St. Jude's Elder Care III

Allegation investigated: Resident sustained multiple bruises due to staff neglect or physical abuse

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint investigation visit on 08/11/2026 to deliver findings regarding the above allegation. LPA was greeted by facility staff and explained the purpose of the visit. Administrator Judy Ragano arrived shortly thereafter. During the investigation, LPA reviewed and obtained copies of the Staff Roster, Resident Roster, R1's Physician's Report, Face Sheet, and medication order. LPA also conducted a tour of the facility and observed the resident care environment. Additionally, LPA interviewed three (3) staff members (S1–S3) and three (3) residents (R1–R3). The investigation further included a review of records and documentation related to the allegation. (continued on 9099C) Unsubstantiated Allegation: Resident sustained multiple bruises due to staff neglect or physical abuse It is alleged that R1 sustained multiple bruises while residing at the facility due to staff neglect or physical abuse. During staff interviews, S1–S3 denied observing bruising on R1's chest area or hands and denied knowledge of any incident that may have caused the reported bruising. Staff reported that R1 could become combative during personal care. S2 stated that S3 would sometimes assist by holding R1's hands to prevent R1 from hitting staff. Staff denied restraining or handling R1 roughly and reported that the only known skin concerns were pre-existing/healing wounds. During resident interviews, R1–R3 reported that they like living at the facility and are treated with respect and kindness. All three residents denied being handled roughly by staff. During the facility tour, LPA observed residents to appear appropriately cared for, with no immediate concerns observed regarding their care or overall condition. Based on the investigation conducted, which included interviews with staff and resident, as well as a review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 28-AS-20260807084643

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection visit. LPA was greeted by staff and explained the purpose of the visit. The facility is licensed to serve six (6) residents age range 60 and over of which five (5) can be non-ambulatory and one (1) bedridden. Hospice waiver in place for six (6) residents. There are currently five (5) residents in care, of which two (2) are receiving hospice services and one (1) resident is bedridden. The facility in operating within the limitations of there license. The facility is a single-story home located in a residential area of San Dimas. The home consists of a living room, kitchen, dining area, family room, four (4) resident bedrooms, two (2) bathrooms, attached garage with laundry, front and back yards. LPA utilized the Compliance and Regulatory Enforcement (CARE) tool for the today’s visit and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Gonzalez observed combination carbon monoxide/smoke detectors in hallways. Four (4) resident rooms were observed to contain required furniture, linens and lighting, all in good repair. LPA observed grab bars near toilets and inside shower as well as no-slip coating on shower floors. Passageways and exits are clear of obstructions. Continued on LIC809C Food Service: LPA observed sufficient supply of non-perishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and operable at time of visit. Planned Activities: LPA observed magazines, and other activities for residents. At the time of visit, the staff and residents were celebrating St. Patrick’s Day. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Emergency drills are conducted quarterly, last drill was conducted 03/03/26. Residents with Special Needs: No pools or large bodies of water were observed. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: Centrally stored medication are secured in a locked kitchen cabinet. LPA observed Centrally Stored Medication and Destruction Record. LPA observed morning medications were not dispensed for R1 for March 17, 2026. Deficiency cited for missed medication. Personnel Records Training: LPA reviewed three (3) staff files and observed required annual training, CPR and First Aid for two (2) out of the three (3) personnel records reviewed, Health screening with TB testing results, fingerprint clearance and job applications. Resident Records/Incident Reports: LPA reviewed resident records for five (5) residents in care. Resident records are maintained at the facility and contained required documentation. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during today’s visit are documented on the LIC809D. Exit interview held and a copy of this report along with appeal rights were provided to Caregiver Maria “Josie” Albertothe state’s words, verbatim · CDSS document, Mar 17, 2026

Allegation investigated: Resident sustained a pressure injury while in care.

Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Josie Alberto Caregiver and explained the reason for the visit. The investigation consisted of the following: On 4/1/25 LPA Flores conducted an initial investigation visit and collected pertaining documents. On 4/23/25 LPA Flores requested resident #1(R1) medical records. On 5/13/25 LPA Flores received documents from Home Health agency. On 6/9/25 LPA Flores received hospital medical records. On 7/29/25 LPA Flores requested a clinical consult to the department’s clinical consult program. On 10/25/25 LPA Flores conducted a subsequent complaint visit and delivered findings. The investigation revealed the following: Regarding allegation: Resident sustained a pressure injury while in care. It is alleged R1 developed an unstageable wound due to neglect. Interviews with residents revealed staff ensure to provide care and assist those that are in bed. (CONTINUED ON LIC 9099) Unsubstantiated Interviews conducted with staff revealed, R1 was receiving services from a home health agency. Per staff, they followed home health nurse’s recommendations, provided assistance to R1 by repositioned at least every two hours. Per staff, R1 was cognitive and would choose to sit in R1’s wheelchair daily to be able to move around. Interview conducted with responsible party revealed, responsible party visited the facility and had no concerns of neglect from the facility staff. Documents reviewed revealed, R1 was admitted to receive home health agency services on 3/3/25. Per home health records dated 3/3/25, R1 had a stage 2 wound to left buttock, and will be provided care by a skilled professional to perform wound care three times a week. Wound care order dated: 3/3/25 notes skill professional “to provide wound care to stage 2 pressure ulcer on left buttock.” Wound care order dated: 3/15/25 notes R1 was observed with a change in condition unrelated to the wound and send to the hospital. Per medical records R1 was admitted to the hospital on 3/15/25. Hospital assesses the wound on 3/16/25 as a stage 2 wound to the right buttocks and unstageable to the left buttocks. Although, the wound to the left buttocks was noted as unstageable on 3/16/25 R1 was receiving care by a skill professional under home health care since 3/3/25. Documents reviewed do not corroborate the allegation. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 25, 2025 · control 28-AS-20250328145917

