D'Vine Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Magda Malcore arrived unannounced to conduct the required annual visit to the facility. LPA met with caregiver, Flordeliza Salvatierra and stated purpose of the visit. The facility is a (6) bedroom, (2) bathroom, Residential Care Facility for Elderly (RCFE) with a license capacity of (10), and a current census of (9). LPA conducted a general inspection of facility, which included, but was not limited to, the following: Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees fahrenheit. Resident bedrooms were equipped with mattresses, night stands, storage space, chairs and lighting. LPA observed ceiling fans in six (6) resident bedrooms and kitchen/dining areas were covered with dust. Client bathroom equipment were functional and bathrooms were equipped with slip mats and grab rails. Water temperatures tested at 119 degrees fahrenheit. The facility is equipped with operational carbon monoxide alarms, charged fire extinguisher, battery operated night lights, and first aid kit with manual. Posters such as, facility license, community care complaint poster, Ombudsman poster, weekly menu, infection control plan, emergency exit plan and telephone numbers were posted in a common area. Cleaning supplies and bleach were observed unlocked and left unattended. There are no firearms, ammunition, swimming poosl or bodies of water in the facility. Medications was observed locked and inaccessible to clients. The facility has 24hour/7days a week care staff. Food Service: Non-perishable and perishable food supply is sufficient for residents in care. The facility has a variety of food and snacks available. Dishes, cups, and utensils were also stored properly. Yards/Outside: The facility has a shaded patio, side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions. Record Review: four (4) staff records were reviewed for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings. Four (4) resident records were reviewed for admission agreements, updated physician reports, client personal property records, needs and services plans. Deficiencies were cited in accordance with Title 22, of the California Code of Regulations. An exit interview was conducted where this report and correction plans were discussed. Report copies were provided with appeal rights to Caregiver Salvatierra.the state’s words, verbatim · CDSS document, Sep 29, 2025

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff retaliated against a resident for reporting concerns Staff are involuntarily transferring a resident to another facility Facility does not maintain sample menu for resident review Staff did not provide assistance to resident after fall

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Caregiver, Floredeliza Salvatierra and discussed the purpose for the visit. Regarding the allegation, staff retaliated against a resident for reporting concerns, staff interviewed deny retaliating against a resident for reporting concerns. Four (4) residents interviewed deny that staff retaliated against them for reporting concerns. Regarding the allegation, staff are involuntarily transferring a resident to another facility, staff interviewed deny that they are involuntarily transferring a resident to another facility. Four (4) residents interviewed deny that they are in the process of eviction or that staff are involuntarily transferring them to another facility. Regarding the allegation, Facility does not maintain sample menu for resident review, LPA observed a weekly menu was posted on the kitchen refrigerator. (Continued on LIC9099-C) Unsubstantiated Staff interviewed deny not maintaining a sample menu for residents to review. Three (3) out of four (4) residents interviews reveal that they have not requested to review the facility menu. Regarding the allegation, Staff did not provide assistance to a resident after a fall, staff interviewed deny not providing assistance to a resident after a fall. Four (4) residents interviewed deny that staff have not assisted them after a fall. Based on record review, interviews with staff and residents, the allegations are Unsubstantiated. Unsubstantiated meaning that 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. An exit interview was conducted where reports (LIC 9099 & LIC9099-C) were discussed, and a copy with appeal rights was provided to Caregiver Salvatierra at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 10, 2025 · control 56-AS-20250904132613

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Magda Malcore conducted a case management visit based on observations made during complaint investigation 56-AS-20250904132613. LPA met with Caregiver, Floredeliza Salvatierra and informed the purpose of the visit. Today (9/10/25), LPA observed resident #1 (R1) with a forehead injury. R1 did not respond to LPA’s interview attempt due to their cognitive condition. Staff interviews reveal that, on 8/28/25, R1 sustained a forehead injury due to a fall. Staff called 911 and R1 were admitted to hospital. R1 was discharged the same day. Staff interviews reveal that a written incident report was not submitted to the Community Care Licensing Division (CCLD) regarding R1. A deficiency is being cited in accordance with Title 22 of the California Code of Regulations. An exit interview was conducted where reports (LIC809 & LIC809-D) were discussed. Report copies were provided with appeal rights to Caregiver Salvatierra at the conclusion of visit.the state’s words, verbatim · CDSS document, Sep 10, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 12, 2025

