Acacia Guest Home

Allegation investigated: Staff do not ensure resident's toileting needs were met. Staff inappropriately handled resident. Facility staff do not ensure medication records are maintained properly.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit regarding the allegations listed above. LPA met with Administrator, Jacklyn Peng Lee Concepcion and the purpose of the visit was explained. The investigation consisted of the following: On 05/28/2026 and 06/08/2026, LPA toured the facility, obtained and reviewed the staff and resident rosters, Staff training files, facility files and schedules, and (5) Resident files pertinent to the investigation. LPA interviewed Staff #1 (S1) - Staff #2 (S2), Resident #1 (R1) - Resident #4 (R4) and telephonically interviewed Staff #3 (S3). LPA attempted to interview Resident #5 (R5) but unsuccessful due to no response. Resident #6 (R6) was not interviewed as they were just admitted to the facility.******CONTINUED ON LIC9099-C***** Substantiated The investigation revealed the following: Allegation: Staff do not ensure the resident's hygiene care needs were properly met. It is alleged that residents are not given showers or bed baths and shave. All staff interviewed denied the allegation stating that they assist residents with their hygiene needs, including bathing and shaving. Staff indicated that some residents refuse to take a bath or shower and to be shaven. Staff also stated that most of their residents have home health nurses that give them bed or sponge baths. S1 stated that the bathrooms were not renovated at the same time and ensured that there was one working bathroom for residents' use. During the tour of the facility, LPA did not observe unkempt or unshaven residents and bedrooms did not have a noticeable urine odor. Interviewed residents stated that they could not remember when they last took a bath or shower but mentioned that they get sponge baths or bed baths sometimes. Reviewed documents did not show any residents being hospitalized due to any health related issues associated with bad hygiene. Although the facility did not maintain the ADL (Activities of Daily Living) charts or hygiene routine logs, LPA did not observe residents with rashes or dry skin that could have been caused of lack of showers or baths. Therefore, there was insufficient evidence to corroborate with this allegation. Allegation: Licensee does not ensure staff are properly trained. It is alleged that med tech was administering insulin injections even though staff was not licensed as an LVN. Staff interviewed denied the allegation, claiming this was a false statement. Staff denied being a med tech and there are no med tech staff employed in the facility. Staff also stated that there are no residents administering insulin injections. Staff explained that a resident routinely checks their blood sugar with a needle/lancet, however, the resident was the one doing it. Some residents interviewed believed that the staff are properly trained as they know how to handle their day-to-day needs. Documents reviewed revealed that the facility administrator has current, valid certification. Additionally, staff records and required training documentation, including medication training align with Title 22 regulations. Therefore, there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Jacklyn Peng Lee Concepcion, Administrator. The investigation revealed the following: Allegation: Staff do not ensure resident's toileting needs were met. It is alleged that staff double-diapering residents instead of providing appropriate toileting and hygiene care and this explains why the residents get frequent UTI's. During interviews, staff confirmed that they are using double diapers to incontinent residents to prevent leakage, especially at night. S3 stated witnessing a staff double diapering R1-R2 and was concerned about this practice as it poses a high risk for infection. S1 stated that they are unaware of this practice and thought that staff were placing pads inside the diapers and not double diapering. (2) incontinent residents were interviewed and confirmed that staff use double diapers on them. Reviewed documents revealed that the facility did not maintain a record or log for toileting assistance, repositioning or continence care plan. Additionally, incident reports between March-April 2026 showed that (3) residents were sent to the hospital due to Urinary Tract Infection (UTI). And although staff had received personal care training, it was not specified if that training included incontinent care. Therefore, there is sufficient evidence to corroborate with this allegation. Allegation: Staff inappropriately handled resident. It is alleged that a staff member pinched a resident because he was being combative. Interviewed staff admitted having pinched the resident’s cheek but stated it was just a joke. According to the interviewed staff, "I pinched him on the face, but as a joke only. I joke with him everyday." Staff also stated that it was not done firmly as they have no intention of harming the resident, and no injury was reported. S3 stated that they witnessed the incident but did not see an injury to the resident. During the visits on 05/28/2026 and 06/08/2026, LPA did not observe any physical marks such as redness or bruising on R1's face or arms. Interviewed residents were unaware of the incident and did not comment on the allegation. Therefore, there is sufficient evidence to corroborate with this allegation. Allegation: Facility staff do not ensure medication records are maintained properly. It is alleged that the MARs (Medication Administration Records) were not properly documented or maintained. Staff interviewed stated that the residents' medication administration records (MARs) are usually recorded at the end of the day or hours later after the medications were given. S1 stated that they noticed a recurring pattern where the MARs were not initialed or recorded by staff at the time of medication administration. LPA reviewed and cross-referenced the residents' physicians’ order against the medication logs/MARs for April-May 2026. Reviews revealed that there were unsigned doses, unrecorded prescribed medications, duplicate medications, unrecorded PRN (as-needed) and over the counter vitamins medication administration. It also revealed that medication record keeping is outdated and incomplete as several entries lack the required staff initials verifying administration. Furthermore, new or changed medications were not reflected on the MAR. Residents interviewed could not recall if they have experienced missed doses, wrong medications, or delays in receiving PRNs. Documents reviewed and interviews corroborate with this allegation. Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Administrator, Jacklyn Peng Lee Concepcion, Administrator along with the Appeal Rights.the state’s words, verbatim · CDSS document, Jun 12, 2026 · control 28-AS-20260522093149

