St. Christopher Manor

Allegation investigated: Staff neglect resulted in a resident to be hospitalized Staff did not meet a resident's incontinence needs Staff did not timely address a resident's change in medical condition Staff did not properly report an incident involving a resident Staff did not seek timely medical attention for a resident

On 09/10/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA Lee met with Licnesee Norma Benitec and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the above allegations. The current census is four. A brief interview was conducted with Licensee Benitec. It was alleged that staff neglect resulted in a resident to be hospitalized. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. Throughout the course of the investigation, it was learned that on 02/18/2026, at approximately 10:00 a.m., R1 sustained an unwitnessed fall in R1’s bedroom. Licensee Norma Benitez informed R1 that she intended to call an ambulance; however, R1 refused. At approximately 1:30 p.m. that same day, Licensee Benitez contacted emergency medical services. Paramedics responded to the facility, but R1 refused to be evaluated or transported to the hospital. CONTINUED LIC 9099-C Unsubstantiated On 02/25/2026, Licensee Benitez contacted R1’s responsible party and reported that R1 was experiencing pain in the hip area where R1 had fallen. Licensee Benitez requested that the responsible party take R1 to the hospital. A follow-up medical appointment was scheduled for 02/27/2026. According to UC Davis medical records, no fractures were identified, and R1 was diagnosed with arthritis. Moreover, during another incident on 03/02/2026, R1 was admitted to UC Davis Medical Center with a blood pressure reading of 77/44. R1 was admitted to the intensive care unit and diagnosed with septic shock. According to R1’s responsible party, R1 was admitted to the intensive care unit because hospital staff were unable to stabilize R1’s blood pressure. R1 did not return to the facility following this hospitalization. Based on the records reviewed, R1 did not require special supervision but required full assistance with activities of daily living. R1 was able to ambulate and transfer independently. At the time of the fall, R1 had resided at the facility for approximately 20 days, and no prior falls had been documented. After the fall was discovered, the facility contacted emergency medical services, but R1 refused evaluation and transportation. Therefore, the Department was unable to corroborate the allegation that staff neglect resulted in a resident to be hospitalized. It was alleged that staff did not meet a resident’s incontinence need. This investigation consisted of interviews with staff and residents, observations, and record reviews. The Licensee Benitec stated that residents receive incontinence care every three to four hours and as needed. Three of three residents interviewed confirmed that staff assist them with incontinence care, like living in the home and reported no concerns. During a facility visit on 07/10/2026 and today’s visit (09/10/2026) LPA Lee did not detect any incontinence odors. It was learned that the facility does not document when residents’ incontinence briefs are changed or when staff assist residents with toileting. However, staff reported monitoring residents every three to four hours and as needed, therefore, the Department was unable to corroborate the allegation that staff did not meet a resident’s incontinence need. It was alleged that staff did not properly report an incident involving a resident. This investigation consisted of interviews with staff and R1’s responsible party, as well as a review of records. Administrator Benitez denied the allegation and stated that incidents involving R1 were reported to R1’s responsible party and faxed to the Department. According to coordinator notes dated 02/18/2026, R1 sustained a fall, and staff notified R1’s responsible party. Because R1 refused evaluation by paramedics, the responsible party agreed to transport R1 to the hospital that afternoon but did not arrive. PAGE 2 CONTINUED LIC 9099-C The incident reports were faxed to the Department on 02/18/2026 at 11:57 p.m. On 03/02/2026, staff notified R1’s responsible party that R1 was coughing up yellow phlegm. X-ray results showed no fractures, only arthritis. A home health nurse evaluated R1 and noted low blood pressure. Staff requested that 911 be called; however, R1 refused. On 03/04/2026, R1’s responsible party transported R1 to the hospital. The related incident reports were faxed to the Department on 03/04/2026 at 6:44 p.m., therefore, the Department was unable to corroborate the allegation that staff failed to seek timely medical attention. It was alleged that staff did not timely address a resident’s change in medical condition and staff did not seek timely medical attention for a resident. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. Throughout the course of the investigation, it was learned that on 02/18/2026, at approximately 10:00 a.m., R1 sustained an unwitnessed fall in their room. Licensee Benitez called paramedics at approximately 1:30 p.m.; however, R1 refused evaluation and transportation. R1 was later transported to the hospital on 02/20/2026. No injuries were identified, and R1 was discharged with a diagnosis of arthritis. On 02/27/2026, R1 spent the day with their responsible party, who reported no signs of illness. On 02/28/2026, staff observed that R1 appeared tired and went to bed after breakfast. On 03/01/2026, R1 continued to report fatigue and began producing yellow phlegm. On 03/02/2026, R1 was transported to UC Davis Medical Center with low blood pressure and was admitted to the intensive care unit with septic shock. Records and interviews showed that staff contacted paramedics after R1’s fall, but R1 refused medical care. Staff continued monitoring R1 and sought medical attention when R1’s symptoms persisted and worsened. Therefore, the Department was unable to corroborate the allegation that staff did not timely address a resident’s change in medical condition and that staff did not seek timely medical attention for a resident. The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Licensee Benitec and the LIC 9099 report was provided to the facility at the end of the visit. PAGE 3the state’s words, verbatim · CDSS document, Sep 10, 2026 · control 27-AS-20260304151756

