Villa Elisa-Folsom

Allegation investigated: -Facility failed to seek timely medical attention

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the house manager, Sandra Mohrmann, to deliver complaint investigation findings regarding the above stated allegation. The licensee, Maggie Posadas-Worsfold, joined via phone call. During the course of the investigation, the department conducted interviews and obtained documentation pertinent to the investigation. **********************************************Continued LIC9099-C******************************************************** Substantiated Resident (R1’s) Medication Administration Record (MAR) indicated that, on April 2, 2026, at around 11am, they had a blood glucose reading of 482mg/dl (milligrams per deciliter). According to interview with R1’s physician, if R1 had blood glucose higher than 400mg/dl, then R1 must be taken to the hospital. Interview with staff (S1) indicated that, if R1’s blood glucose reading was above 400mg/dl, they would give R1 additional insulin and then retest R1’s blood glucose level approximately 30-60 minutes later. According to R1’s MAR and interview with S1, S1 did not retest R1’s blood glucose level after 11am on April 2, 2026. Also, R1 did not receive their scheduled insulin injection at 4pm on April 2, 2026, due to R1 sleeping. On April 3, 2026, at around 8am, R1’s blood glucose reading was 497mg/dl, and at around 11am they missed their scheduled insulin injection as they were sleeping. S1 indicated that they did not retest R1’s blood glucose level after their 8am injection on April 3, 2026. On April 9, 2026, at around 8am, R1’s blood glucose reading was 400mg/dl. S1 indicated that, around lunchtime, R1’s blood glucose was over 500mg/dl. According to medical records, S1 called 911 on April 9, 2026, at around 2:14pm, and R1 was transported to the hospital around 3:32pm. R1 had a blood glucose level of 552mg/dl. Interview with R1’s responsible party indicated that, when R1’s blood glucose is higher than 400mg/dl for several days, R1 could have an infection as R1 frequently had urinary tract infections (UTIs). Hospital records indicated that R1 was diagnosed with hyperglycemia, severe sepsis, UTI, acute pyelonephritis, hypothyroidism, benign prostatic hyperplasia, coronary artery disease, and was seen having seizure-like activity. The physician notated that, “overall, the presentation is most consistent with sepsis secondary to a urinary source (UTI/pyelonephritis), complicated by acute kidney injury and significant hyperglycemia.” Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview conducted. A copy of the report and appeal rights provided. According to resident (R1’s) Medical Assessment LIC602A, dated October 16, 2025, R1 was diagnosed with type one diabetes and limbic encephalitis autoimmune etiology. Interview with R1’s physician indicated that, if R1 has a blood glucose level higher than 400mg/dl, then they must be taken to the hospital. R1’s April 2026 Medication Administration Record (MAR) indicated that they had blood glucose readings above 400mg/dl on April 2, 2026, April 3, 2026, and April 9, 2026. R1 was sent to the hospital on April 9, 2026, due to having a blood glucose reading over 500mg/dl. According to medical records, R1 was diagnosed with hyperglycemia, severe sepsis, UTI, acute pyelonephritis, hypothyroidism, benign prostatic hyperplasia, coronary artery disease, and was seen having seizure-like activity. The physician notated that, “overall, the presentation is most consistent with sepsis secondary to a urinary source (UTI/pyelonephritis), complicated by acute kidney injury and significant hyperglycemia.” On May 13, 2026, R1’s physician indicated in the discharge summary that, “I do certify that post-acute [skilled nursing facility] (SNF) services are required to be given on an inpatient basis because of this patient’s need for a skilled nursing care on a continuing basis for the condition(s) for which the patient was receiving inpatient acute services prior to [their] transfer for the SNF.” On May 13, 2026, at around 4:45pm, R1 was discharged from the hospital to a SNF and placed on hospice services. According to R1’s death certificate, R1 passed away on May 20, 2026 with the leading cause of death listed as “Other Encephalitis and Encephalomyelitis”, and the time between onset and death was “Years”. Based on interviews conducted and documentation obtained, although the 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, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 16, 2026 · control 59-AS-20260702134242

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Sep 17, 2026

87466 Observation of the Resident-The licensee shall ensure that residents are regularly observed for changes in physical…functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure that residents (R1) received timely medical care for their change in condition, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: Licensee agrees to conduct an in-service training with all staff regarding timely medical for changes in residents’ conditions and provide documentation of training to LPA by the POC due date of 9/17/26. Licensee requested an extension on POC due date and will submit proof of training by 9/25/26.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Administrator, Maggie Posadas Worsfold, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and three (3) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 120 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed four (4) resident files and also reviewed three (3) staff files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Apr 9, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Administrator Maggie Worsfold to conduct an annual inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed six (6) resident rooms, three (3) resident bathrooms, common areas, and perimeter of the care home. LPA observed perimeter of the care home to be free of debris and clutter. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 120 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care home. Fire extinguisher and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files, two (2) staff files and resident medications. Facility has a current copy of certificate of liability insurance and LPA obtained a copy. As a result of this visit, no deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted with Administrator.the state’s words, verbatim · CDSS document, Mar 4, 2025

Type of visit: Case Management - Licensee Initiated

On April 17, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to see if the accusation was posted in the facility in a prominent area. LPA met with caregiver, Agi Saut and explained the reason for the visit. The licensee had the accusation posted where the rest of the facilities posters are, In the kitchen. Caregiver, called the licensee. however he did not answer. Per California Code of Regulation Title 22, no citations were issued. An exit interview was conducted and a copy was sent to facilities email address.the state’s words, verbatim · CDSS document, Apr 17, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Administrator Maggie Posadas Worsfold during today's inspection. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 5 resident rooms, 2 bathrooms, kitchen, common living spaces, and backyard. There is a pool present with a locked gate surrounding the pool area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. LPA reviewed 2 of 5 resident files and 2 staff files. LPA reviewed medications of two residents comparing with Centrally Stored Medication Record and physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. LPA observed a copy of current liability insurance. Deficiencies cited on 809-D. Exit interview conducted and copy of appeal rights provided.the state’s words, verbatim · CDSS document, Feb 22, 2024