Villa Descanso Senior Living

Allegation investigated: Medication is not being dispensed properly. Staff are not reporting incidents. Facility is not in good repair.

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegations listed above. LPA met with staff member Valerie Rutherford and explained the purpose of the visit. The licensee, Gabriela Torres, was contacted. LPA Rico was unable to leave a voicemail as the inbox was full.The investigation consisted of staff interviews, resident interviews, and a review of facility records. For the allegation, Medication is not being dispensed properly: During staff interviews, S1 admitted that there was a medication error on their Medication Administration Record (MAR). During a medication audit, LPA Rico observed that staff were not following R2’s medication orders. R2’s medication order states the medication should be administered five days out of seven; however, staff were documenting that the medication was given every day. In addition, LPA Rico observed that medications had been transferred into another container. Medications must remain in their original packaging. Substantiated For the allegation, Staff are not reporting incidents: During staff interviews, S1 informed LPA that they have been submitting incident reports to Community Care Licensing. However, based on record review, LPA Rico observed that the facility has not been submitting incident reports to Community Care Licensing. The last incident report submitted to the Department was in 2020. For the allegation, Facility is not in good repair: During staff interviews, 2 out of 3 staff stated that the facility is not in good repair. During resident interviews, 2 out of 3 residents also stated that the facility is not in good repair. During the facility tour, LPA Rico observed that the kitchen stove had missing knobs and the dishwasher did not turn on or off. In addition, LPA Rico observed S2 using a lighter to turn on the stove. Based on the evidence gathered during today’s investigation, the three (3) allegations listed above are deemed SUBSTANTIATED. A finding of SUBSTANTIATED means the allegations are valid because the preponderance of evidence standard has been met. During today’s visit, three (3) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D were discussed with and provided to staff Valerie Rutherford, along with a copy of the appeal rights. For the allegation Due to staff neglect, a resident was left on the floor for hours: During staff interviews, 3 out of 3 staff stated no residents have been left on the floor for hours. During resident interviews, 3 out of 3 residents stated they have not been left on the floor for hours. For the allegation Staff are violating residents’ personal rights: During staff interviews, 3 out of 3 staff stated they have not violated residents’ personal rights. During resident interviews, 3 out of 3 residents stated staff have not violated their personal rights. For the allegation Staff are injecting needles: During staff interviews, 3 out of 3 staff stated they are not injecting needles. Staff also indicated that Resident #1 (R1) administers their own insulin. During resident interviews, R1 confirmed they handle their own insulin. A review of R1’s Physician’s Report indicated that R1 is able to self-administer insulin. Based on the evidence gathered during the investigation, the five (5) allegations listed above are deemed UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed with and provided to Administrator Crystal Cortez.the state’s words, verbatim · CDSS document, Jun 18, 2026 · control 56-AS-20260218153924

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(1) · Plan of correction due date: Jun 19, 2026

87465(h)(5)Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by;Based on interviews and records review (R2) medication was transfer to a different container. This posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: The licensee stated they will have an all staff medication training. A copy will provided to LPA Rico. POC due date 6/19/2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 19, 2026

87211(a)(1) Reporting Requirements.. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by;Based on interviews and records review that licensee has not reported incidents to Community Care Licensing. This posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: The licensee stated they will complete a reporting requirement training. A copy will be provided to LPA Rico.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 19, 2026

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by;Based on interviews and facility tour, S2 turning on the stove with a lighter, stove missing knobs and dishewasher out of service. This posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: The licensee stated they will complete the repairs, and send proof to LPA Rico. POC dute date 6/19/2026

Type of visit: Case Management - Deficiencies

On 6/18/2026 Licensing Program Analyst (LPA) Mary Rico conducted an unannounced case management visit to amend the report that was provided on 2/19/2026. LPA Rico met with staff member Valerie Rutherford. The licensee, Gabriela Torres, was contacted. LPA Rico was unable to leave a voicemail as the inbox was full. Based upon an Audit conducted by the Department which included interviews and review of records, it was found that Resident #1 (R1) was financially abused. Audit revealed that from around 8/15/2019 to at least 5/10/2023, licensee representative (S2) had access and control of R1’s monies. R1 did not provide approval for Staff #1 (S1) and S2 access or control. During the time period, charges/purchases for various goods and services at retail and vendors such as Door dash in San Francisco, Uber pass in San Fransico, Ralphs, Target, Postmates, Instacart, Amazon, Coach, Ulta, and Walmart were made using R1 bank cards. R1 bank cards were in possession of (S2) and R1 did not have access to cards or finances, despite indication from physician report that R1 was able to do so. R1 further indicated that R1 was not aware of the various charges made and did not make these purchases. It is also noted that R1, S1, and S2 1 acknowledged that R1 did not take trip to San Francisco. The Department Audit revealed multiple transactions for the goods and services between August 15, 2019, to May 10, 2024, totaling $10,801.75. S1 and S2 were unable to provide any documentation or receipts showing that R1’s money had been used in accordance with Title 22 regulations nor with R1 approval. In addition, S2 did not maintain and supervise R1 financial records. Based on information gathered, the following are being cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) (LIC809D) was discussed and provided to staff Valerie Rutherford. Along with a copy of Appeal Rights.the state’s words, verbatim · CDSS document, Jun 18, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jun 19, 2026