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management-Other regarding the appeal of deficiency issued on 04/25/2025. LPA Ramirez was greeted by Care giver Maria Alberto and explained the purpose of the visit. On 04/28/25, the department received an appeal regarding deficiency 87303(a)-Maintenance and Operation, which was issued on 4/25/25 during the facility's annul inspection. During this inspection, LPA Ramirez observed kitchen cabinets above microwave and stove to be sticky with residue and issued a Type B deficiency. After review of your appeal request, the department is dismissing the citation, and a Technical Violation is being issued on 06/24/25. Exit interview was conducted and a copy of this report was provided via email.the state’s words, verbatim · CDSS document, Jun 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Sakinah Madyun conducted an annual inspection visit on 04/25/2025 and was greeted by Caregiver Maria Alberto. LPAs identified themselves and explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed no-slip coating in showers. LPA Ramirez observed seated shower chairs in bathrooms. LPAs observed kitchen cabinets above microwave and stove to be sticky with residue. LPA Ramirez will issue Type B deficiency based on this observation. LPA Ramirez observed video surveillance in common areas. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. LPAs observed a container of overflow medications refills stored in lower food pantry cabinet and pantry was observed to be unlocked. LPA Ramirez will issue Type A deficiency based on this observation. Staff removed overflow medications and placed in centrally stored mediations cabinet after LPA Ramirez advised staff of observation. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). See 809-C Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 04/01/2025 & 03/04/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in garage. Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: Medications are centrally stored in the medication closet and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. Staffing: Administrator Certificate for Judy Ragano 11/10/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are not maintained at the facility. Staff files arrived shortly after LPA Ramirez requested files. LPA Ramirez will issue Type B deficiency based on this observation. LPA Ramirez observed required annual training, CPR and First Aid for three (3) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel record reviewed. Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for six (6) residents over the age of 59 years old, of which five (5) may be non-ambulatory and one (1) bedridden. This facility may retain no more than six (6) hospice residents. There was one (1) resident on hospice during time of inspection. Resident Records/Incident Reports: LPA reviewed resident records for four (4) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. Three (3) deficiencies were cited during this inspection. A copy of this report, 809-D page and appeals rights was provided via email.the state’s words, verbatim · CDSS document, Apr 25, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit during a complaint investigation visit due to observed deficiencies. LPA met with Judy Ragano and explained the reason for the visit. On 4/1/25 LPA Flores conducted a complaint investigation visit and observed the following deficiencies: Cleaning supplies were observed in the supplies closet which does not have a lock, and in bathroom #2 under the sink accessible to the residents in care. LPA observed a full bed rail in room #1(BR#1)'s bed and half bed rails in room #2(BR#2)'s bed. No other health and safety risks were observed. A hospital bed request is on file. However they did not include the bed rails request. Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 1, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Apr 2, 2025

87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidence by: Based on observation licensee fail to ensure staff maintained cleaning solutions inaccessible to the residents in care at all times which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Apr 1, 2025

Plan of correction: Administrator moved the items during the visit and will conduct an in-service with the staff and submit a copy to the department by POC due date 4/2/25.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87608(a)(5)(B) · Plan of correction due date: Apr 2, 2025

87608 Postural Supports: (a) ... Postural supports may be used... (5) Under no circumstances shall postural supports...(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care... This requirement is not met as evidence by: Based on observation licensee did not ensure to obtain a physician's bed rail request for full bed rails was in the resident's file who is not on hospice which poses a immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Apr 1, 2025

Plan of correction: Adminnistrator will request a half bed rail request for Resident #2 and will remove the other half bed rail and will submit the bed rail request and will send a picture of the bed rail to the department by POC due date 4/2/25. If nto able to obtain will remove the bed rails and submit a picture to the dept.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Apr 8, 2025

87608 Postural Supports : (a) ... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.... This requirement is not met as evidence by: Based on observation resident #1's bed was observed with half bed rails and a physician's order request was not observed on file which poses a potential risk to the health, safety, or personal rights of the person's in care.the state’s words, verbatim · CDSS document, Apr 1, 2025

Plan of correction: Administrator will request a physician's half bed rail request for Resident #1 and submit a copy to the department by POC due date 4/9/25.

