Mother Gertrude Home

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Nadia Shahbazian and Licensing Program Manager (LPM) Mary Flores made an unannounced Case Management visit to clarify the physical plant of the facility. LPA and LPM met with sister Elia Caro Administrator and explained the reason for the visit. The purpose of today's visit is to clarify the use of the licensed facility rooms, census, and capacity. The building is a two story structure which is licensed as an RCFE in which cared is provided by the Franciscan Missionary Sisters of the Immaculate Conception. At 8:50am LPA, LPM and Administrator toured the physical plant of the facility and observed the following: Rooms # 101-105, 108-111, 208-215 are used for private residents. Rooms # 112-117, 201-205, 217-220 are used for sister's of the congregation which are consider residents and are currently being provided care and supervision. Rooms # 217, 218 and 220 are currently being used as staff rooms. Private signs were observed in doors or stairways leading to the areas where the sisters of the congregation reside. The signs are used to follow the Catholic church's law of privacy for the sisters. Per administrator, even though the rooms where the sister's reside are labeled as private, our department and LTCO have access to these rooms. Files are being kept for the sisters. Per administrator also the showers in different areas of the facility, mostly in rooms used for non-ambulatory residents throughout the facility are being remodeled to accommodate accessibility. Facility sketch was reviewed. Administrator informed LPA/LPM that every one living on the second floor are ambulatory. The facility is operating within capacity. Based on today's observations the Administrator will make the following changes by 4/8/26: The sister's will be added to the census of the facility. (CONTINUED ON LIC 809C) Will ensure that private signs in areas used by the sisters are updated to "Sister's area" to ensure access to CCLD, LTCO, and other agencies is clear and the public is aware that is sisters' area. Will ensure to maintain all required documents as part of resident files for the sisters that are receiving care and supervision. Will submit an updated sketch to the department, to include the rooms that will be assigned for staff, chapel in the first floor, change of use of offices, employee lounge, sister's dining area, and terrace in the second floor. Will submit a plan to the department to ensure residents are accommodated during the remodeling of the showers. No deficiencies were noted during today's visit. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 3, 2026

Type of visit: Required - 1 Year

On 02/06/2026 at approximately 11:30am, Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced annual required visit and met with Sister Elia Caro - Administrator. LPA explained the purpose of today’s visit. The Residential Care For Elderly (RCFE) facility has an approved fire clearance for thirty six (36) non-ambulatory and sixty one (61) ambulatory elderly adults 60 years old and above. Current census is twenty four (24) residents. The building is a two-story structure consisting of the RCFE area and a separate convent area for Franciscan Missionary Sisters of Immaculate Conception. Facility consists of the following: Resident suites with private bathrooms, public restrooms, staff rooms, administrative office, staff meeting room, lobby, a chapel, an activity room, a dining room, a kitchen, laundry room, medication room, inside patio and exterior courtyards. At 12:25pm LPA and Administrator toured the physical plant. Required postings were posted at the front entrance, lobby and office areas. Facility has multiple exists but uses the front entry as the main exit. There are multiple fully charged fire extinguishers throughout both floors of the facility. Fire extinguishers, smoke detectors/mono-oxide carbon detectors were all inspected by the Fire Department on 01/07/2026. In addition there are fire sprinklers throughout, including all the resident rooms. Disaster and fire drills are conducted quarterly, the last being completed on 12/03/2025. Entry/exit gates and pathways were free of obstruction. A raised fountain was observed in the inside patio area. There is an inside patio space for outdoor activities. The patio furniture includes chairs, benches, tables, umbrellas and three (3) swings, sufficient for number of residents. There is also a large gated courtyard with exit doors. Continued on 809-C Resident Rooms: The resident suites consist of two bedrooms and shared bathrooms for each bedroom. The bedrooms were randomly inspected for health and safety in both floors. Bedrooms were observed to have cabinets, dresser drawers, beds, chairs and adequate lighting. Bedrooms were clean and supplied with ample mattress, bedding/linens. LPA observed that a signal system is activated by a pull cord in each bathroom and bedroom. The signal system was tested in resident room 108A and in room 211A. In each instance staff responded to the signal within 2 minutes. LPA ensured that grab bars were properly installed in bathrooms and showers had non-skid mats. Bathrooms were clean and operational. Water temperature was measured at multiple rooms in both floors, ranging between 108.6 – 119.2 degrees Fahrenheit. Kitchen/Dining Room: The facility has a commercial kitchen area that is equipped with two (2) commercial refrigerators, one (1) walking refrigerator, freezer, stove/oven, microwave oven. LPA also observed two (2) walking pantries. There was an adequate supply of non-perishable food items observed for (7 days) and (2 days) of perishable supplies. Kitchen is not accessible to residents, since sharp objects are kept locked in the kitchen. Dining room is furnished with multiple round tables, chairs and long tables for games and celebrations. There is also a piano, television set and musical area in the dining room for musical performances. Laundry Room: LPA observed three (3) regular size washing machines and two (2) regular dryers, two (2) commercial sized washers and two (2) commercial dryers in the laundry room. Detergents and cleaning supplies were locked near the appliances. Laundry room is quite large and has storage space. In addition there is a small bathroom for staff use, in the laundry room. Medications/Records: LPA observed that medications were locked in the Medication Room with proper labels for each resident. Medications were counted in random and compared for accuracy of administration, based on physician orders. Resident records for five (5) residents were reviewed for completion of required documents. At 3:20pm LPA conducted an audit of six (6) staff files to ensure all trainings and records are complete. The facility is current in CCLD annual fees. The Administrator certificate is valid through 03/23/2028. The facility has a current liability insurance effective 11/04/2025 through 11/04/2026. Pursuant to Title 22 Division 6 of the CA Code of Regulations, no immediate health and safety hazards were observed at the time of this inspection. No deficiencies were cited. Exit Interview Conducted / A Copy of the Report provided to Administrator.the state’s words, verbatim · CDSS document, Feb 6, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Nadia Shahbazian conducted an unannounced site visit continuation of the required annual inspection conducted on 02/27/2025. LPAs met with Sister Elia Caro – Administrator, and explained the reason for the visit. At 02:50pm LPA conducted a quick tour of the physical plant to ensure health and safety of residents. Facility bathrooms, surrounding areas and common areas are clean, sanitary and the equipment/furnishings are in good condition. The outdoor area was free of hazards, obstructions and compliant with Title 22 regulations. Staff files: LPAs reviewed staff files to ensure staff has fingerprint clearance, association to the facility, and current 1-st Aid, CPR, and Crises Prevention Intervention (CPI) certification. A total of six (6) staff files were reviewed, all records appeared to be complete and current. Resident files: LPAs reviewed client records to ensure their files include, but not limited to: Medical assessments, appraisals, emergency contact information, and admission agreements. A total of five (5) resident files were reviewed; all five (5) resident records appeared to be complete and current. Pursuant to Title 22 Divisions the CA Code of Regulations, there were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility Administrator.the state’s words, verbatim · CDSS document, Mar 20, 2025

