Just Like Your Are Home 2

Allegation investigated: Resident sustained severe pressure injuries due to staff neglect

On September 5, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings into the allegation listed above. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Alicia Lira was present and assisted with today's visit. During the course of the investigation, the Department conducted interviews with staff, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, resident sustained severe pressure injuries due to staff neglect, the following has been concluded: It was alleged that Resident #1 (R1) sustained severe pressure injuries due to staff neglect. During the investigation, the Department conducted a file review for R1 and observed that R1 was admitted to the facility on May 17, 2025. R1 was not admitted to the facility under Hospice or Home Health services. R1 passed away on March 19, 2026, while at the hospital. CONTINUED ON LIC9099-C Substantiated Per R1’s certificate of death, the listed causes of death are asystole, severe decubitus sacral ulcers, severe protein calorie malnutrition, and stroke with residential left sided weakness. Per R1’s Physician’s Report dated May 9, 2025, R1’s diagnosis included Cerebrovascular accident with left sided hemiparalysis, Hypertension, Atrial fibrillation, Dyslipidemia, and Mitral valve insufficiency. It also states that R1 required continuous bed care, had a history of skin breakdown, and was bedridden. There was also no indication that R1 had any open wounds at this time. Per R1’s Preplacement Appraisal Information, Reappraisal, and Appraisal/Needs and Services Plan dated May 17, 2025, it described R1 as needing full assistance with activities of daily living (ADLs), such as transferring, bathing, toileting, and with medication. The records also do not indicate that R1 had any open wounds upon their admission to the facility. A review of the wound care progress notes for R1 revealed the following information: On January 28, 2026, R1 was observed to have a stage four pressure ulcer on their left buttocks and a stage four pressure ulcer on their sacrum. It also states that care giving staff were advised to reposition R1 every two hours. On February 4, 2026, R1 was observed to have a third wound to their left hip which was also diagnosed as a stage four pressure ulcer. It also indicates that the wounds to R1’s left buttocks and sacrum did not improve and remained at stage four pressure ulcers. On February 12, 2026, R1’s wound to their left hip did not improve and remained at a stage four pressure ulcer. R1’s wound to their left buttocks was diagnosed as a stage three pressure ulcer. R1’s wound to their sacrum was not evaluated during this visit. Despite R1 having a change of condition due to the pressure ulcers, there is no documented evidence that the facility updated the care plan for R1 to address this area. There is no documented evidence that described how the facility would be assisting R1 with their pressure ulcers. Additionally, there is also no documented evidence that the facility staff repositioned R1 every two hours as instructed by the wound care specialist. A review of internal communications from the facility revealed the following information: Staff #3 (S3) reported observing two areas of redness on R1’s tailbone area on December 2, 2025. S3 reported their observations to the facility Administrator, Staff #1 (S1), but did not specify to S1 the name of the resident that they were referring to. S3 provided wound care treatment to R1 between the dates of December 2, to December 24, 2025, including putting patches and ointment on the red areas of R1. It should be noted that S3 does not have any formal education or training on wound care. S3 is also not a licensed medical professional that is able to provide wound care treatment. S3 also acknowledged that the redness to R1’s tailbone area did not improve during these dates and that the wounds only worsened in condition. S1 reported that they only became aware of wounds that R1 had on January 21, 2026. CONTINUED ON LIC9099-C Staff interviews conducted confirmed that there was a delay in seeking medical attention for R1 due to internal confusion of the identify of which facility resident had wounds. S1 was under the impression that R1’s wounds belonged to a different resident. Therefore, the facility did not seek any medical attention or wound care treatment for R1 until January 21, 2026, despite the facility staff first observing redness to R1’s tailbone area on December 2, 2025. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, resident sustained severe pressure injuries due to staff neglect. The preponderance of evidence standards has been met; therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D page. An immediate civil penalty is also being issued in the amount of $500.00 on the attached LIC421IM page. A civil penalty is pending determination by Community Care Licensing Division per Health & Safety Code 1569.49. An exit interview was conducted with Administrator Alicia Lira. A copy of the report and appeal rights were provided at time of visit.the state’s words, verbatim · CDSS document, Sep 5, 2026 · control 22-AS-20260319142233

