Tessie's Place Loving Care Home #2

Allegation investigated: Resident sustained unexplained scratches while in care Staff do not follow resident's care plan Staff leave resident in wet diapers for extended periods of time Resident developed a pressure injury due to staff neglect Staff do not provide a comfortable environment for resident

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with facility staff and explained the reason for the visit. The investigation into the allegation, resident sustained unexplained scratches revealed the following. It was reported that Resident 1 (R1) had four nail marks on the top of their right hand and scratches on their forearm which were noticed by a witness on February 10, 2025. It was reported the scratches were caused by staff members. R1 moved into the facility on January 8, 2025 and moved out of the facility on February 25, 2025. R1 has been diagnosed with Parkinson's disease. The Administrator reported that staff had informed him of the scratches and staff did not know what caused the scratches. Witness 1 (W1) reported that R1 told them staff caused the scratches. LPA attempted to interview R1 but they were not oriented to the time or their location. R1 did not respond to any questions from the LPA. 4 out of 4 staff interviewed who assist R1 denied the allegation. Unsubstantiated The Administrator reported they reported the issue to R1's responsible party. W1 reported that they never witnessed any abuse by the staff toward any of the residents. The cause of the scratches on R1 is unknown. LPA interviewed R1's physical therapist who reported they have never witnessed any type of abuse at the facility. 2 out of 5 residents interviewed reported they have never witnessed or experienced any abuse from staff. 3 out of 5 residents did not respond to LPAs questions and could not be interviewed. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, 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. The investigation into the allegation, staff do not follow resident's care plan, revealed the following. It was reported that R1 was not assisted with their incontinence and not changed as often as listed in their doctors orders and R1 is to be kept upright for 10 to 15 minutes after taking medication and drinking liquids. The Administrator reported that the care plan is based off of doctor's orders and no such orders were provided. A review of records shows the only doctor's orders provided are for R1 to be rotated every 2 hours to assist with blood flow, prevention of pressure injuries and to check every 2 hours for incontinence to ensure proper hygiene to minimize pressure injuries. The Administrator reported that R1's responsible party asked them to keep R1 upright after taking medications and drinking liquids for 10 to 15 minutes but they never provided a doctor's order so they didn't do it. 4 out of 4 staff reported that R1 was checked every hour and changed at least 3 times a day and whenever required to ensure they were clean and to minimize any skin breakdown. R1's responsible party reported they had additional doctor's orders but they were not provided to the LPA and they could not explain why they weren't provided to the facility. The Administrator reported they follow all doctor's orders and attempted to work with R1's responsible party but they did not receive a response. R1's responsible party could not explain why they didn't respond to the Administrator. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, 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. The investigation into the allegation, staff leave resident in wet diapers for extended periods of time, revealed the following. It was reported that R1 was left in soiled briefs for extended periods of time. No specific details were provided as to the date or time when this occurred. R1's responsible party reported that they have never witnessed R1 in soiled briefs and did not have any first hand knowledge of R1 ever being left in soiled briefs. R1's physical therapist reported they have never witnessed R1 being left in soiled briefs and thought the staff were very attentive to all the residents. The Administrator reported that all staff are trained to check each resident at least every 2 hours and to check R1 every hour because of their condition. 4 out of 4 staff interviewed denied the allegation and reported that R1 is changed checked and changed regularly and has never been left in soiled briefs. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, 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. The investigation into the allegation, resident developed a pressure injury due to staff neglect, revealed the following. It was reported that because the facility staff did not clean R1 regularly, did not rotate R1 regularly and did not change R1 regularly, R1 developed a pressure injury while residing at the facility. The Administrator reported that R1 moved in with a stage 1 pressure injury and had home health visits starting right after they moved in. Staff 1 reported they saw R1's stage 1 pressure injury on the day they moved in they were told to keep R1 clean and dry and to rotate R1 every 2 hours. 4 out of 4 staff reported they kept R1 clean and rotated them every 2 hours. R1's physician report dated July 1, 2024 which was provided to the facility when R1 moved in, shows R1 has a stage 1 pressure injury on their coccyx, is prone to fungal infections and pressure injuries. The Administrator reported that R1 had home health visits twice a week for their pressure injury. R1's responsible party verified this information. LPA contacted the Home Health company to interview the 2 home health nurses who provided care to R1 but never received a response. 4 out of 4 staff reported they followed the instructions from the nurses and R1 was properly cared for. The Administrator reported that R1 moved out of the facility on February 25, 2025 prior to their wound completely healing and reported that wound was improving. R1's responsible party verified this information. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, 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. The investigation into the allegation, staff do not provide a comfortable environment for resident, revealed the following. It was reported that R1 was not provided a comfortable environment. No details were provided regarding this allegation. LPA measured the temperature of the facility and it was 75.0 degrees Fahrenheit. LPA did not observe any obstacles or hazards or any strong odors in the facility. LPA interviewed 2 out 5 residents who reported they were comfortable at the facility and had no issues. R1 did not respond to any of the LPA's questions so they were not interviewed. 3 out of 5 residents did not respond to LPA's questions so they were not interviewed. LPA observed R1's bed had a mattress with a foam pad and clean linens and R1 was clean, dressed and groomed. The Administrator reported that no one has complained to them about an uncomfortable environment. 4 out of 4 staff reported that none of the residents or visitors has reported anything about an uncomfortable environment. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, 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. An exit interview was conducted with facility staff and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 15, 2026 · control 22-AS-20250213114436