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87413(a)(2) · Plan of correction due date: Jun 26, 2026

87413 Personnel - Operations (a) In each facility: (2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement is not met as evidenced by: Based on interviews, the Administrator did not comply with the section cited above in which staff admitted to pinching R1’s cheek/face which poses a potential health, safety or personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Jun 12, 2026

Plan of correction: Administrator agreed to submit a signed self-certification that they have read, reviewed and understood Title 22 Regs. 87413. Additionally, the administrator will conduct staff training about personal rights (Section 87468.1) and personnel requirements (Section 87413). Self-certification and in service training log signed/dated by staff shall be submitted by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(1)-(3) · Plan of correction due date: Jun 26, 2026

87465 Incidental Medical and Dental Care (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: (1) There is written direction from a physician, on a prescription blank....instructions regarding a time or circumstance (if any) when it should be discontinued,...(2) Once ordered by the physician the medication is given....(3) A record of each dose is maintained in the resident's record.... include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by: Based on observation, interviews and records review, the Administrator did not comply with the section cited above in which the medication administration records (MARs) for R1-R5 were outdated, incomplete, and medication administration were not recorded timely with several entries lacking the required staff initials verifying administration. which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 12, 2026

Plan of correction: Administrator agreed to re-train staff on the right procedure for recording MARs and proper medication administration to residents as prescribed by their Physicians. Administrator to submit in service training log along with topics discussed by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 26, 2026

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews and records review, the Administrator did not comply with the section cited above in which staff admitted and had been witnessed to use double diapers to (3) incontinent residents and there was no record or log for toileting assistance, repositioning or continence care plan which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 12, 2026

Plan of correction: Administrator agreed to submit a signed self-certification that they have read, reviewed and understood Title 22 Regs. 87468.1. Additionally, the administrator will develop and maintain a record or log for toileting assistance, repositioning and incontinence care plan for the residents. Both documents shall be submitted by POC due date.

