Gentle Senior Care

Allegation investigated: - Staff abandoned resident at the hospital

On this day, Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit to investigate the above allegation. LPA Tea was greeted and granted entry by facility staff and explained the purpose of the visit. Lead Staff (LS) Eliseo Manuel arrived shortly to assist with the visit. LPA Tea also spoke with Administrator (AD) Priscilla Mirabueno by telephone, who stated that she was currently out of the country and was informed of the visit. On June 3, 2026, the Department received a complaint alleging that staff abandoned a resident at the hospital. During the investigation, LPA reviewed hospital records, facility records, and conducted interviews. The investigation revealed that Resident 1 (R1) was hospitalized and intended to return to the facility following discharge. Hospital records showed that medical social workers made multiple attempts to (Complaint Report continued on LIC9099C) Substantiated contact the facility regarding R1's return. Facility staff informed the hospital that only the administrator could approve R1's return and that the administrator was out of the country. Hospital staff were unable to reach the administrator and were also unable to leave messages for the manager because voicemail had not been set up. During an interview, AD Mirabueno confirmed that she was outside of the country at the time and acknowledged that she did not have a designated substitute administrator available to make decisions in her absence. AD Mirabueno stated that she wanted to consult with a physician regarding R1's behaviors before approving their return to the facility. R1 remained hospitalized until they were readmitted to the facility on June 7, 2026. AD Mirabueno also confirmed that R1 had not been evicted and remained a resident of the facility. Based on records reviewed and statements obtained during the investigation, the Department determined that the administrator failed to ensure adequate administrative coverage during her absence. As a result, no designated person was available to make decisions on behalf of the facility, which delayed R1's discharge from the hospital and return to the facility. Therefore, the allegation that staff abandoned the resident at the hospital is determined to be SUBSTANTIATED, meaning the allegation is valid because the preponderance of evidence standard has been met. Pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited. An exit interview was conducted with the facility. A copy of this report, the LIC 9099D, and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Jun 12, 2026 · control 22-AS-20260603100004

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jul 3, 2026

All facilities shall have a qualified and currently certified administrator...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. This requirement was not met as evidenced by: The facility failed to ensure administrative coverage during the administrator's absence. As a result, no designated person was available to make decisions regarding Resident 1's return to the facility, delaying the resident's discharge from the hospital and return to the facility.the state’s words, verbatim · CDSS document, Jun 12, 2026

Plan of correction: Facility shall develop a written plan identifying the designated back up administrator and outlining responsibilities during periods when the administrator is unavailable. POC will be submitted to LPA by the POC due date.

Type of visit: Required - 1 Year

On January 13, 2026, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Caregiver Mel Manuel was available to assist with the facility inspection. The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for three (3) residents. Facility serves as a Residential Care Facility for The Elderly (RCFE) and serves Dementia residents Currently, there are two (2) Hospice residents present during today’s visit. This is a single story with attached garage facility. The facility has four bedrooms (two private and two shared resident rooms), and three bathrooms. LPA conducted a tour of the physical plant accompanied by caregiver, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 113.1 degrees F. A comfortable temperature of 73 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for toxins and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained. Facility has one fire extinguisher which was charged and mounted. CONTINUED ON 809C During the visit, LPA observed the facility's infection control practices and sign in area for visitors. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations upon entry. LPA observed the facility has a supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. Facility has a supply of emergency food and water LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on June 4, 2025. The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 6/23/25 – 6/23/26 . A review of five residents (R1-R5) service files and two staff (S1-S2) personnel files revealed to be complete. The facility has the current administrator's certification on file for Maria Mirabueno - Expiration 11/01/2026. No deficiencies during this inspection visit. An exit interview was conducted with caregiver, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 13, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met Caregiver Melgasbal (Mel) Manuel at approximately 8:15 AM and explained reason for visit. Administrator Maria Mirabueno was notified by telephone. The facility is licensed for 6 non-ambulatory residents. The facility has a Hospice waiver for 3 residents. The facility is in a residential area, and it is a one-story family home. A tour of the single-story facility included the living room, kitchen, dining room, five (5) resident bedrooms, three (3) bathrooms, front yard, backyard, and attached garage. LPA toured the facility and observed the following: Each resident bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke detectors/carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. The facility has one (1) fully charged fire extinguisher which is kept in kitchen. Cleaning supplies and toxic substances are inaccessible locked in cupboards in kitchen. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. Bathrooms had required grab bars and nonskid mats. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. SEE LIC 809C Three (3) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Five (5) residents files were reviewed and included physicians report, TB clearance. Last fire/earthquake drill was conducted in September of 2024. Infectious control plan will be emailed to LPA. Two (2) staff and (1) resident was interviewed. Five (5) resident medications were reviewed. Medications are centrally stored and locked MAR log is used. No deficiency was observed during today’s visit. Exit interview was conducted with Caregiver and a copy of report was provided.the state’s words, verbatim · CDSS document, Dec 14, 2024