Port Minoa

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility for the purpose of completing an annual required inspection. LPA arrived at the facility, was greeted by facility staff, and was granted entry. LPA explained the nature and purpose of the visit. Scott Messick and Ryan Roche, Administrators, arrived shortly thereafter and met with LPA. There are six (6) residents currently residing at the facility, one (1) of whom are receiving hospice services. The facility is a single-story home with five resident bedrooms, one of which is shared, one staff bedroom, two resident bathrooms, a living room, a dining room, a kitchen, a laundry room, a staff office, and an attached two car garage. LPA conducted a tour of the interior and exterior of the facility. Department required postings were observed throughout the facility. The facility was operating within its approved capacity limitations. The facility maintained a minimum of one (1) week of nonperishable food and two (2) days of perishable food supplies. Emergency food, emergency water, and emergency supplies were observed stored in the kitchen pantry and the laundry unit. The facility is maintained at a comfortable temperature. LPA inspected the centrally stored medications, which were maintained in a secured and locked storage closet located in the hallways in the facility entry way. LPA reviewed the medications and observed that they were appropriately labeled and stored in a manner inaccessible to residents in care. LPA also observed the first aid kit and first aid manual stored with the medication. CONTINUED ON LIC809-C LPA inspected the facility bathrooms and measured the hot water temperature at 118.7 degrees Fahrenheit. All bathrooms were observed to have adequate supplies of soap, toilet paper, and towels. Bathrooms were equipped with required safety features, including nonskid mats and grab bars. Lighting throughout the facility was sufficient to ensure the safety and comfort of residents. The facility was equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions, and disinfectants were stored in secured cabinets within the laundry room and underneath the kitchen sink. The laundry room is equipped with a keypad entry door, which was kept locked to prevent access by residents in care. The facility maintained a clean and adequate supply of linens. LPA inspected the residents' bedrooms and observed sufficient lighting to ensure safety and comfort. All bedrooms inspected contained the required components, and adequate storage space was provided for residents' personal belongings. Smoke detectors and carbon monoxide detectors were tested and found to be operational. LPA toured the exterior of the facility and observed that outdoor passageways were free of obstructions. Shaded seating areas were available for residents' use and enjoyment in the backyard areas of the facility. LPA observed a fire extinguisher located in the kitchen. The fire extinguisher was charged, properly mounted, and had a service date of March 26, 2026. The facility conducts fire drills every three (3) months. LPA reviewed the facility's fire drill logs and verified that the most recent fire drill was conducted on September 10, 2026. LPA proceeded with a review of facility records. LPA reviewed three (3) resident records and observed that all required documentation was present and maintained in the residents' files. LPA also reviewed two (2) employee records. All employees present had current criminal record clearances and were properly associated with the facility. LPA observed that the employee records reviewed contained current First Aid certifications. Based on the observations and records reviewed during today's visit, no deficiencies were noted in the areas inspected pursuant to Title 22, Division 6 of the California Code of Regulations. This report was reviewed with the Administrator, and a copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 24, 2026

Allegation investigated: Resident fell multiple times due to staff neglect. Resident sustained injuries due to staff neglect. Staff are not awake for the night shift. Staff did not call emergency services for resident.

Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to deliver the findings on the above allegations. LPA met with administrators, Scott Messick and Ryan Roche and explained the purpose of the visit. During the investigation, the following was completed: LPA inspected the facility, interviewed staff and residents, obtained and reviewed resident records including Admission Agreement, Medical Assessment dated September 4, 2025, Appraisal, Needs and Services plan, emergency contact information. The investigation revealed the following: It was alleged that Resident 1 (R1) fell multiple times due to staff neglect. R1 moved to the facility on September 4, 2025, and moved out of the facility on October 10, 2025. Based on interviews conducted, R1 had three unwitnessed incidents of falls, on September 7, 2025, September 11, 2025, and September 23, 2025. On September 11, 2025, this fall incident resulted in a hospital visit. None of the falls were reported to the Department. Continued LIC9099-C. Substantiated LPA attempted to interview R1 and no response was received. Five out of five residents interviewed did not witness R1’s fall incidents. R1’s medical assessment dated September 4, 2025, shows R1 is diagnosed with Alzheimer’s Disease and engages in unsafe wandering, exhibits lack of hazard awareness, and requires monitoring for safety. R1 was under hospice care at the time of move-in. LPA attempted to contact the hospice nurse to request R1’s hospice records, however the hospice company is no longer in business. LPA obtained hospital records dated September 11, 2025, that show R1 was treated for the fall incident. Per R1’s physicians report dated September 4, 2025, R1 had a wandering and lack of hazard awareness behavior that was not in the facility plan of care. Per hospital record dated September 11, 2025 the CT-scan on R1, show no acute lumbar abnormality of spine, no evidence of traumatic intrathoracic injury of chest, no evidence of traumatic intra-abdominal/pelvic injury, no evidence of acute cervical abnormality of cervical spine, no acute intracranial abnormality of the head, and no acute fracture or dislocation along the right elbow. There is soft tissue swelling posterior to the elbow. Four out of four staff interviewed reported that R1 had a fall mat next to R1’s bed to help reduce the risk of injury. LPA observed during the review of facility records that the fall mat is not documented in the facility fall prevention plan. Four out of four staff interviewed had stated that R1 was a fall risk and R1 does not ask for help when ambulating or transferring. R1 had a one-on-one caregiver hired by R1 family and a bed alarm was implemented. The facility did not implement any other procedures to mitigate R1’s fall risk. It was alleged that resident (R1) sustained multiple injuries due to staff neglect. Based on interviews conducted, R1 had three unwitnessed incidents of falls, on September 7, 2025, September 11, 2025, and September 23, 2025. LPA attempted to interview R1 and was unsuccessful. Four out of four staff interviewed reported that R1 had a fall mat next to R1’s bed to help reduce the risk of injury. Record review revealed that R1’s medical assessment dated September 4, 2025, shows R1 is diagnosed with Alzheimer’s Disease and engages in unsafe wandering, exhibits lack of hazard awareness, and requires monitoring for safety. R1 requires assistance with bathing, grooming, and toileting needs. On September 11, 2025, R1 had a fall, resulting in a swollen elbow. On September 17, 2025, a large bruise was noticed on R1’s back. Four out of four staff interviewed were unable to pinpoint the cause. On October 1, 2025, R1’s left leg became stuck between the bed rails. Based on photo evidence, R1 sustained a bruise on her left knee as a result. Staff 1 (S1) admitted that staff do not go to check on residents every few hours. Continued on LIC9099-C. It was alleged that Staff are not awake for night shift. Records review revealed that R1’s physician’s report dated September 4, 2025, R1 is diagnosed with Alzheimer’s Disease and engages in unsafe wandering, lacks hazard awareness, and is at risk for elopement. These issues are not addressed in R1’s care plan. Per plan of operation, the facility maintains “trained staff 7 days a week and 24 hours a day.” Due to R1’s inability to alert staff at night, and staff not being awake to monitor R1, staff are unable to care for R1 during the night shift. Interview with four out of four staff confirmed caregivers are asleep during the nighttime. Two out of four staff reported R1 is unable to use the call button. It is alleged that Staff did not call emergency services for resident. On October 1, 2025, resident's leg got stuck between the bed rails. Responsible Party instructed staff to call 911. Responsible Party’s brother arrived at the facility and was able to dislodge R1’s leg. Hospice nurse arrived later to assess the resident and provided an assessment of R1’s leg and body. R1 sustained a bruise and wound care was provided by hospice nurse. Three out of four staff admitted that 911 was not called because Responsible Party was able to dislodge R1’s leg safely. There was no documentation of emergency services being called. Based on evidence gathered through interviews and documentation review, the preponderance of evidence has been met, therefore, the above allegations are found to be Substantiated. Violations are being cited per Title 22 of California Code of Regulations. See LIC 9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator, Scott Messick and a copy of this LIC9099, LIC9099-D, along with a copy of the Appeal Rights were left at the facility. Two out of four staff interviewed reported that they are aware that an exception must be made if a camera were to be placed in R1’s bedroom. Four out of four staff stated a camera was never implemented in R1’s shared bedroom. Resident interviews confirmed that no one has a camera in their rooms. Based on the evidence gathered, the allegation is deemed Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has therefore dismissed the complaint. An exit interview was conducted with the Administrators and a copy of this LIC9099 report was left at the facility. R1 requires assistance with bathing, grooming, and toileting needs. Interviews with two out of four staff reported they assist residents when they hear the call alarm. R1’s family retained a private caregiver between the dates of 9/11/25-9/16/25, 9/17/25-9/20/25, 9/23/25-9/27/25, 10/1/25-10/10/25. R1 only had 1 fall on September 23, 2025, during that time. Interviews with two out of four staff stated they made it clear to family that the facility has live-in caregivers who sleep at night. LPA attempted to interview R1 but was unsuccessful. Interviews with five out of five residents stated they’ve never needed assistance at night and are unable to confirm whether staff come to assist when they need help. Based on the evidence gathered during this investigation, 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 conducted with Administrators, and a copy of the report was reviewed and provided. Appeal rights provided.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 22-AS-20251203153959

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f) · Plan of correction due date: Mar 20, 2026

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and [...] 1569.2(c). This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R1 received care and supervision, as a result R1 suffered multiple injuries because of falls, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Licensee agrees to train all staff on CCR 87464 and will submit a written plan within 24hrs to schedule staff training and will follow up to provide the proof of training to LPA by March 31, 2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 20, 2026

(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified [...]. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not call 911 when R1’s leg was lodged between the bedrails on October 1, 2025, resulting in bruising, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Licensee agrees to submit a written plan within 24hrs to schedule all staff training and will follow up to provide the proof of training to LPA by March 31, 2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(2) · Plan of correction due date: Mar 20, 2026

For facilities with fewer than 16 residents, ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal, or observation, to require awake night supervision. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not have an awake night staff person on duty even though R1 was observed to engage in wandering and lacks hazard awareness.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Licensee agrees to adhere to CCR 87705 and to sign a statement of understanding and submit proof to LPA within 24hrs by March 20, 2026. Licensee will submit a written plan to LPA regarding awake staff supervision for residents who are wanderers or in need of supervision at night. This is due by March 31, 2026.

