Francesca's Home

Allegation investigated: Staff did not administer medication as prescribed Staff withhold meals from resident as a form of retaliation Staff do not ensure that residents are provided a comfortable accomodations Staff do not treat residents with dignity and respect Staff not providing records to the authorized representative/resident

On 08/18/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Licensee, Bessie Coello, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During the initial visit conducted on 06/23/2026, LPA inspected the facility, interviewed Staff S1-S3, interviewed Residents R2-R6, interviewed Witnesses W1 and W2, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Identification & Emergency Information (dated 05/16/2026), Admission Agreement (dated 05/16/2026), Program Description (05/16/2026), Medication Procedures (dated 05/16/2026), House Rules (dated 05/16/2026), Personal Rights of Resident’s in Privately Operated Residential Care Facilities for the Elderly (dated 05/16/2026) Medical Assessment for Residential Care Facilities for the Elderly (dated 05/14/2026), Centrally Stored Medication and Destruction Record (dated 05/16/2026), Medication Return Form & Release of Responsibility (dated 05/28/2026), Unusual Incident/Injury Report (dated 05/29/2026, 06/02/2026, 06/05/2026, 06/10/2026, 06/16/2026 and 06/17/2026), Notification Letters from the Facility Unsubstantiated (dated 06/02/2026, 06/11/2026, 06/12/2026, and 06/16/2026), Presbyterian Intercommunity Hospital Discharge Orders (dated 05/06/2026), Presbyterian Intercommunity Hospital Document Review Report (dated 05/16/2026), Presbyterian Intercommunity Hospital Adult Discharge Instructions (dated 05/04/2026) Staff Notes from 05/18/2026 to 06/22/2026, and Weekly Menu. The investigation revealed the following: Allegation: Staff did not administer medication as prescribed The allegation alleges that a resident stated they need the brand name of a medication and the pharmacy provided the generic brand, resulting in the resident not getting the medication they requested. During the facility inspection, LPA observed Staff S2 providing medications to residents. LPA observed S2 reviewed the Physician’s Orders, the Medication Administration Record (MAR), and the prescription label to ensure medications are provided as prescribed. LPA conducted a medication review for Resident’s R2-R6. LPA observed five (5) out of five (5) residents Centrally Stored Medications are consistent with their Physician’s Orders. During record review, LPA received and reviewed Resident R1’s Admission Agreement, signed and dated 05/16/2026, that lists under Basic Services: page 3 number 16) Assistance with taking prescribed and over-the-counter medications in accordance with physician’s instructions unless prohibited by law or regulations. LPA received and reviewed the Program Description: Residential Care Facility for the Elderly, signed and dated 05/16/2026, that states “ medications will be issued according to the physician’s instructions and the instructions on the label. If there are changes to the dispensing, the facility will obtain these changes in writing from the client’s physician.” LPA received and reviewed Medication Procedures, signed and dated 05/16/2026, that states in number 9. “The Administrator shall follow the doctor’s prescriptions strictly as prescribed by the doctor’s written prescription in dispensing medications to residents.” LPA additionally received and reviewed Discharge Orders from Presbyterian Intercommunity Hospital – PIH Health, dated 05/16/2026, that indicates R1 was to start a new prescription of Dilantin 100mg oral capsule, extended release 1 cap orally 3 times a day and to discontinue Dilantin 100mg oral capsule, 1 cap orally 3 times a day. LPA observed the medication that was delivered to the facility on 06/10/2026, is labeled Dilantin 100mg Capsule, which was discontinued on 05/16/2026. Additionally, LPA received and reviewed an Unusual Incident/Injury Report dated 06/16/2026, stating the police were at the facility due to medication being withheld by staff. Police were informed by Staff S1 that they do not have an order from the Physician indicating a change in medications. Police Officers were provided documentation to verify the information and left without incident. No Report was indicated on the City of Torrance Police Department card left with an incident number of 260023565. During interviews with Staff S1-S3, were asked how they ensure residents are provided with their medications as prescribed, three (3) out of three (3) stated they follow the Physician’s Orders and the prescription label. Durning interviews with Residents R2-R6, were asked if they receive their medications as prescribed, five (5) out of five (5) stated yes, they receive their medications as prescribed. During interviews with Witnesses W1 and W2, were asked if their resident receives their medications as prescribed, two (2) out of two (2) stated yes, their resident receives their medications as prescribed. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff withheld meals from a resident as a form of retaliation The allegation alleges that staff are not providing a resident with meals due to staff retaliation. During the facility inspection, LPA inspected the food supply and observed the facility has a 3-day supply of perishable foods and a 7-day supply of nonperishable foods properly packaged, labeled, and dated. Upon entering the facility, LPA observed residents finishing breakfast. At 10am, LPA observed residents were offered a snack. At 11:30am, LPA observed staff preparing lunch and serving the residents’ lunch at 12pm. During record review, LPA received and reviewed Resident R1’s Admission Agreement, signed and dated 05/16/2026, that lists on page 2, under Basic Services include Food Services, consisting of: 1. Three nutritious meals daily and snacks, and 2. Special diets as prescribed by a doctor. In the Program Description: Residential Care Facility for the Elderly, signed and dated 05/16/2026, LPA observed it states, The basic services include: Three (3) nutritious meals daily and between meals, nourishments and snacks. Modified diet available, if required. LPA received and reviewed Staff Notes that indicate Resident R1 refused meals the following date and times: on 05/18/2026 refused breakfast, 05/19/2026 refused breakfast and dinner, 05/20/2026 refused breakfast and dinner, 05/23/2026 refused snacks, lunch, and dinner, 05/24/2026 refused breakfast, 05/26/2026 refused dinner, 05/28/2026 refused dinner, 06/01/2026 refused lunch, 06/02/2026 refused breakfast, 06/03/2026 refused lunch, 06/04/2026 refused breakfast, dinner, and