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 6, 2026

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not evidenced by: Based on records reviewed & interviews conducted, the Licensee did not ensure that R1 was adequately supervised & received medical attention in a timely manner for their pressure ulcers that developed & progressed in their care. This posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2026

Plan of correction: The Administrator stated that they will conduct in-service training with all facility staff regarding providing adequate supervision and seeking medical attention for residents when necessary. The Administrator agreed to provide LPA proof of training and a detail written plan to ensure this incident does not reoccur, via email or fax by POC due date.

Type of visit: Case Management - Deficiencies

On September 5, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Deficiencies visit. Administrator (AD) Alicia Lira was present and assisted on today's visit. This visit is being conducted in conjunction with complaint control 22-AS-20260319142233. During the investigation, the Department conducted a file review for Resident #1 (R1). The Department observed that R1 was admitted to the facility on May 17, 2025. R1 resided at the facility until February 16, 2026, when they were hospitalized and did not return to the facility afterwards. The Department reviewed R1’s Physician’s Report dated May 9, 2025, which stated that R1 required continuous bed care and was bedridden. The Department reviewed additional records for R1 including Per R1’s Preplacement Appraisal Information, Reappraisal, and Appraisal/Needs and Services Plan dated May 17, 2025. The records support that R1 was bedridden and required full assistance with activities of daily living (ADLs), such as transferring, bathing, toileting, and with medication. The Department reviewed the facility’s fire clearance and observed that they are only approved for six non-ambulatory residents and that they are not approved for any bedridden residents. Therefore, the facility violated their fire clearance by retaining R1, who was bedridden, between the dated of May 17, 2025, and February 16, 2026. During the investigation, the Department observed that the facility first observed a change of condition in R1 on December 2, 2025, due to R1 developing redness in their tailbone area. Despite the change in condition, the facility did not update R1’s Reappraisal to address this new condition. The Department also learned that the facility did not communicate with R1’s responsible party, or their primary care physician, regarding the change of condition until January 21, 2026. CONTINUED ON LIC809-C Based on the information gathered, deficiencies are being cited on the attached LIC809-D pages. An immediate civil penalty in the amount of $500.00 is also being issued on the attached LIC421IM page. An exit interview was conducted with Administrator Alicia Lira. A copy of the report and appeal rights were provided at time of visit.the state’s words, verbatim · CDSS document, Sep 5, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Sep 6, 2026

87202 Fire Clearance: (a) All facilities shall maintain a fire clearance ...Prior to accepting or retaining any of the following types of persons, the applicant.. shall ... obtain an appropriate fire clearance approved by the city, county,.. This requirement is not evidenced by: Based on records reviewed, the Licensee did not adhere to their fire clearance as they retained a resident who was bedridden between May 17, 2025, and February 16, 2026, when they are not approved for a bedridden resident. This posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2026

Plan of correction: The Administrator stated that they will complete a statement of understanding regarding the regulation cited and will apply for an updated fire clearance. The Administrator agreed to provide LPA the statement of understanding and the following documents: Written letter requesting a bedridden resident, a completed LIC200, and a completed LIC999. The Administrator agreed to provide the statement and documents via email or fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Sep 14, 2026

87463 Reappraisal:(a)The pre-admission appraisal... shall be updated in writing as frequently as necessary... to note significant changes in condition ..., the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not evidenced by: Based on records reviewed, the Licensee did not update R1’s Reappraisal after they noted a change in their condition due to pressure ulcers developing on December 2, 2025. This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2026

Plan of correction: The Administrator stated that they will complete a statement of understanding regarding the regulation cited and will provide a written plan as to how they will prevent this incident from reoccurring. The Administrator agreed to provide LPA the statement and plan via email or fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Sep 14, 2026