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced annual required visit and met with Sister Elia Caro - Administrator at 9:15 am. LPAs explained the purpose of today’s visit. The facility has an approved fire clearance for thirty six (36) non-ambulatory and sixty one (61) ambulatory elderly adults 60 years old and above. Current census is twenty eight (28). The facility is a two-story structure consisting of the following: Thirty three (33) resident room suites with private bathrooms, public restrooms, staff rooms, administrative office and staff meeting room, lobby, a chapel, an activity room, a dining area, a kitchen, a laundry, medication room and exterior courtyards. Physical building structure was observed to be in good conditioned with nicely maintained landscaping. LPA observed required postings at the front entrance, lobby and office areas. Positing included but were not limited to: Facility license, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights and the facility sketch. (Continued on 809-C) At 10:25 am LPAs and administrator toured the physical plant. Fire sprinklers were located throughout the facility on both floors, including resident rooms. LPAs observed several fully charged throughout each floor. Fire extinguishers, smoke detectors/mono-oxide carbon detectors were all inspected by the Fire Department on 12/27/2024. Facility conducts quarterly disaster drills. The last Fire/Disaster Drills was conducted on 12/05/2024 . Resident rooms were randomly inspected for health and safety in both floors. Bedrooms were observed to have cabinets, dresser drawers, beds, chairs and adequate lighting. Bedrooms were clean and supplied with ample mattress, bedding/linens. LPAs observed that a signal system is activated by a pull cord in each bathroom and bedroom. The signal system was tested in resident room 102A at 11:05 and in room 212B at 11:23 In each instance staff responded to the signal within 2-3 minutes. Each bedroom has it's own bathroom. LPAs ensured that grab bars were properly installed in bathrooms and showers had non-skid mats. Bathrooms were clean and operational. Water temperature was measured at multiple rooms in both floors, ranging between 106.6 – 117.4 degrees Fahrenheit. Kitchen: The facility has a commercial kitchen area that is equipped with two (2) commercial refrigerators, one (1) walking refrigerator, freezer, stove/oven, microwave oven and sink. LPA also observed two (2) walking pantries. There was an adequate supply of non-perishable food items observed (7 days) and (2 days) of perishable supplies. Medications: LPA observed that medications were locked in the Medication Room with proper labels for each resident. (Continued on 809-C) Laundry Room: LPA observed two (2) regular size washing machines and two (2) regular dryers, two (2) commercial sized washers and two (2) commercial dryers in the laundry room. Detergents and cleaning supplies were locked near the appliances. LPA toured the patio area and backyard. Entry/exit gates and pathways were free of obstruction. There were several exit doors throughout the facility. A raised fountain was observed in the patio area. There is ample patio space for outdoor activities. There were appropriate furniture, including chairs, benches, tables, umbrellas and three (3) swings for outdoor use, sufficient for number of residents. Due to time constraints, LPA will need to return to facility to review staff and resident records on a different date. A Copy of the Report provided to Administratorthe state’s words, verbatim · CDSS document, Feb 27, 2025