87468.1 (a) (3) Personal Rights of Residents in all Facilities..Residents in all residential care facilities for the elderly shall have all of the.. rights: .To be free from punishment,. such as withholding residents’ money..This requirement was not met as evidenced by; Based on interviews and records review (S2) had access and control of R1 finances and subsequently spent R1 monies in the amount of $10,802.75. R1 did not acknowledge approval of access or expenditures. This posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: The Licensee is to refund R1 $10,802.75. POC due date 6/19/2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR87217(b)(g) · Plan of correction due date: Jun 19, 2026

87217(b)(g) Safeguards for Resident Cash, Personal Property, & Valuables..Every facility.. measures to safeguard residents' cash resources, personal property and valuables.. the residents receipts for all such articles or cash . entrusted to his care This requirement was not met as evidenced by; Based on interviews and records review, (S2) did not provide documents and receipts which ensure compliance with safeguarding R1 monies and expenditures. This posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: The Licensee stated they will complete a training for Safeguards for Resident Cash Personal Property& Valuables. A copy will be provided to LPA Rico. POC due date 6/19/2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d) · Plan of correction due date: Jun 19, 2026

87405(d) Administrator, Qualifications and Duties (d) .. is also the administrator, all requirements for an administrator shall apply. (1) Knowledge..2) Knowledge of and ability to conform to the applicable laws, rules..regulations..Thisrequirement was not met as evidenced by; Based on interviews and records review, (S2) S2 did not maintain and supervise R1 financial records. This posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: The Licensee stated they will complete a training regarding Administrator Qualifications. A copy will provided to LPA Rico. POC due date 6/19/2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR87205(a) · Plan of correction due date: Jun 19, 2026

87205 Accountability of Licensee Governing Body (a) The licensee..shall exercise general supervision over the affairs of the licensed facility..operation in conformance with these regulations and the welfare...This requirement was not met as evidenced by; Based on interviews and records review, Licensee representative (S2) did not exercise general supervision over the facility operations resulting in the financial abuse of R1. This posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: The Licensee stated they will complete a training regarding Accountability of Licensee Governing Body. A copy will be provided to LPA Rico. POC due date 6/19/2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with caregiver Bernice Calles and was granted entry to the facility. The facility is a (5) bedroom, (3 and 1 / 2), bathroom home, with a kitchen/dining area, (2) living rooms, and attached garage. Licensed capacity is (6) current census (6). LPA was accompanied by Administrator Gabriela Torres, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. During facility tour, LPA Rico observed R1 had a baby monitor from the brand “ Hello Baby”. The Administrator stated the facility does not have written consent from R1's responsible party. In addition, R1 shares a bedroom with R2. The baby monitor was removed during inspection visit. Furthermore, The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. LPA observed four expired food cans since August 2025. Cans were removed from the kitchen pantry. In addition, LPA Rico observed the kitchen pantry shelves and the dining room chairs/ bench located in the main kitchen area to be dirty with stains. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (6) resident file for admission agreements, updated physician reports, and needs and services plans. LPA also verified (6) resident's medications. LPA also reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screening. Based on the observations made during today’s visit, (3) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Gabriela Torres. Along with a copy of Appeal Rights.the state’s words, verbatim · CDSS document, Mar 25, 2026