snacks, 06/05/2026 refused breakfast, lunch, and dinner, 06/07/2026 refused dinner, 06/08/2026 refused breakfast, 06/09/2026 refused breakfast and snack, 06/10/2026 refused breakfast, 06/11/2026 refused breakfast and lunch, 06/12/2026 refused breakfast, lunch, and dinner, 06/13/2026 refused breakfast, lunch, and dinner, and 06/15/2026 refused dinner. LPA observed on occasion R1 requested an alternative such as tuna, spaghetti, or ravioli and would have food delivered. During interviews with Staff S1-S3, were asked if a resident’s meals were withheld at any time, three (3) out of three (3) stated no, no meals have been withheld from a resident. During interviews with Residents R2 -R6, were asked if there was a time they were not provided with a meal or snacks, five (5) out of five (5) stated no, they have always received their meals. During interviews with Witnesses W1 and W2, were asked if there was a time their resident was not provided with a meal, two (2) out of two (2) stated no, not to their knowledge. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff do not ensure that residents are provided a comfortable accommodations. The allegation alleges the hospital bed the resident was provided with is broken. During the facility inspection, LPA observed Resident R1’s room was furnished with a bed, dresser, nightstand with a lamp, chair, and storage space for resident’s belongings. LPA observed that the mattress and box spring are maintained in good condition. During record review, LPA received and reviewed Presbyterian Intercommunity Hospital Discharge Order dated 05/06/2026 and observed a hospital bed was ordered as DME equipment and delivered by Apria. LPA observed in the Staff Notes on 06/03/2026 Resident R1 complained to the doctor that the bed is broken. The bed was checked by the doctor and staff, and it was “working perfectly fine.” Additionally, LPA observed in the Staff Notes on 06/11/2026 the Licensee received a call from the home health risk management stating Resident R1 called and reported their bed was broken. The bed was checked and the Licensee informed them the bed was not broken. LPA received and reviewed Resident R1’s Admission Agreement and Program Description: Residential Care Facility for the Elderly, signed and dated 05/16/2026, on page 1, under Basic Services, that states a “Comfortable and suitable bed and bedroom furniture.” During interviews with Staff S1-S3, were asked how they ensure residents are provided with comfortable accommodations, three (3) out of three (3) stated they ensure the rooms are clean and have the furniture the residents require. During interviews with Residents R2 -R6, were asked if they are provided with comfortable accommodations, five (5) out of five (5) stated yes, they are provided with comfortable accommodations. During interviews with Witnesses W1 and W2, were asked if their resident is provided with comfortable accommodations, two (2) out of two (2) stated yes, their resident is provided with comfortable accommodations. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff do not treat residents with dignity and respect The allegation alleges staff brought their dog to the facility when asked not to, retaliated against resident for calling the police, and was not given the password for the television. During the facility inspection, LPA observed interactions between staff and residents. LPA observed the staff speaking respectfully to residents and while providing care staff provided them with privacy. During record review, LPA observed LPA received and reviewed Resident R1’s Personal Rights of Residents in Privately Operated Residential care Facilities for the Elderly, signed and dated 05/16/2026, that states on page 2 residents have the right “to be accorded dignity in their personal relationships with staff, residents, and other persons,” and the right to “ to have reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.” LPA received and reviewed Staff Notes for Resident R1 that indicates on 06/10/2026 and 06/15/2026, R1 was provided with the Wi-Fi password. During interviews with Staff S1-S3, were asked how they ensure residents are treated with dignity and respect, three (3) out of three (3) stated they listen to their wants and needs, and provide privacy when assisting residents, or when they have a visitor or are on the phone. During interviews with Residents R2 -R6, were asked if staff treat them with respect and dignity, five (5) out of five (5) stated yes, staff treat them with respect and dignity. During interviews with Witnesses W1 and W2, were asked if staff treat their resident with respect and dignity, two (2) out of two (2) stated yes, staff treat their resident with dignity and respect. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff not providing records to the authorized representative/resident The allegation alleges the resident asked to be shown the medication and the staff would not show them. During the facility inspection, LPA observed Centrally Stored Medications secured in a locked filing cabinet, in a locked staff room. During record review, LPA received and reviewed Resident R1 Staff Notes that states on 06/14/2026, R1 requested to take a picture of their medication that they have been working on getting a refill for. A picture of the bottle was taken with R1’s cell phone. Additionally, LPA received and reviewed Resident R1’s Personal Rights of Residents in Privately Operated Residential Care Facilities for the Elderly, signed and dated 05/16/2026, that states on page 5, residents have the following personal right “to have prompt access to review all of their records and to purchase photocopies of their record. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.” During interviews with Staff S1-S3, were asked residents and/or responsible person is provided with requested information and/or documents, three (3) out of three (3) stated yes, they are provided right away. During interviews with Residents R2-R6, were asked if staff provide residents and/or their authorized representative with requested records or information, five (5) out of five (5) stated yes, they receive it right away and there have been no issues. During interviews with Witnesses W1 and W2, were asked if staff provide them with requested records or information, two (2) out of two (2) stated yes, they are provided with documents right away and provided information on any changes. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. LPA did not observe or cite any deficiencies. An exit interview was conducted with Licensee, Bessie Coello, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2026 · control 11-AS-20260615182651