Allegation investigated: Staff do not provide resident with comfortable accommodations.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit regarding the allegations listed above. LPA met with James Alfonso Loppies, Caregiver and explained the purpose of the visit. Shortly after, Administrator, Jacklyn Peng Lee Concepcion arrived and the purpose of the visit was explained. The investigation consisted of the following: On 05/28/2026, LPA toured the facility, obtained and reviewed the staff and resident rosters, Staff schedule, Staff orientation checklist and training logs, ADL schedules, Resident #1 (R1) - Resident #5 (R5) files suchas as Identification and Emergency information/Face sheet, Resident appraisal, Admission agreement, Physician's report, Medication Administration Records (MARs for April & May 2026),Physician's orders and Care plans. During today's visit, LPA toured the facility, obtained the staff and resident rosters, Unusual incident/injury report (May 2026). LPA interviewed Staff #1 (S1) - Staff #2 (S2) and Resident #1 (R1) - Resident #4 (R4). LPA attempted to interview Resident #5 (R5) but unsuccessful due to no response. Resident #6 (R6) just arrived as a new resident at the time of the visit. ******CONTINUED ON LIC9099-C***** Substantiated The investigation revealed the following: Allegation: Staff do not provide resident with comfortable accommodations. It is alleged that residents appeared to be neglected and were often kept confined to their rooms without proper monitoring or routine care checks. Staff interviewed stated that there’s adequate staffing but due to the facility's recent renovations, staff acknowledged that they did not allow residents to leave their rooms or offer activities despite conducting regular safety checks on the residents. Staff indicated that they haven't been able to encourage the residents to take part in various activities because there aren't any activities planned for the residents. Residents interviewed stated that they spend all day in their rooms listening to music or watching television. Some residents stated that they typically stay in their rooms because there were no activities offered to them. Documents reviewed revealed that the facility lacked a documented care plan to monitor safety checks and routine care for residents, especially incontinent residents. Additionally, the medication administration records (MARs) were not documented properly including not initialing the medications that were administered. Although LPA did not observe uncomfortable accommodation during the facility inspection, it was observed that despite having (2) staff members on duty, residents were not encouraged to leave their rooms to socialize or engage in any activities. Therefore, there was sufficient evidence to corroborate with this allegation. Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Administrator, Jacklyn Peng Lee Concepcion, along with the Appeal Rights.the state’s words, verbatim · CDSS document, Jun 8, 2026 · control 28-AS-20260522093149

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jun 22, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on observation, interviews, records review, the Administrator did not comply with the section cited above in which the residents were neglected as they were kept confined in their rooms, and were not provided a variety of planned activities which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 8, 2026

Plan of correction: Administrator to ensure that residents will not be confined in their rooms, staff provide activities, care and supervision necessary to meet their needs, and to review and understand the Title 22 regs. 87468.2. Administrator to develop daily planned activities for the residents which will be posted in the facility and will send a copy to CCL/LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by James Alfonso Loppies, Caregiver and explained the purpose of the visit. The administrator, Jacklyn Peng Lee Concepcion was called and arrived at 11:45am to assist LPA with the inspection. The facility is approved to serve residents age range 60 and over, (6) non ambulatory, of which (1) may be bedridden. Hospice waiver approved for (3) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility is continuing to follow their Infection Control Plan. Administrator reviewed and updated the Infection Control plan annually. Staff are trained in the proper use of all required PPEs. Operational Requirements: Plan of operation was reviewed. The facility accepts and retains residents with dementia. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 07/24/2026. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (4) resident bedrooms, (2) staff bedrooms, (1) with en-suite bathroom, (1) communal bathroom, living room with fireplace, dining area with fireplace, kitchen, laundry area, attached garage, and backyard with shaded area with tables and chairs. There are currently (6) residents, 60 years and older residing in the facility, (2) are under hospice care and (1) bedridden. The interior and exterior physical plant was inspected. LPA observed both fireplaces to be uncovered, unsecured and accessible to residents. Resident bedrooms were toured. Each bedroom has a bed, linen, light, chair and sufficient closet space. There are (3) refrigerators/freezers, (2) in the kitchen/dining area and (1) near the laundry area. There are no working auditory devices in the exit points. The backyard was inspected and was observed to be disorganized with miscellaneous junk and toxic materials around the area. There are (2) fire extinguishers in the facility and one purchased in December 2025 was not mounted on the wall. Smoke detectors and carbon monoxide detectors were tested and operable. The facility is not following the existing sketch as one of the designated room for the resident has been changed to a staff room. There are cameras with audio at the facility. The hot water temperature was measured between the required range of 105-120 degrees F.*****REPORT CONTINUED ON LIC809-C***** Staffing: A total of (3) caregivers plus the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 have criminal background clearance, fingerprint cleared and associated to the facility. However, staff files are incomplete, such as personnel records and none of them have completed the first aid/CPR training. Personnel Records-Training: Four (4) staff files were reviewed for criminal background clearance, training and have health/TB screenings. Administrator has completed the required administrator courses, no certificate yet but it is valid through 07/21/2026. Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all residents and have access to the facility phone. Administrator provides ongoing training for staff. Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in the Plan of Operation. The facility provides sufficient space to accommodate both indoor and outdoor activities. Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Pesticides and cleaning supplies are kept away from the food preparation areas. (2) residents require modified diet. Incidental Medical Services: Residents' medications were reviewed during the visit. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are stored in a medical cart and inaccessible to residents. LPA observed errors in administering and documenting medications to the residents. Resident Records-Incident Reports: (6) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, Medical Consent, Medication Records. However, some required files are missing. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency/disaster drills are conducted quarterly, recent one was conducted on 02/06/2026. Residents with SHN: (2) residents are under hospice care. Physicians order for bed rails for the residents were on file. There are no residents utilizing oxygen at this time. Deficiencies cited. Technical Advisories issued. Exit interview and a copy of this report was provided to the Administrator, Jacklyn Peng Lee Concepcion.the state’s words, verbatim · CDSS document, Mar 6, 2026