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes... the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's person responsible, if any. This requirement is not evidenced by: Based on records reviewed & interviews conducted, the Licensee did not notify R1’s responsible party, or physician, after they noticed a change in condition on 12/2/25. This posed a potential health, safety, & personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2026

Plan of correction: The Administrator stated that they will complete a statement of understanding regarding the regulation cited and will provide a written plan as to how they will prevent this incident from reoccurring. The Administrator agreed to provide LPA the statement and plan via email or fax by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to complete the Required One-Year Inspection. Upon arrival, LPA was greeted by and granted entry by Administrator (AD) Alicia Lira. LPA explained the purpose of today’s visit.The facility is a one-story home consisting of five resident bedrooms, three resident bathrooms, a living room, kitchen, sitting area, two caregiver rooms, staff bathroom, office, laundry room, and an attached two-car garage.LPA and AD tested the smoke detectors and carbon monoxide detectors located in the common areas and resident bedrooms; all were operational. Resident bedrooms contained the required furnishings, bed linens, and adequate closet and drawer space to accommodate each resident comfortably.LPA observed a fire extinguisher mounted in the kitchen area with the last inspection date of May 3, 2025. Review of facility records indicated the last emergency drill was conducted on July 3, 2025. Sharps and knives were observed locked in the kitchen and were inaccessible to residents in care.Restrooms, toilets, and water faucets were observed to be operational. Grab bars were securely installed, and showers were free from mold and mildew. Water temperature was measured between 118.6 and 118.9 degrees Fahrenheit. LPA and AD toured the backyard area and observed a shaded seating area available for residents’ use. All emergency exits were unobstructed.LPA observed all required Department postings displayed on the facility wall. The facility maintained at least one week of nonperishable food and two days of perishable food. A review of resident and staff files revealed all required documentation was present and current.Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6 of the California Code of Regulations.An exit interview was conducted, and a copy of this report was provided to the Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 16, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and were greeted and granted entry by designated Administrator (AD) Stevelyn Reroma. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was received by CCL on 3/6/2024. Structure: The facility is a one-story home with five resident bedrooms, three resident bathrooms, living room, kitchen, sitting area, two caregiver rooms, staff bathroom, office, laundry room and an attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room area. There is a back yard with one exit gate on one side of the house. There is a seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard. All resident bedrooms had the required furnishings and ample lighting. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Signal System: Facility has as console that can plug into any socket. The console has 6 buttons numbered 1 through 6. Each resident is assigned a number and has their own button they can press via remote. When a resident presses the button, a doorbell rings and their associated number lights up on the console so that staff can go and check on resident requesting assistance. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residnets and will be stored and locked in the chemical closet in the kitchen. Medication, First Aid Kit and Manual are stored in a locked cabinet in the kitchen. The first aid kit has all the required elements. Resident & Staff Files are kept locked in cabinet in the laundry area. LPA reviewed three out of six resident files and three staff files. Each contained the required elements. Fire extinguishers are charged and last serviced on 4/25/2024 as indicated by their attached service tags. Activity Materials: The facility has books, magazines, crossword puzzles, puzzles, coloring books, board games and televisions. Fire clearance was approved by a fire inspector of Orange County Fire Authority on 05/13/2024. Component III was conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. Staff Bedrooms: Two bedrooms will be occupied by staff. There is only one overnight staff currently. All bathrooms have working plumbing and designated hand washing posters. Hot water measured between 105-120 degrees Fahrenheit in the three resident bathrooms. Resident bathrooms also have shower mats in all showers. A supply of extra linen and hygiene supplies are stored in the hallway closets/cabinets. Emergency Phone Numbers, Exit Plan & Menu are posted and available for review Food Service: There is a 2-day supply of perishables and 7-day of non-perishable food on hand. Smoke detectors and carbon monoxide detectors tested operational. Appliances: Stove/oven, 3 refrigerators/freezers, dishwasher, microwave, washer/dryer are operational. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report and the Component III presentation were provided to designated AD.the state’s words, verbatim · CDSS document, Sep 10, 2024