Type of visit: Required - 1 Year

On 2/6/2026, Licensing Program Analyst (LPA) Cynthia Tamay arrived at St. Christopher Manor RCFE for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Norma Benitez an entrance interview was conducted and together conducted a tour of the home. St. Christopher Manor is age range 60 and over, fire clearance approved for 4 non-ambulatory residents with a hospice waiver for two. There are four residents in care. Three residents were in the living room watching a selected cooking video and one resident selected to remain in their room and watch a television program. LPA toured the facility with S1 and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 121 degrees Fahrenheit, which is is not within the required range of 105 and 120 degrees. S1 adjusted the water heater level during this visit and will ensure the water temperature is within regulation. One resident is receiving oxygen and there are posted sings. LPA Tamayo observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Tamayo observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA observed a locked cabinet for the storage of medication. Continued on 809-C LPA Tamayo observed locked cabinets for the storage of cleaning solutions and knives. The exterior of the building was inspected by the LPA. LPA observed an activity calendar posted in the hallway which included playing Wii, , sitting fitness, walking, play dough, reading, and movie nights. There were no outbuildings or bodies of water present and the yard was completely fenced in. There was also a sitting area for residents in the backyard. Both staff and resident files were made available for inspection during this visit. LPA reviewed three resident files (R1-R3) and three staff files (S1-S3). LPA compared the LIC 500 with the roster of staff obtained from Guardian to ensure that all staff had the appropriate background clearances to be working with the residents in care. All were in compliance at the time of this inspection. Administrator certificate # 7009205740 and it 11/30/2026. LPA interviewed 2 staff members and four residents. LPA requested the following documents: Administrator certificate LIC 500: Personnel Report LIC 308: Designation of Administrative Responsibility LIC 309: (for any LLC or Corp) if applicable LIC 402: Surety Bond, if applicable LIC 610E: Emergency Disaster Plan Copy of Liability Insurance According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided and an exit interview conducted.the state’s words, verbatim · CDSS document, Feb 6, 2026

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 2/21/2025 at 1:20 P.M. Licensing Program Analysts (LPAs) Cynthia Tamayo and Kevin Gould arrived at St. Christopher Manor RCFE for the purpose of conducting a required 1 year annual inspection. LPAs met with Administrator, Norma Benitez and together conducted a tour of the home. LPAs and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPAs observed the facility to be free of odor and clean. LPAs observed there was a screen door that is listed as an emergency exit is not working properly and cannot be opened. LPAs observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPAs measured the water temperature, temperature measured at 124 degrees F which does not meet the 105-120 degree Fahrenheit regulation and the administrator was able to lower the hot water temperature so it meets the 105-120 degree. LPAs observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPAs notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPAs observed centrally stored medications secure from residents. LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 309 Administrative Organization ,LIC 999 Facility Sketch, and LIC 9020 client roster and current administrator certificate. The Dementia training requirement was not met for one staff member. Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Feb 21, 2025

Type of visit: Required - 1 Year

On 2/15/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a Required - 1 Year inspection visit. LPA met with Administrator Norma Benitez and explained the purpose of the visit. Administrator holds current certification #6031100740 and expires on 11/30/2024. The facility is licensed for a capacity of 4 There is one resident who is using oxygen at this time. LPA toured the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, garage, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 113.4*F which was within the required range of 105-120*F. The temperature inside the facility measured at 76*F which was within the required range of 68-85*F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. Proof of current liability insurance was observed. Continued on 809-C LPA requested resident and staff files for review. LPA reviewed (1) staff files and (4) resident files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following forms and documents were requested to be submitted within 15 days: LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Copy of Administrator Certificate, LIC 610 Emergency Disaster Plan and Proof of Current Liability Insurance. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed. Exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 15, 2024