The state marks this report as 11 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection on 3/18/25. LPA met with Staff, Maria Sanubari, and explained the purpose for the visit. The facility is licensed for (6) non-ambulatory residents, ages 60 and over, of which 1 may be bedridden. There is a hospice waiver approved for 3 residents. The facility consists of 4 resident bedrooms, 1 staff room with bathroom, one communal bathroom, a storage room, living room, dining room, kitchen, laundry room, and attached garage. There is an shaded area in the backyard with table and chairs. The facility is continuing to follow their Infection Control Plan. Staff are using gloves when assisting residents. The facility has a dementia care plan to accept or retain residents with dementia. There is one resident on hospice. The facility has the sufficient amount for liability insurance covering injury to residents and guests. Knives, cleaning solutions, and disinfectants are locked. The hot water temperature was measured between the required range of 105-120 degrees F. Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability. There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The foods are properly stored in the refrigerator. LPA reviewed 5 resident files and files are complete. The Local Ombudsman and Residents personal rights information are posted at the facility. LPA reviewed the administrator and 2 other staff files. The administrator's (Jacklyn Concepcion) certificate expires on 7/21/26. Staff employed are over the age of 18 and are fingerprint cleared. One of the staff did not have the TB test or First Aid completed. Staff are receiving on-going training. Medications are centrally stored in their original containers and they are given as prescribed by the physician. The facility has the updated Emergency Disaster Plan. Drills are being conducted however, LPA provided a technical advisory to ensure the documentation meets the criteria. Deficiencies are issued on the LIC809D. An exit interview was held with the Administrator. A copy of this report, LIC809D, and appeal rights were given.the state’s words, verbatim · CDSS document, Mar 18, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff do not ensure residents are provided with a comfortable environment.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA arrived unannounced and met with Staff, Brandy Guinto. The purpose of the visit was explained. Administrator, Jacklyn Concepcion, arrived shortly after. LPA obtained copies of the resident and staff rosters, reviewed Resident #1’s file, and toured the facility. Interviews were held with the administrator, 2 staff, and 2 residents. For allegation, staff do not ensure residents are provided with a comfortable environment. It is alleged that Resident #1 (R1) is yelling all day long and nothing was done by the owner. LPA interviewed the administrator, staff, and residents. The administrator stated that when it was brought to her attention, she immediately intervened and tried to figure out the cause. She contacted the family member to speak with the resident and the doctor for recommendations to reduce the behavior. She stated the doctor had adjusted the medication several times for R1 since admitted in September 2024 because of the behavior. Unsubstantiated Staff interviewed stated they are trying their best to provide a comfortable environment for residents. When R1 displays the behaviors, staff try to redirect R1 which does not seem to work. Staff stated R1 is given the PRN which was prescribed by the doctor and that helps reduce the behavior a little. Staff also had been communicating with the hospice nurse regarding the verbal behavior. LPA interviewed residents who stated R1 had been screaming or talking loudly some nights which interrupts their sleep. Based on information gathered, staff have been addressing R1’s behavior with the doctor and nurses and trying to reduce the frequency of its occurrence. 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. An exit interview was conducted with the Staff Guinto. A copy of this report along was provided.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 28-AS-20241107150127