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) N. Galarza arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation. LPA was greeted and granted entry by caregiver Helia De La Cruz. Administrator Bessie Coello arrived shortly after. Administrator's certificate expires 1/4/2027. The following was observed during the inspection: Infection Control: The facility has an Infection Control Plan. Operational Requirements: The Residential Care for The Elderly (RCFE) facility has Dementia and hospice waiver for 5 residents. A fire clearance for 5 non-ambulatory and one (1) bedridden resident in room #4. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 11/3/2026. Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. The facility is a single-story home located in a residential area consisting of four (4) bedrooms, 2 of which are shared, 2 bathrooms w/grab bars, kitchen, dining room, living room, laundry room/medication room, backyard, and office. Resident rooms are equipped with required furniture, lighting, bed linens, mattress pads, closet/drawer space to accommodate each resident comfortably. Cleaning supplies and toxic substances are inaccessible to residents. The facility has one fire extinguisher. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Electrical smoke and carbon monoxide detectors were tested and are operational. The facility maintains emergency food supply and water. Emergency Phone numbers, exit plan and programming schedules are posted. The facility is equipped with central air conditioning and heating. Exit doors are free of any obstruction and there are no pools. There are outdoor and indoor surveillance cameras. Medication “Diclofenac Sodium Topical Gel” was observed unlocked. Room #3 has 2 oxygen tanks, but no "No Smoking-Oxygen in Use". The last Emergency Disaster drill was conducted on 7/1/2026. Staffing: A total 12 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Five (5) staff files were reviewed for criminal background clearance, staff training, health screening & TB clearance, 1st Aid/CPR. *Note: Staff (S2) is not associated. Licensee disagrees. A citation was issued. Resident Records/Incident Reports: A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. RCFE complaint poster and Personal rights were observed posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have modified diets. Incident Medical and Dental: Two (2) centrally stored / 30-Day supply of medications were reviewed. Medical and dental transportation is provided by family. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. Residents with Special Health Needs: Two (2) residents receive hospice services. There are currently no bedridden residents. Pursuant to California Code of Regulations, Title 22, deficiencies were cited. An exit interview was conducted with Administrator Bessie Coello and plans of correction were developed with Licensee. A copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jul 18, 2026

