St. Andrews Home for the Aged

Allegation investigated: Facility is forcing resident/client to participate in exercise.

On July 22, 2026, Licensing Program Analysts (LPAs) Eboni Bentley and Taylor Simerly conducted an unannounced initial complaint investigation visit into the above allegations. LPAs were greeted and granted entry by staff and met with Administrator Victoria Valencia after explaining the purpose of the visit. During the visit, LPAs obtained Client/Staff rosters, Emergency and Information Form, Physician’s report, Needs and Service Plan, Individual Program Plan (IPP), Medication Administration Records, and Hospital Records. LPAs also conducted client and staff interviews. The following was determined during the course of the investigation: Regarding the allegation, Facility is forcing client to participate in exercise, it was alleged that Staff #1 (S1) forces Client #1 (C1) to walk when client communicates that they do not want to walk. Continue to LIC9099-C...... Substantiated The Physician’s Report for C1 dated January 6, 2026, indicates that C1 is non-ambulatory, requires assistance with transferring, and is able to communicate needs. The Needs & Service Plan dated November 1, 2025, reports that C1 walks with an unsteady gait, is at risk of falls, and uses a walker but has a difficult time maneuvering it. Two out of three clients interviewed denied the allegation. LPAs were unable to take statements for two clients due to their medical condition and others were out of the facility during the visit. One client initially confirmed the allegation and later denied the same allegation during the interview. Four out of five staff denied the allegation, stating staff do not force clients to exercise if they do not want to. During an interview, S1 confirmed the allegation by admitting they continue to have C1 take 2-3 steps after C1 communicates they do not want to continue trying to walk. Based on interviews that were conducted and records reviewed during the investigation, the preponderance of evidence standard has been met for allegation: Facility is forcing client to participate in exercise is deemed SUBSTANTIATED. A deficiency is being cited on the attached LIC 9099-D, as per Title 22, Division 6, Chapter of the California Code of Regulations. An exit interview was conducted with Administrator Victoria Valencia and a copy of this report, LIC9099-D, LIC811, and appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 22-AS-20260715164200

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(3) · Plan of correction due date: Jul 31, 2026