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cynthia Chan conducted a follow up case management visit on the incident reported to licensing on 8/1/24. LPA arrived unannounced and met with Staff, Francesca Olivia. LPA spoke to administrator, Jacklyn Concepcion, via telephone to explain the reason for the visit. On 8/8/24, LPA Chan conducted a visit due to an incident report submitted to LPA on 8/1/24 alleging that a staff member was inappropriately touching Resident #1 (R1). LPA conducted a health and safety check, interviewed 2 staff and 2 residents. Alleged staff denied inappropriately touching R1. On 9/12/24, LPA interviewed Resident #1 via telephone who confirmed the allegation. LPA also interviewed R1's responsible party. Per the administrator, the police was informed of the incident and provided the report number. Based on record review and interviews, there is no witness to testify to this claim. Therefore, there is insufficient evidence to prove the allegation at this time. No deficiencies were issued today. A copy of this report was given to the staff.the state’s words, verbatim · CDSS document, Sep 12, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management to issue a deficiency. LPA met with Staff, Andrea Oei, and explained the reason. During the tour of the facility today, LPA observed the common room next to the kitchen used as a resident room. There was a bed, recliner, chair, t.v., and dresser. LPA interviewed staff and residents who confirmed it belongs to a resident. A deficiency is being issued and a civil penalty is being assessed due to a repeated violation. An exit interview was held. A copy of this report and appeal rights are given to the staff.the state’s words, verbatim · CDSS document, Aug 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(2)(B) · Plan of correction due date: Aug 15, 2024

87307 Personal Accommodations and Services (a) Living accommodations and grounds...(2) Resident bedrooms shall be provided...(B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This requirement is not met as evidenced by: Based on observation, Resident #1 was moved to a dining room area per the facility sketch which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2024

Plan of correction: The licensee will appropriately place Resident #1 in a resident room as indicated on the facility sketch. The licensee will also provide photos of all resident #1's belongings removed from the room. This POC is due by 8/15/24. **A civil penalty has been issued due to a repeated violation.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit due to an incident that was reported by the facility. LPA arrived unannounced and met with Staff, Efren Maralit. The purpose of the visit was explained. The incident report submitted to LPA on 8/1/24 alleged that a staff member was inappropriately touching Resident #1. LPA conducted a health and safety check, interviewed 2 staff and 2 residents. LPA requested documents pertaining to Resident #1 to be emailed. LPA will continue to gather information on this incident. No deficiencies were issued today. A copy of this report was given to the staff.the state’s words, verbatim · CDSS document, Aug 8, 2024

Allegation investigated: Staff did not feed resident in care. Lack of care resulting in resident sustaining wounds.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver findings for the allegations listed above. LPA met with Staff, Maura Demapan, and explained the purpose of the visit. On 2/29/24, LPA Chan conducted the initial visit to gather documents for Resident #1. Interviews were held with the administrator, 2 Staff, and 4 Residents. LPA interviewed the hospice agency nurse on a different date. Allegation – Staff did not feed resident in care. It is alleged that Resident #1 (R1) has not eaten for over 3 days. The administrator and staff stated they offered R1 three meals a day but R1 sometimes refused to eat. They offer to cook any food R1 would like to eat, but R1 would also decline. When R1 does not eat, they would try to give a nutritional shake/drink to provide some nutrients. LPA interviewed the hospice nurse who was aware of R1 not eating for several days before hospitalization. Unsubstantiated Staff and the hospice nurse tried to encourage R1 to eat a little bit and/or to seek a higher level of care, however, R1 rejected any recommendation. They also indicated that R1 was not on any dietary restrictions and was simply refusing to eat. LPA interviewed 4 out of the 6 residents and 3 stated staff provided them with food and snacks. During the visit, LPA observed staff cooking and preparing meals for the residents. They provided R1 with the Ensure drink, as R1 did not want to eat the food made. Allegation – Lack of care resulting in resident sustaining wounds. It is alleged that R1 developed wounds in the back, neck, groin, coccyx, abdominal folds, and legs. The administrator and staff interviewed indicated that R1 was admitted to the facility with wounds. They often try to reposition and change R1 but client was resistive to any staff help. They stated that a hospice agency nurse came out 3 times a week to treat the wounds. LPA interviewed the hospice agency nurse who confirmed R1 was being treated for these chronic wounds on the body. The nurse also indicated that R1 was non-compliant with the care being provided and repositioning. They have tried to educate R1 about the importance of treating the wounds and accepting the care, however, R1 would become angry. The hospice nurse also stated that R1 was very selective and had resisted any care being provided by certain nurses or staff. LPA interviewed 3 other residents who stated that staff are caring and assist them when needed. Based on the information gathered, R1 refused the care being provided and not that there was a lack of care from staff. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Staff Demapan. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 28-AS-20240221112607