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Romualdo Amante was notified via telephone and could not assist in person There are currently five residents in care, three of which are receiving hospice care at this time out of a waiver capacity of two. Deficiency cited. Residents are observed relaxing in their respective bedrooms and in the common areas. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with four private and one shared bedrooms used by residents in addition to one staff room. There are two bathrooms used by residents. None of the residents are bedridden at this time. All occupied bedrooms appear clean and sanitary. There are four beds equipped with full rails or combined half-rails. Two residents have no orders on file. Citation issued. One resident not receiving hospice care also has a bed with full rails. Deficiency cited.All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary and are all equipped with grab bars and slip mats. Hot water temperature measured at 114F in two bathrooms with faucets used for personal grooming. LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items, cleaning supplies and the medication central storage are verified to be secure. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 Fire extinguishers are present and verified to be charged, however their maintenance tags are dated December 2022 and are therefore out of date. Type B deficiency cited. Carbon monoxide and smoke detectors are present and operational. LPA and facility staff toured the outside of the facility. LPA observed multiple shaded outdoor seating areas with outdoor furniture for resident use in the backyard. The identified routes of egress are free of clutter and obstructions. There are self-latching gates on both sides of the premises. There are no bodies of water on the premises and the facility does not utilize either locked perimeters or delayed egress. LPA reviewed five resident records. LPA reviewed resident medication records and prescription orders with no discrepancies observed for four residents. LPA reviewed staff records for four staff members during the visit. All staff members on the schedule are background cleared and associated. Proof of current CPR training reviewed. Annual and initial training reviewed and found to be missing for staff member S1. Deficiency issued. Disaster drills are conducted quarterly. The administrator certificate is current. Based on the observations conducted during the present visit, five type B deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Dec 11, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the annual required inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Romualdo Amante and explained the reason for the visit. Administrator Mel Amante's Administrator's certificate expires on March 26, 2025. Facility is licensed for 6 non-ambulatory residents, hospice waiver for 2 residents. Facility has 5 bedrooms, 3 bathrooms, living room, kitchen, dining room, storage room, activity room/family room and an attached 3 car garage that is used for storage and kept locked. LPA and the Administrator toured the facility. LPA observed the See Something, Say Something poster posted in the main entrance of the facility. .LPA observed all 3 bathrooms are clean and operational. Hot water measured 115.1 degrees Fahrenheit in all 3 bathrooms. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. Medications are kept locked in a kitchen cabinet. Knives and sharp objects are kept locked in a kitchen drawer. Cleaning supplies are kept locked under the kitchen sink. The storage room is located next to the kitchen and is a pass through to the garage. The storage rooms has an exit door to the backyard. The storage room has boxes and furniture stored in such a way that access to the garage and exit door are blocked. It is not possible to walk through the storage room. LPA observed clean linens stored in the hall closet. LPA observed the 5 resident rooms are clean and have all the required furnishings. LPA observed 3 out of the 5 resident rooms did not have a smoke detector. The smoke detectors in the two other resident rooms and throughout the facility tested operational. The carbon monoxide detector in the entry way of the facility tested operational. LPA toured the backyard. No bodies of water observed. LPA observed both exit gates are operational. LPA observed a shaded patio with seating to sit outside. LPA reviewed 2 staff records, 6 resident records and medications. LPA observed that 3 out of 6 residents are on hospice and the facility has a hospice waiver for 2, facility is operating beyond the limits of the license. No other discrepancies noted. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. Civil penalty assessed on today's date. (SEE LIC 421IM) for citation (CCR) 87203 Fire Safety. An exit interview was conducted and a copy of the report provided along with appeal rights.the state’s words, verbatim · CDSS document, Jan 8, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.