Allegation investigated: Staff unplugged residents oxygen

On 06/4/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct and deliver findings for the alleged allegation. LPA identified herself and met with Bessie Coello- Administrator who was informed of the purpose of the visit. The investigation consisted of: On 5/6/2026, At 08:15 AM, LPA Allen requested the following documents: Staff roster dated June 4, 2026, and Client roster dated May16 2026. The department conducted a review of six (6) clients files which consisted of admissions agreements, needs and service plans, and physician’s reports which all six (6) files appeared to be current. The Department conducted interviews with four (4) staff members (S1–S4) and Clients 1–3 (C1–C3) and The Department attempted to interview Client 4 (C4); however, C4 was unable to participate in a clear conversation. Unsubstantiated Attempts were also made to interview Clients 5 and 6 (C5–C6), but they were not available during the visit. The Department was also able to interview Witness 1 (W1) and attempted to contact C1’s next of kin. The investigation revealed the following: Allegation 1: Staff unplugged residents’ oxygen During the investigation, Staff 1–4 (S1–S4) were asked whether any staff member had ever unplugged a client’s oxygen machine or whether they had ever needed to plug a client’s oxygen machine back in. All four staff members stated they have never unplugged a client’s oxygen machine, nor have they ever had to plug one back in. The clients’ oxygen machines remain plugged in at all times. An interview conducted with Client 1 (C1) reported S1 unplugged their oxygen machine and that S2 after an hour later plugged it back into the wall. When asked to identify who plugged the machine back in, C1 was unable to provide a name and when asked if there was a witnessed to the incident C1 said no. Interviews with Clients 2 and 3 (C2–C3) indicated that they do not require oxygen and have not seen or heard of anyone’s oxygen being turned off. The Department attempted to interview Client 4 (C4); however, C4 was unable to participate in a clear conversation. The Department was also unable to interview Clients 5 and 6 (C5–C6), as they were not available at the time of the visit. An interview conducted with Witness 1 (W1) revealed that they have not heard any rumors or experienced any incidents involving oxygen. The Department also attempted to interview Client 1’s (C1) next of kin; however, they were unable to be reached. During a tour of the facility, the Department observed that the oxygen machines in use within the home were plugged in and operating. Based on the records reviewed, the clients in care who require oxygen were actively receiving oxygen. Based on interviews, file review and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Bessie Coello- Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 11-AS-20260526130158