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit on 4/25/24. LPA met with Staff, Maura Demapan and explained the purpose of the visit. During the visit, LPA observed Resident #1 (R1) residing in the room to the right of the entrance. According to the facility sketch, the space was indicated as the dining room. The room does not have a door and the facility uses a fabric curtain to provide privacy to the resident. Staff stated R1 was moved to the area a few months ago. LPA issued a deficiency for resident residing in a common area. There are a total of 6 residents observed at the home. An exit interview was held. The plan of correction was discussed with the administrator via telephone. A copy of this report along with appeal rights were emailed to the administrator per request.the state’s words, verbatim · CDSS document, Apr 25, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(2)(B) · Plan of correction due date: May 2, 2024

87307 Personal Accommodations and Services (a) Living accommodations and grounds...(2) Resident bedrooms shall be provided...(B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This requirement is not met as evidenced by: Based on observation, Resident #1 was moved to a dining room area per the facility sketch which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: The licensee shall appropriately place Resident #1 in a resident room as indicated on the facility sketch. The licensee shall submit a statement acknowledging this regulation has been read. The licensee will also provide photos of the resident #1's belongings removed from the common area and into an assigned room. This POC is due by 5/2/24.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Cynthia Chan and Christian Gutierrez conducted the required annual inspection using the CARE tools. LPA arrived unannounced and met with staff, Maura Demapan, who allowed entry. The purpose of the visit was explained. The facility is licensed for 6 non-ambulatory residents, ages 60 and over, of which 1 may be bedridden. The hospice waiver is approved for 3 residents. LPAs toured the facility, reviewed records, and interviewed 2 staff and 2 residents. The following were observed: Infection Control: The facility staff are using gloves when needed to assist residents. Facility has sufficient PPE supplies. Staff receive Infection Control training annually. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 6 residents residing at the facility. There is one resident on hospice and 2 receiving home health services. The facility has the sufficient amount for liability insurance covering injury to residents and guests. Physical Plant & Environment Safety: The facility does not have any swimming pool on the premises. There are 5 resident bedrooms, 1 live-in staff room with bathroom, 1 communal bathroom, living room, dining room, kitchen, laundry area, and attached garage. Facility has operable smoke detectors and a carbon monoxide detector located in the dining area. Knives, cleaning solutions, and disinfectants are locked. The hot water temperature was measured between the required range of 105-120 degrees F. Staffing: The administrator's (Jacklyn Concepcion) certificate expires on 7/21/24. Staff employed are over the age of 18 and are fingerprint cleared. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed the Administrator and 2 other staff files. There were sufficient annual training on file. CPR & First Aid certificates are current for all 3 staff. Resident Records-Incident Reports: Resident files are maintained at the facility. LPAs reviewed all 6 resident files and they have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights. Resident Rights-Information: The Local Ombudsman and Residents personal rights information are posted at the facility. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The foods are properly stored in the refrigerator. Incidental Medical & Dental: The medications are centrally stored in their original containers. LPAs reviewed 6 residents' medications and there are discrepancies found for 3 of the residents (Resident #2, #4, and #5). Some of the medications were not properly marked on the MAR log as given. Also, some of the medications did not appear to be given as prescribed, as the medications were still in the bubble pack. The start date noted on the bubble pack did not correspond to today's date. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and procedures. . Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. There are currently 1 resident on hospice. A deficiency was issued on the LIC809D. An exit interview was held with the Administrator via telephone. A copy of this report, LIC809D, and appeal rights were given to the staff.the state’s words, verbatim · CDSS document, Apr 9, 2024