Type of visit: Required - 1 Year

On September 2, 2025, Licensing Program Analysts (LPAs) Brandon Lopez and Garlli Tat made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (ADs) Scott Messick was notified via telephone and later arrived to assist with the inspection. LPAs observed that Scott Messick has a valid Administrator certificate which expires on December 1, 2025. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, of which one may be bedridden, and has a hospice waiver for six. The facility is a single-story home with five resident bedrooms, one of which is shared, one staff bedroom, two resident bathrooms, a living room, a dining room, a kitchen, a laundry room, a staff office, and an attached two car garage. LPAs accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPAs observed three residents in care and two care giving staff present. LPAs observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPAs inspected the five resident bedrooms, and they were observed to be free of any hazards. LPAs observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPAs observed additional linens are stored in the hallway cabinets. LPAs inspected the two resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 107.9 and 108.1 degrees Fahrenheit. LPAs observed the staff bedroom can be kept locked. LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. CONTINUED ON LIC809-C LPAs observed kitchen appliances to be clean and operational. LPAs observed kitchen knives are stored in a locked kitchen cabinet. LPAs observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. Fire extinguishers are located in the kitchen and in the garage. Fire extinguishers were observed the be charged and serviced as of April 4, 2025. LPAs tested the wired smoke detectors and carbon monoxide detectors which tested operational. LPAs observed the facility conducted their last emergency disaster drill on July 3, 2025. The centrally stored medication is kept in a locked closet by the resident hallway. LPAs also observed a First Aid Kit to be stored in the closet. The door leading to the laundry room was kept locked and inaccessible to residents in care. LPAs observed the door leading to the attached two car garage is kept locked and inaccessible to residents in care. The garage is used for storage. LPAs observed chemicals and toxins to be stored in the garage. LPAs observed the facility has an three day emergency food and water supply stored in the garage. LPAs and AD conducted a tour of the exterior portion of the facility. LPAs observed the exterior portion to be clear of obstructions and hazards. LPAs observed a shaded outdoor seating area with furniture for resident use. The perimeter gate is self-latching and can be opened in an evacuation. There are no bodies of water on the premises. LPAs reviewed all three resident files. All the required documentation were present and current in the resident files reviewed. LPAs reviewed residents’ medication and medication records. LPAs reviewed three staff files. All staff are background cleared and associated to the facility. Based on today's observations, there are no deficiencies being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Scott Messick and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 2, 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: Resident sustained multiple falls while in care resulting in fractures due to staff neglect.

On 05/19/25, Donna Gurriere, Licensing Program Analyst (LPA) contacted the licensee/ administrator via phone to deliver final findings regarding a complaint that was received 12/06/2024. LPA Gurriere spoke with Ryan Roche, Administrator and explained the purpose of the call. Resident sustained multiple falls while in care resulting in fractures due to staff neglect. During the interview process, the administrator, four staff persons and the resident (Resident 1) were interviewed. In addition, documents were reviewed and obtained to include the Physicians Report, Appraisal and Needs, Incident Report, Hospital Discharge paperwork, Personnel Report, Resident Roster, and Admission Agreement. continued Unsubstantiated During the investigation of a complaint received on 12/06/24 it was reported that on 12/05/24 the resident complained of pain in her lower right back by grabbing the area with her hand, moaning and facial grimacing. Two staff persons checked the area and believed that the area was swollen. The resident was transferred to the hospital where she was diagnosed with lower right side (back) rib fractures. The staff reported that the resident had not been seen by suffering a fall or any other type of accident. Medical records indicated that the resident had suffered numerous fractures throughout her body that were healed, healing or acute. There was adequate staff supervision (two staff) during the time that the resident complained of her pain and staff responded quickly and appropriately reporting the resident’s pain/change in condition and getting her medical aid. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated. Licensee or administrator was advised a copy of this report will be sent via certified mail. Two copies of the report will be sent. Licensee or administrator is to sign and return a copy to the Orange County Regional Office.the state’s words, verbatim · CDSS document, May 19, 2025 · control 22-AS-20241206161458

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents of which one may be bedridden. Facility has an approved hospice waiver for 6 residents and the home currently has 5 residents, with 1 resident on hospice. Administrators (ADs) Ryan Roche Scott Messick arrived shortly to conduct facility tour. Each AD has a valid certificate that expires on 12/1/2025. AD provided updated liability insurance that expires on 9/15/2025. LPA along with ADs toured the facility at 12:50 PM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 6 resident bedrooms, staff room, living room, dining room, and kitchen as well as 2 bathrooms. 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 shower was free of mold/mildew. Water temperature measured between 114.6 degrees F and 116.7 degrees F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguisher was fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill was conducted on 12/30/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of games, exercise, and music therapy. There is shaded outdoor seating for residents. Exit gate is unlocked and operational. LPA observed the emergency food and water supply. LPA reviewed five resident files and two staff files. CONTINUED ON LIC 809C DATED 3/4/2025 All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in a locked closet. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Mar 4, 2025