Type of visit: Required - 1 Year

On 07/25/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator, Bessie Daniella Coronado-Vigil. CCLD staff explained the purpose of the visit and was accompanied by House Manager/Caregiver, Cynthia Campos inside and outside the facility during this inspection. This facility is licensed to serve 6 non-ambulatory adults ages 60 and above, of which 1 may be bedridden. This facility has an approved hospice waiver for 5 residents. Room 4 is approved for bedridden only. A total of 6 residents are currently residing in this facility. The Annual Licensing Fees are current. Facility Layout: The facility is a one-story house located in a residential street. The home consists of 4 resident bedrooms; 2 full bathrooms; 1 laundry room with medication storage; 1 great room which includes the living room area, dining room area, and kitchen area; 2 utility/storage closets; 1 attached garage which has 1 full bathroom; 1 backyard patio area with shaded seating. Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to residents in care. There is fire extinguisher in the kitchen area, and it was last serviced on 08/19/2024. There is a landline telephone. Living Room/Community Indoor Space: There are games/activity work (i.e. board games, books, and magazines) for residents in the living room area. There are couches and chairs for residents to sit at. Resident Bedrooms: 4 out of 4 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Bathrooms: Non-skid mats were in place. Adequate lighting and toiletries accessible to residents. The hot water temperature measured 117.6 Fahrenheit. Medications: were inaccessible to residents in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. 5 out of 5 Medication Administration Records (MARs) were reviewed and they were current and up to date. Garage: is used as a storage room and as an office for the Administrator. Miscellaneous: Documents are posted as mandated. Last fire and disaster drill was conducted on 07/02/2025. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. 5 staff records were reviewed, 5 out of 5 staff records had required documentation. 5 resident records were reviewed and, 5 out of 5 resident records had required documentation. CCLD staff had a conversation with the Administrator, Bessie Daniella Coronado-Vigil about updating the facility sketch. The Administrator agreed to request for facility sketch to be updated. A technical advisor is being provided regarding documenting residents’ systolic blood pressure. No deficiencies are being cited based on observation and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report was left with the Administrator, Bessie Daniella Coronado-Vigil.the state’s words, verbatim · CDSS document, Jul 25, 2025

Type of visit: Case Management - Annual Continuation

On 06/28/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent visit to the facility above to continue an annual from 06/27/24. LPA met with Administrator, Bessie Coello, and the purpose of today’s visit was explained. The facility is licensed for 6 residents over the age of 60, five (5) non-ambulatory of which 1 may be bedridden. The facility has an approved hospice waiver for 2 residents. Physical Plant/Structure The facility is a single-story home located in a residential neighborhood. The home consists of the following: four (4) bedrooms, two (2) bathrooms, living room, dining area, kitchen, laundry/utility room, and attached garage. Outside, LPA observed a shaded patio with a table and chairs accessible for resident’s use. LPA observed all walkway around the home to be clean, clear, and free of obstruction, debris, and hazards. LPA did not observe any bodies of water on the premises. Bedrooms LPA inspected all resident rooms and found them to be clean and in good repair. LPA observed the rooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an additional supply of linens stored in a closet in the hallway. All linens and mattress were observed in good condition. All rooms were observed to have ample lighting. Bathrooms LPA observed all bathrooms to be operable and within Title 22 regulations. The toilet, facets, and shower work properly. The bathrooms were observed clean. The showers were observed with secured safety handrails, nonskid mats, and a shower chair. The showers were observed to be free of mold and mildew. LPA observed storage space for residents’ hygiene products. LPA observed an ample supply of towels and hygiene products available for residents. The water temperature measured 114.8-degrees Fahrenheit. Kitchen LPA observed the kitchen to be clean and sanitary. LPA observed all appliances to be operable. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All foods were observed properly labeled, dated, packaged, and stored. LPA observed knives and sharps to be secured in a cabinet in the laundry/utility room and are inaccessible to residents. LPA observed cleaning supplies to be secured in locked cabinet in the laundry/utility room and are inaccessible to residents. The water measured 107.7-degrees Fahrenheit. Common Rooms LPA observed the living room to have a chair and two couches to accommodate all residents. LPA observed in the dining room a large table to accommodate all residents. LPA observed activities and reading material available for residents. All walkways and hallways in the home were observed to be clean, clear, and free of hazards and obstructions. The facility was kept at a comfortable temperature. All rooms and hallways were observed to have ample lighting. Safety LPA observed the smoke detectors and carbon monoxide detector to be operable. LPA observed a fully charged fire extinguisher last serviced on 08/24/23, located at the kitchen. The last emergency drill was conducted on 06/01/24. The facility has a working landline telephone. LPA observed the facility’s Emergency and Disaster Plan and required postings posted in the hallway near the entrance. LPA reviewed the Liability Insurance (PHPK2621828) through Acord that is valid till 11/03/24. During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Administrator, Bessie Coello, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 28, 2024