Allegation investigated: Staff handled resident(s) in a rough manner while in care. Staff spoke inappropriately to resident(s) while in care. Licensee is retaining resident(s) with a higher level of care need.

Licensing Program Analyst (LPA) Daniel Konishi conducted an Initial 10-Day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Administrator, Judy Ragano. The investigation consisted of: LPA conducted interviews with Administrator, Judy Ragano, Staff #1 (S1) to Staff # 3 (S3), and Former Resident #1 (FR1#) and Resident # 2 (R2) to Resident #4 (R4). Resident #5 (R5) was unable to be interviewed since R5 is in the hospital. LPA requested copies of Staff and Resident Rosters. LPA request FR1 to R5 personnel file documents to be emailed: Identification and Emergency Information, Physician's Report for Residential Care Facilities for the Elderly (RCFE), Preplacement Appraisal Information, Personal Rights, Admission Agreement. Allegation: Staff handled resident(s) in a rough manner while in care. It is alleged that facility staff handles a resident in a rough and rude manner. Unsubstantiated Interviews conducted with Admin and three (3) out of three (3) staff revealed that they have not heard or witnessed any staff handled resident in a rough manner. Staff stated that they receive training on Residents Rights on a regular basis and facility has zero tolerance policy on abuse. S1-S2 stated that they never received any report concerning any staff handling residents in a rough manner. S1-S3 denied ever treating any resident aggressively nor handling any resident in a rough manner. FR1 and R2-R4 residents interviewed denied the allegation and indicated that they are satisfied with the services and do not have any concerns. R5 was unable to be interviewed since R5 is currently at the hospital. FR1 and R2-R4 interviewed stated that staff are helpful and assist them whenever they asked. Residents stated that they were never treated aggressively by any staff. Therefore, there was insufficient evidence to corroborate with this allegation. Allegation: Staff spoke inappropriately to resident(s) while in care. It is alleged that a facility staff speaks inappropriately to and makes rude and inappropriate comments to facility residents. Interviews conducted with Admin and three (3) out of three (3) staff revealed that the facility staff do not make inappropriate comments to facility residents and do not speak inappropriately to facility residents. Interviews conducted with four (4) out of five (5) residents revealed that the facility have not made rude and inappropriate comments or spoken to them inappropriately. R5 was unable to be interviewed since R5 is currently at the hospital. FR1 and R2-R4 interviewed residents did not have any concerns, stated that they are satisfied with the services they receive at the facility and stated that staff treat them with respect and do not speak and/ or treat them inappropriately. Based on interviews conducted with facility staff, and facility residents, there was not enough supportive evidence to concur with the reported allegation. Allegation: Licensee is retaining resident(s) with a higher level of care need. It is alleged that the residents here not receiving specialized care in relation to their Dementia / Alzheimer's diagnosis. Interviews conducted with Admin and three (3) out of three (3) staff denied the allegation. Interviews conducted with FR1 and S2-S4 could not corroborate the allegation. Documentation obtained for S1-S2 personnel file staff training annual 8 hour Dementia training date completed 02/10/2024 and S3 annual 8 hours Dementia training date completed 12/21/2024. In addition, all residents interviewed indicated that they feel they receive the required care needed to meet their needs. Per documentation obtained during today's visit, none of the residents are currently diagnosed with Dementia. There is not enough evidence to substantiate. Based on LPA observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be UNSUBSTANTIATED. Exit interview was conducted with S1 and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 28-AS-20240924110535

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Caregiver, Josie Alberto and explained the purpose for the visit. During today's visit, LPA Maldonado conducted a tour of the physical plant with Caregiver, observed the facility food supplies, reviewed (5) resident medications, (5) resident files, (5) staff files, and conducted interviews with (2) staff, and attempted interviews with (5) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (5) non-ambulatory residents and (1) bedridden resident. It has an approved Dementia Care Plan and a Hospice Waiver approved for (6) residents. There are currently (2) resident receiving hospice services. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file. LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are (2) full bathrooms in the home- both equipped with required grab bars and non-skid mats for the shower. The hot water was tested and measured between 108*F-110*F, which is in compliance. Food supplies was observed and was sufficient as required. Emergency food supplies and water were available. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. The last fire drill was conducted this morning, 5/02/24 prior to LPA's arrival. Auditory devices were observed at all entrances/exits of the home and were operational. (5) resident files and (5) staff files were reviewed and observed to be complete with all required documentation. (5) resident medications were reviewed and were observed to be documented properly and given as prescribed. No deficiencies were observed or cited during today's visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 2, 2024