Type of visit: Case Management - Deficiencies

On 2/19/2026 Licensing Program Analyst (LPA) Mary Rico conducted an unannounced case management visit. LPA Rico met with Administrator Gabriela Torres and introduced herself and explained the purpose of the visit. On February 7, 2022, the Department received a complaint alleging staff attempted to gain access to resident’s financial account. The investigation determined that staff did attempt to gain access to resident’s financial account and the substantiated finding was delivered on October 27, 2023. Pertaining control number 18-AS-20220207165851. Based on the substantiated findings Community Care Licensing conducted a Trust Audit that revealed the licensee had possession of resident’s back cards. S1 reported that R1 was not able to handle her own finances. However, R1’s physician report indicated that R1 was able to handle her own cash resources. In addition, R1 reported that they had no access to their own money and R1 did not approve for the owners to use R1’s money. The Trust audit showed multiple transactions between the date of August 15, 2019 to May 10, 2024 totaling $10,801.75. The licensee was unable to provide any documentation or receipts showing that R1’s money had been used appropriately. Therefore, the licensee should refund R1 $10,802.75. In addition, the Administrator failed to maintain and supervise R1 financial records. Based on the information gathered, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) (LIC809D) was discussed and provided to Administrator Gabriela Torres. Along with a copy of Appeal Rights.the state’s words, verbatim · CDSS document, Feb 19, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(3) · Plan of correction due date: Feb 20, 2026

87405(d)(3) Administrator - Qualifications and Duties (3) Ability to maintain or supervise the maintenance of financial and other records. Based on record review, the licensee did not comply with the section cited above by Administrator failing to maintain and supervise R1 financial records which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: The Administrator stated they conduct an in-service training. Proof of training will provided to LPA Rico. POC due date 2/20/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(3) · Plan of correction due date: Feb 20, 2026

87468.1(a)(3) Personal Rights of Residents in All Facilities (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination Based on record review, the licensee did not comply with the section cited above by staff withholding R1 money which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: The Administrator stated they will have an in-service training. Proof of training will be provided to LPA Rico. POC due date 2/20/2026.

Type of visit: POC

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to the facility to verify clearance of Plan of Correction from visit on 4/1/2025. LPA Rico met with caregiver Anthony Durham and was granted entry to the facility. The Administrator Gabriela Torres was contacted and explained the reason of today's visit. The Licensee was cited on 4/1/2025 for 87307(a) Personal Accommodation Services. During today's visit, based on observation and interview, LPA Rico observed that the Licensee did not remove the three bedframes from the common area, located on the second floor. The Plan of Correction was to send LPA Rico proof of removal. Therefore, the Plan of Correction was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for eight (8) days. An exit interview was conducted and this report, LIC809 along with Civil Penalty Assessment pages, and Appeal Rights were reviewed and provided to caregiver Anthony Durham.the state’s words, verbatim · CDSS document, Apr 10, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with staff Valerie Rutherford and was granted entry to the facility. Licensed capacity is (6) current census (6). LPA was accompanied by Administrator Gabriela Torres to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated space for resident/staff files. During facility tour, LPA Rico observed the facility had three bed mattress setup in the common area on the second floor. A pervious report with same citation was made on 3/11/2024. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (3) resident medications. LPA also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. Based on the observations made during today’s visit, (1)deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809)(LIC809D) was discussed and provided to caregiver Valerie Rutherford. Along with a copy of appeal rights.the state’s words, verbatim · CDSS document, Apr 1, 2025

Allegation investigated: Staff mistreated a resident while in care.

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with staff member Joaquin Thompson and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, and record review. For the allegation, Staff mistreated a resident while in care. During staff interviews, 4 out of the 5 staff stated they have witness S1 yell at their residents. In addition, S1 admitted they have yelled at R1. During residents interviews, 3 out of the 4 residents stated they have been yelled by S1. Based on the evidence gathered during today’s investigation, the one (1) allegation listed above are deemed SUBSTANTIATED. Substantiated A finding that the complaint are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to staff member Joaquin Thompson. A finding that the complaint are SUBSTANTIATED means that the allegation are valid because the preponderance of evidence the standard has been met. During today’s visit, one (1) deficiency were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to staff member Joaquin Thompson. along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Feb 11, 2025 · control 56-AS-20250110085626

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Feb 12, 2025

87468.1(a)(3) Personal Rights of Residents in All Facilities (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as.. interfering with daily living functions such as eating, sleeping, or elimination. Based on interviews, the Licensee did not comply with the section cited above by not ensuring residents are free from punishment, and intimidation which poses an immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: Administrator stated they will train their staff on the regulation cited and will send confirmation to LPA Rico. POC due date 2/12/2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: POC