Type of visit: Required - 1 Year

On 06/27/24, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced annual visit to the facility listed above. LPA met with Administrator, Bessie Coello, and the purpose of today’s visit was explained. The facility is licensed for 6 residents over the age of 60, five (5) non-ambulatory of which 1 may be bedridden. The facility has an approved hospice waiver for 2 residents. File Review/Interviews LPA reviewed the files for the six (6) residents and observed they had the required documents. LPA interviewed three (3) residents, and both were happy with the care they receive at the facility. LPA reviewed the administrator and two (2) staff files and found they contained the required documents, certification, and training. The administrator’s Administrator Certificate is valid till 01/01/25. Medication LPA observed all Centrally Stored Medications secured in a locked filing cabinet, in a locked staff room, and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the medications and Medication Administration Record (MAR) for the six (6) residents. Six (6) out of six (6) resident’s MARs and medication are consistent with properly documented records. Infection Control Upon entry, LPA observed a sanitizing station and visitor sign-in log. LPA observed on the table there is a thermometer, hand sanitizer and masks available. LPA observed all visitor temperature was taken and logged. LPA observed all required Infection Control signs posted in the facility. Due to time constraints, LPA will return to complete the annual visit. During today's visit, LPA did not observe or site any deficiencies. An exit interview was conducted with Administrator, Bessie Coello, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 27, 2024

Allegation investigated: Resident sustained unexplained injuries due to lack of staff supervision. Staff did not address resident’s change in condition. Staff did not report incident(s) involving resident. Staff handled resident in a rough manner. Staff are not adequately trained to care for resident(s).