Allegation investigated: Facility staff force fed resident resulting in multiple oral burn Facility staff do not treat resident with dignity and respect

Licensing Program Analyst (LPA) Antonia Alvizar-Ettima made an unannounced subsequent visit to the facility to deliver finding for the above noted allegations at approximately 10:30AM. LPA Alvizar-Ettima met with Administrator and disclosed the purpose of the visit. On 04/11/2024, Community Care Licensing Department (CCLD) received a complaint alleging that facility staff neglected and/or failed to provide an adequate level of care to the resident #1 (R1) resulting in R1 sustaining burns to their mouth due to being force fed hot soup. The allegation was referred to Community Care Licensing Departments (CCLD) Investigation Bureau (IB) and the investigation was assigned to Senior Investigator (SI) Christine Ferris. Initial visit was conducted on 04/12/2024 at approximately 10:00AM by LPA Antonia Alvizar-Ettima. During initial visit, at approximately 10:20AM, physical plant inspection was made to ensure that there are no Unsubstantiated immediate health and safety hazard affecting residents. At 12:30PM LPA requested and received copies of R1’s ID/Emergency, Admission Agreement, Physician Report, Medication Administration Records, Unusual Incident Reports, Resident History Chart, Facility Menu, Resident and Staff roster. Investigation was continued by SI Ferris. Interviews of the staff conducted by SI on 05/20/2024, revealed that staff denied the allegation. On 05/30/24 SI spoke with witnesses (W1) and (W2) who had knowledge about R1’s health care. W1 indicated that doctors were unable to establish the cause of R1’s injury and could not confirm they oral ulcer was a result of a thermal burn. Per witness (W2) R1’s statement regarding the incident was “nonsensical” and W2, had no worries or concerns with staff or the facility. On 06/03/2024, SI spoke with R1 and other residents. R1’s statements were inconsistent as to what occurred and other residents who R1 stated witnessed the incident denied seeing the incident. A review of R1’s record conducted on 05/01/24 did not revealed any information to support the allegation. Overall investigation did not provide sufficient information and/or evidence to substantiated neglect/lack of care. Therefore, based on observation, interviews and record review, the allegation is UNSUBSTANTIATED at this time. Facility staff do not treat resident with dignity and respect. It was alleged that staff get frustrated when residents gives them a hard time. During today's visit, at approximately 10:50AM LPA conducted physical plant tour, interview residents, administrator, and staff. Interview with three (3) out of thirty-two (32) residents revealed that staff always treats them with dignity, respect and they do not have any concerns regarding this allegation. Residents reveal staff are never frustrated, staff are nice and help when they need it. Interview with Administrator and three (3) staff members reveal staff always treat residents with dignity and respect. Administrator indicated not receiving a complaint from residents, residents family members or other staff about staff not treating residents with dignity and respect. Administrator reveal that all residents, staff and visitors are treated with dignity, values and respect. Two (2) staff reveal residents are treated like family and they always respect the residents. LPA did not observe staff being frustrated at residents in care. Based on information obtained through interviews and observation there is not enough sufficient evidence to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No Deficiencies noted at time of visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 31-AS-20240411103116

Type of visit: Required - 1 Year

On 05/04/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Sister Elia Caro. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (36) non-ambulatory and (61) ambulatory elderly adults 60 years old and above. The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (24) resident room suites. Room suites have shared toilet and shower in the unit, public restrooms, staff rooms, administrative offices, a lobby, a chapel, an activity room, a dining area, a kitchen, a laundry, and exterior courtyard. LPA and administrator toured the physical plant. There were no bodies of water on the premises. Selected rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #103, #108, #111, #206, #209, and #212. Rooms and toilets had call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.2 – 115.5 degrees F. A comfortable temperature was maintained in the facility at 72 - 74 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. All commercial appliances were in working condition. (Evaluation Report continues LIC 809C Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. Disaster and fire drills with all shifts are conducted quarterly, the last being completed on 03/06/24. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. LPA conducted an audit of resident #1-#5 (R1-R5) service files, and staff #1-#6 (S1-S6) personnel files were in order and complete. Interviews conducted with (4) facility staff and (3) residents. The facility is current in CCLD annual fees. The facility has a current administrator certificate for Sister Elia Caro #601355874 valid through 03/23/26. The facility has a current liability insurance effective 03/22/24 thru 03/22/2025. No deficiencies during this visit. An exit interview conducted with Sister Elia Caro and a copy of the report is provided.the state’s words, verbatim · CDSS document, May 4, 2024