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to the facility to verify clearance of Plan of Correction from visit on 1/17/2025. LPA Rico met with caregiver Valerie Rutherford and was granted entry to the facility. During today's visit, LPA Rico cleared Plan of Correction and conducted resident interviews for complaint control number 56-AS-20250110085626. An exit interview was conducted, and this report was discussed and provided to caregiver Valerie Rutherford.the state’s words, verbatim · CDSS document, Jan 22, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Rico met with caregivers Sandra Sanchez and Valerie Rutherford to initiate an unannounced case management visit and was granted entry to the facility. During record review, LPA Rico review staff criminal record clearance. LPA Rico observed S1 did not have a criminal record clearance. In addition, S1 stated they have been working at the facility since 1/10/2025 and do not have their criminal clearance. During today’s visit the facility a deficiency will be issued, and Civil Penalties were assessed with the amount of $500.00 for S1. An exit interview was conducted where this report (LIC809), (LIC809D), (LIC421BG) and Appeal Rights were discussed and provided to caregiver Valerie Rutherford.the state’s words, verbatim · CDSS document, Jan 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jan 20, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not obtaining Staff #1 (S1) criminal record clearance before allowing S1 to work at the facility since 1/10/2025 which pose immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 17, 2025

Plan of correction: Licensee stated to not allow S1 to work at the facility without obtaining the required Criminal background clearance and submit copy of Staff Schedule and Personnel Summary Report (LIC500) to LPA Rico at Plan of Correction due date. POC due date 1/20/2025

Type of visit: Required - 1 Year

On 03/11/2024 at 08:35 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Staff #3 (S3) and was granted entry to the facility. At the time of the visit there were two (2) staff present, and six (6) residents present. Administrator Gabriel Torres -Thompson was contacted and informed of the visit. Facility Director Joaquin Thompson arrived during the visit. LPA Brown explained the purpose of the visit to Facility Director Joaquin Thompson. The facility is a five (5) bedroom, four (4) bathroom home with a kitchen/dining area, living room, laundry room and detached garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which four (4) can be ambulatory and two (2) non-ambulatory residents and one (1) may be bedridden resident. The facility has one (1) Hospice Waiver. The current census is six (6) residents. LPA Brown was accompanied by Staff #3 (S3) to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor passageways but observed obstruction to outdoor passageways/area. LPA Brown observed glass window in the the backyard and a fire pit not used, metal chairs and metal table in disrepair. Deficiency will be issued. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. However, LPA Brown observed insufficient lightning in Room #1 and S3 reported to LPA Brown that the light in Room #1’s not working and need to be replaced. Deficiency will be issued. Also, LPA Brown observed 2nd floor loft being utilized as bedrooms, three (3) beds observed and one (1) large sectional also being utilized as a bed. Deficiency will be issued. . ***Continuation in LIC809C *** Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. Also, LPA Brown observed Resident #3 (R3) and Resident #5 (R5) with half bed rails Facility Director Thompson reported to LPA Brown that R3 and R5 does not have written order from the physician indicating the need for half bed rail for mobility. Deficiencies will be issued. LPA Brown measured and observed the water temperatures in the bathroom to be at 106 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide alarms and charged two (2) Fire Extinguisher. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster and the disaster plan were posted in a common area. In addition, during the tour of the facility, LPA Brown observed two (2) big gallons of paint in the backyard of the facility, not locked and accessible to residents in care. Deficiency will be issued. There was a designated storage space for resident/staff files. Also, there is a designated area for the resident’s medications that's locked. Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility. Care & Supervision: The facility has an administrator and a facility director present in the facility. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care except for night (NOC) shift. Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and care plans. LPA Brown observed no Pre-placement appraisal completed by the Licensee as required for Resident #2 (R2), Resident #3 (R3) and Resident #6 (R6) in their facility file. Deficiency will be issued. Also, LPA Brown observed Resident #3 (R3) not having an updated Physician Report, physician signature date is 07/26/2022 and per records review, R3 has dementia. Deficiency will be issued. LPA Brown reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis test result. LPA Brown observed that the files were complete. However, during the visit on 03/11/2024, LPA Brown interviewed Staff #3 (S3) and S3 reported to LPA Brown that S3's administering R3 glucose testing for R3. Deficiency will be issued. ***Continuation in LIC809C *** LPA Brown explained that S3 should assist R3 on glucose testing using "hand over hand" but not to do it for R3. S3 verbalized understanding. In addition, LPA Brown observed no staff scheduled to work on a night shift (NOC) shift. Staff #3 (S3) reported to LPA Brown that S3 sleeps when the resident sleeps at night and confirmed no staff are scheduled to work at night, awake and working at night. Deficiency will be issued. An exit interview was conducted where this report (LIC809), LIC809D, LIC9102 TA and Appeal Rights were discussed and provided to staff Sandra Hernandez.the state’s words, verbatim · CDSS document, Mar 11, 2024

The state marks this report as 13 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.