On 06/12/2024 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Francesca’s Home facility and was greeted by Administrator Bessie Coello (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Administrator A1, Staff S1, Resident R1-R5, Witness W1-W2. LPA Calderon obtained and reviewed the following: Incident report (date 03/22/2024), Letter from R1 family to administrator (date 03/26/2024), Needs and Service Plan (date 03/26/2024), Emails from R1 family (date 12/12/2023 and 04/11/2024), 30-day notice to administrator (date 03/26/2024), Admission Agreement (date 04/17/2023), Optum Medical records (date 12/22/2023), staff training logs (date 02/1/2023 to 11/1/2023). The investigation revealed the following: Unsubstantiated Regarding Allegation #1: Resident sustained unexplained injuries due to lack of staff supervision. This complaint alleged that due to staffing issues R1 had an unexplained injury while in care. A1 indicates that A1 received notice from staff that R1 had an unexplained bruise to R1 right arm. A1 indicates that on 03/22/2024 R1 husband W2 took R1 for a walk. R1 appears to have fallen and injured R1 right eye and arm. A1 indicates that W2 did not inform A1 of the fall and injury and the next day staff noticed the injury and reported the incident to R1 family and wrote an incident report. A1 indicates that there are no staffing issues. S1 indicates that any injury to a resident is reported to resident family and an incident report is generated. S1 indicates that there are no staffing issues and the unexplained injury to R1 was not from lack of staff. R1 no longer lives at facility and could not be interviewed. R2 was non-verbal and could not answer any questions. R3-R5 indicates no staffing issues and staff take care of their medical needs. W1-W2 indicates that R1 had an unexplained injury under care from the facility. W1-W2 indicate that R1 injury was due to staffing issues. Regarding Allegation #2: Staff did not address residents change in condition. This complaint alleged that staff did not address R1 change in health condition. A1 indicates that R1 health was changing and A1 had a conversation with R1 family and that a review would be needed. A1 indicates that R1 was aggressive with staff due to health condition and new medication would be needed. S1 indicates that R1 change in condition was addressed and S1 advised A1 and R1 family of R1 health changes. R1 moved and could not be interviewed. R2 was non-verbal and could not answer any questions. R3-R5 indicates that staff does keep records and address changes in their medical condition. W1-W2 indicate that staff did not address changes in R1 condition and R1 family had to complain. Reviewed R1 records which indicate: Review letter from administrator to residents’ family (date 3/26/2024), letter indicates injury to resident right eye lid, appears resident hit herself on unknown object and did not inform staff. Reviewed email from A1 regarding R1 (date 12/12/2023) regarding reassessment and level of care for resident. Email communications also regarding diet and care. Regarding Allegation #3: Staff did not report residents involving resident. This complaint alleged that staff did not report incident involving R1. Reviewed incident report which indicates: Reviewed incident report (date 3/22/2024) for R1, on 3/22/2024 at 3:20pm it was noticed by W2 that resident had a slight bruise over R1 right eyelid. R1 had been prescribed a new medication that it was making R1 a bit drowsy, and it was reported to the medical doctor on Monday 3/18/24 and time of dosage was changed per medical doctor and family was informed. Per medical doctor observations it looks like R1 bumped R1 against something and did not say anything to staff. A1 indicates that all staff are trained to generate an incident report for residents in care. A1 indicates that on 03/24/2024 R1 and W2 were walking and R1 had a fall. A1 states that once A1 staff noticed the injury to R1 they reported the incident to R1 family and generated an incident report. S1 indicates that any injury to a resident is reported to Administrator and resident family and if needed 911 is called and resident is cared for. R1 no longer lives at facility and could not be interviewed. R2 is non-verbal and could not answer any questions. R3-R5 indicate that staff do report any incident to their family. Regarding Allegation #4: Staff handled resident in a rough manner. This complaint alleged that staff handled R1 in a rough manner. Reviewed letter from A1 to R1 family which indicates: Review letter from A1 to residents’ family (date 3/26/2024), letter regarding injury to resident right eye lid, appears resident hit R1 on unknown object and did not inform staff. Reviewed email from A1(date 12/12/2023) regarding reassessment and level of care for resident. Email communications also regarding diet and care were noted. A1 indicates that R1 health had changes and R1 was aggressive. A1 indicates that R1 was injured with an unknown object and did not advise staff. A1 indicates that staff would not handle R1 in a rough manner. S1 indicates that R1 health had changed and was more aggressive. S1 indicates that staff would redirect R1 aggressive actions and would never handle R1 or any other resident in a rough manner. R1 could not be interviewed and R1 no longer lives at facility. R2 is non-verbal and could not answer any questions. R3-R5 indicate that staff have never handled them in a rough manner. Regarding Allegation #5: Staff are not adequately trained to care for residents. This complaint alleged that staff are not trained to care for R1. Reviewed training log notes which indicate: Staff are given training in 16 different topics from dementia training to client’s rights to reporting. A1 indicates that all staff are given training every 3 months and no staff would be allowed to care for resident without training. S1 indicates that staff are provided training every 3 months to include dementia care, reporting, clients’ rights. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “resident sustained unexplained injuries due to lack of staff supervision” “staff did not address residents change in condition” “staff did not report incidents involving resident” “staff handled resident in a rough manner” “staff are not adequately trained to care for residents” is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report were provided to the Administrator Bessie Coello (A1).the state’s words, verbatim · CDSS document, Jun 12, 2024 · control 11-AS-20240402153207