80072 Personal Rights (a).. each client shall have personal rights which include, but are not limited to, the following:(3) To be free from. humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature... to physical functioning. Based on interview confirmation, facility staff did not comply with the section cited above, which poses a potential risk to clients in care. During interview, S1 admitting they continue to have C1 take 2-3 steps after C1 communicates they do not towant continue trying to walk.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: Administrator agrees to read and review the regulation with staff during training, and send LPA Bentley a signed statement of acknowledgement and understanding with training records by end of day on POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sam Haddadin conducted an unannounced visit to the facility for the purpose of completing the required annual inspection. Upon arrival, LPA Haddadin was greeted and granted entry by Victoria Valencia, Administrator. LPA explained the nature of the visit, and the Administrator accompanied LPA during the inspection. At the time of the visit, there were six residents in care, and no residents were receiving hospice services. LPA toured the interior and exterior of the facility with the Administrator. Required Department postings were observed throughout the facility, and the facility was operating within its licensed capacity. A minimum of one week of nonperishable food and at least two days of perishable food were available, with additional storage in a spare refrigerator and freezer located in the garage. The facility was maintained at a comfortable temperature. Medication was inspected and observed to be centrally stored in a locked storage cabinet located in the kitchen. Medications were properly labeled and stored inaccessible to residents in care. Bathrooms were inspected, and the hot water temperature measured 112.2 degrees Fahrenheit. Bathrooms contained an adequate supply of soap, toilet paper, and towels, and were equipped with required safety measures, including non-skid mats and grab bars. Lighting throughout the facility was sufficient to support resident safety and comfort. The facility had adequate hand hygiene, cleaning, and disinfecting supplies, and toxic chemicals, cleaning solutions, and disinfectants were stored locked under the kitchen sink and in a locked storage cabinet in the garage. Clean linens were available and properly maintained. Residents’ bedrooms were inspected and observed to have sufficient lighting, required furnishings, and all required components. Adequate storage space was provided for each resident. Smoke detectors were tested and found to be operational. During the exterior inspection, outdoor passageways were observed to be free of obstructions, and shaded seating areas were available for resident use and enjoyment. Fire extinguishers were observed throughout the facility with a service date of June 26, 2025. The facility has a second floor; however, no residents reside on that level, and LPA verified that residents in care do not have access to the second floor. LPA verified that fire drills are conducted as required and confirmed the most recent fire drill was completed on October 30, 2025. LPA reviewed five resident records, and all required documentation was present and current. LPA also reviewed three employee records and verified that all employees had criminal record clearances, were associated to the facility, and maintained current First Aid certifications. Based on observations and records reviewed during today’s inspection, no deficiencies were noted in the areas inspected in accordance with Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with the Administrator, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Michael Tea and Fred Arias conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:00 AM, LPA Tea and Arias were greeted and granted entry into the facility by caregiver Lourdes Anda and explained the reason for the visit. The administrator (AD) Victoria Valencia arrived shortly to assist with the visit. The facility is licensed for six non-ambulatory residents with a hospice waiver for two. Currently there are six residents. Around 8:10 AM, LPAs Tea and Arias reviewed six resident files and three staff files. Resident files and staff files contained all required documentation. Upon review of records, the facility is up to date with required quarterly emergency disaster drills, which was last conducted on Oct 30, 2024. AD Valencia administrator certificate has an expiration date of Oct 31, 2025. Unfortunately, she does not have a physical copy present due to inaccessibility to printing out the certificate on the portal site. LPAs Tea and Arias along with AD Valencia toured the facility at 9:06 AM. LPAs toured the physical plant, checked food service, and the first aid kit. The facility is a two-story home, the first floor consists of 3 resident bedrooms, 1 staff room, 2 bathrooms, living room, dining room, kitchen and attached garage. The second floor is only for staff where live in care staff resides, no residents reside on the second floor. LPAs observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. Water temperature measured between around 113.5 F degrees and 114 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPAs observed sharps locked and inaccessible to residents in a kitchen drawer. LPAs also observed toxin substances secured underneath the kitchen sink. Annual continuation on LIC809-C The fire extinguishers are fully charged throughout the facility. Kitchen appliances are operational during today's visit. LPAs toured the outside grounds and there is ample seating underneath a shaded patio area in the backyard. There is a barbecue grill used during the summer days. There are two exit gates that are self-latching and operational on both sides of the house. LPAs observed PPE supplies, emergency food and water stored in the garage. Facility provides activities based on their personal choice. Residents play bingo and sing karaoke. The staff also takes residents out to the outings like the park, going to the beach or shopping. At the time of the visit, LPAs observed residents lounging in the family room listening to music and having snacks. At 9:33 PM LPAs reviewed medication storage and administration. Medications are stored in a locked cabinet in the kitchen area. Medications are being administered per physician order. P&I funds were accounted and there were no discrepancies. LPAs interviewed residents regarding their quality of care and spoke to staff present regarding care provided. Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Administrator Victoria Valencia and a copy of this report LIC809, along with the 809-C, LIC858, and LIC859 were read and provided to the facility.the state’s words, verbatim · CDSS document, Nov 26, 2024

Allegation investigated: Facility staff prevented clients from seeking medical care Facility staff yell at clients Facility staff behave inappropriately with clients

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Administrator (AD) Victoria Valencia and explained the purpose of the inspection. Interviews were conducted with five facility staff, five residents, and two witnesses, regarding the allegation, facility staff prevented clients from seeking medical care. Five out of five staff interviewed denied having any knowledge of staff preventing residents from seeking medical care and stated residents are allowed and able to seek and receive care services. Four out of five residents stated they are allowed to seek medical care and other care services and staff assist them in attaining these services. One out of five residents was unable to confirm or deny allegation due to being non-verbal. During their interview, both witnesses stated medical and other care services are made available to residents as necessary and stated they have no knowledge of these services ever being denied. (Cont. LIC9099-C) Unsubstantiated Interviews were conducted with five facility staff, five residents, and two witnesses, regarding the allegation, facility staff yell at clients. Five out of five staff interviewed denied personally yelling at residents and denied witnessing any other staff yelling at residents. Four out of five residents denied staff yell at them or other residents. One out of five residents was unable to confirm or deny allegation due to being non-verbal. During their interview, both witnesses denied witnessing staff yelling at residents. Interviews were conducted with five facility staff, five residents, and two witnesses regarding the allegation, facility staff behave inappropriately with clients. Five out of five staff interviewed denied personally behaving inappropriately with residents and denied witnessing any other staff behaving inappropriately with residents. Three out of six residents denied staff behave inappropriately with them and denied witnessing staff behaving inappropriately with other residents. Two out of five residents were unable to confirm or deny allegation. During their interview, both witnesses denied witnessing or having knowledge of staff behaving inappropriately with residents. Due to conflicting information received during interviews conducted, LPA is unable to determine if facility staff prevented clients from seeking medical care, if facility staff yell at clients, or if facility staff behave inappropriately with clients. Although the above 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 at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, May 24, 2024 · control 22-AS-20240517162258