certificate and will email it to LPA Lee. Administrator stated that she will ensure that all staff are CPR/First Aid training are in the staff files at all times. A statement of acknowledgement of understanding and reviewing the regulation cited will be provided to LPA Lee. POC due end of day 5:00 PM on 06/11/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
Page: 5 of 14
Document Has Been Signed on 06/04/2026 02:17 PM - It Cannot Be Edited


Created By: Pang Lee On 06/04/2026 at 10:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HEARTED CARE ASSISTED LIVING FACILITY
FACILITY NUMBER: 342701384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review staff personnel files of two out of two neither staff file contained documentation of required staff orientation or training records. Staff S1 DOH 06/02/2026 and S2 DOH 05/29/2026. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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Administrator stated that she will have both staff complete orientation and training and provide LPA Lee with the documents by end of day 06/18/2026 at 5:00 PM. Training documents, staff sign in sheets and a statement of acknowledgement of understanding and reviewing the regulation cited will be provided to LPA Lee.
Type B
Section Cited
CCR
87465(a)(8)
87465(a)(8) Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation it was observed that the facility’s first aid kit does not have a current edition of a first aid manual approved by the American Red Cross and a Thermometers during today’s visit.
POC Due Date: 06/18/2026
Plan of Correction
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Per the Administrator, she has already purchase a Thermometer. Administrator will also purchase a first aid manual. Proof of purchase and a photo of the items will be emailed to LPA Lee by 06/18/2026 end of day 5:00 PM along with a statement of acknowledgement of understanding and reviewing the regulation cited.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2026 02:17 PM - It Cannot Be Edited


Created By: Pang Lee On 06/04/2026 at 11:34 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HEARTED CARE ASSISTED LIVING FACILITY
FACILITY NUMBER: 342701384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465(c)(2) Incidental Medical and Dental
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met…
(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a review of the resident's (R1) medication records and Medication Administration Record (MAR), the medication Gabapentin 300 mg, prescribed as one capsule by mouth at bedtime, for 06/03/3036 was not initialed on the MAR as having been administered to the resident. A review of the resident's Centrally Stored Medication and Destruction Record (CSMDR) revealed that the medication was not documented on the CSMDR of when the medication start date was, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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The Administrator will provide Incidental Medical and Dental Care training, including medication administration and documentation procedures, to all care staff by 06/18/2026. Copies of the training materials utilized, staff sign-in sheets, and a statement acknowledging staff understanding of and review of the cited regulation will be submitted to the Department by email no later than 5:00 PM on 06/18/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HEARTED CARE ASSISTED LIVING FACILITY
FACILITY NUMBER: 342701384
VISIT DATE: 06/04/2026
NARRATIVE
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The following documents will be emailed to LPA Lee at pang.lee@dss.ca.gov by end of day 06/11/2026 5:00 PM:

(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate
(4) LIC 610 Current Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC 500 Current Personnel Report

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Administrator Aylem and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility. Failure to correct deficiencies may result in civil penalties.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC809 (FAS) - (06/04)
Page: 13 of 14
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HEARTED CARE ASSISTED LIVING FACILITY
FACILITY NUMBER: 342701384
VISIT DATE: 06/04/2026
NARRATIVE
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It was observed that the following information and poster was not posted in the facility "Rights of Resident Councils.” “Personal Rights of Residents in All Facilities” and PUB 475 complaint poster.

Facility thermostat was observed at 68 degrees Fahrenheit, which is within the required regulation of 68 to 85 degrees Fahrenheit. LPA Lee observed toxins located in laundry cabinet and kept locked and inaccessible to resident LPA Lee observed sharp knives kept locked in the kitchen cabinet and inaccessible to resident LPA Lee checked medication storage and found medication to be locked away and inaccessible to resident. The first aid kit was checked, and it did not contain the required components. Based on observation it was observed that the facility’s first aid kit does not have a first aid manual and a Thermometers during today’s visit



LPA Lee audited medications for 1 out of 1 resident medications by reviewing the medication on hand with their Medication Administration Records (MAR) and based on review of the resident's medication records the medication Gabapentin 300 mg, prescribed as one capsule by mouth at bedtime, for 06/03/2036 was initialed on the MAR as having been administered to the resident. However, a review of the resident's Centrally Stored Medication and Destruction Record (CSMDR) revealed that the medication start date was not documented on the CSMDR.

LPA Lee reviewed 1 out of 1 resident file, and they were complete. LPA Lee reviewed 2 staff files, and it was incomplete. Based on record review of 2 staff files, 1 out of 2 of the files did not have CPR/First Aid training. During today's visit, staff 1 (S1) on duty did not have CPR/First aid training in their file. S2 did not have their health screening and TB in their file and was later provided to LPA Lee at the end of the visit. S1 and S1 neither file contained documentation of required staff orientation or training records. S1 date of hire (DOH) is 06/02/2026 and S2 (DOH) is 06/02/2026. Furthermore, during today's visit, Administrator Aylem did not have her personnel file available at the facility for LPA Lee's review. According to Administrator Aylem, she had taken the file home to work on it.

LPA reviewed staff criminal record clearances and a review of staff records revealed that S1 and S2 were not associated with the facility. S1, who was working during today's visit, was found to be fingerprint cleared; however, they have not yet been associated with the facility. LPA Lee advised the Administrator Aylem that all employed, and volunteer individuals must be associated prior to providing care and supervision at the facility.

CONTINUED LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC809 (FAS) - (06/04)
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