87211(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident...This requirement is not met as evidenced by: The Licensee did not comply with the section cited above by not submitting a written incident report after R1 sustained a injury while in care within 7 days of occurance; which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2025

Plan of correction: The Licensee/Administrator shall submit a written incident report to the Licensing Agency by POC due date.

Allegation investigated: Staff did not provide adequate medication assistance to residents in care Staff refuse to call an ambulance for residents in care Staff threatened residents in care Staff did not ensure sufficient food items were available at the facility for residents in care Staff did not prevent residents from engaging in inappropriate interactions Staff yelled at residents in care Staff did not assist residents that sustained falls Staff are not following reporting requirements Staff left residents unattended

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility conduct a complaint investigation on the above allegations. LPA met with Caregiver, Floredeliza Salvatierra, who was informed of today’s visit. Regarding the allegation, staff did not provide adequate medication assistance to residents in care, three (3) staff interviewed deny not providing adequate medication assistance to residents in care. Five (5) resident interviews reveal they are provided with adequate medication assistance. Regarding the allegation, staff refuse to call an ambulance for residents in care, three (3) staff interviewed deny refusing to call an ambulance for residents in care. Five (5) resident interviews reveal staff have not refuse to call an ambulance for them. Regarding the allegation, staff threatened residents in care, three (3) staff interviewed deny threatening a resident in care. Unsubstantiated Five (5) resident interviews reveal they have not been threatened by staff. Regarding the allegation, staff did not ensure sufficient food items were available at the facility for residents in care, LPA observed the facility has the required supply of perishable and nonperishable foods at the facility. Three (3) staff interviewed deny not ensuring sufficient food items were available at the facility for residents in care. Five (5) resident interviews reveal staff serve an adequate quantity of food to meet their needs. Regarding the allegation, staff did not prevent residents from engaging in inappropriate interactions, three (3) staff interviewed deny not preventing residents from engaging in inappropriate interactions. Five (5) residents interviews reveal that no other residents have engaged inappropriately towards them. Regarding the allegation, staff yelled at residents in care, three (3) staff interviewed deny yelling at residents in care. Five (5) residents interviews reveal staff have not yelled at them. Regarding the allegation, staff did not assist residents that sustained falls, three (3) staff interviewed deny not assisting residents that fall. Five (5) resident interviews reveal they have not fallen at the facility. Regarding the allegation, staff are not following reporting requirements, three (3) staff interviewed deny not following reporting requirements. Regarding the allegation, staff left residents unattended, three (3) staff interviewed deny leaving residents unattended. Five (5) resident interviews reveal that they have not been left alone without staff supervision. Based on LPA observations, record review, and interviews with staff and resident, the above allegations are Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and copies with appeal rights were provided to Caregiver Salvatierra at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 10, 2025 · control 56-AS-20241121094816

Allegation investigated: Staff consume liquor while on shift Staff lock facility doors to prevent residents from leaving Staff insert suppositories to residents in care Staff did not complete required trainings Staff facility records are falsified Staff did not maintain resident records Residents are not provided proper food service Staff did not ensure resident’s diapering needs were met Staff did not inform resident’s physician of resident’s change of condition

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility conduct a complaint investigation on the above allegations. LPA met with Caregiver, Floredeliza Salvatierra, who was informed of today’s visit. Regarding the allegation, staff consume liquor while on shift, three (3) staff interviewed deny consuming liquor while on shift. Five (5) resident interviews reveal they have not witnessed staff consume liquor while on shift. Regarding the allegation, staff lock the facility doors to prevent residents from leaving, three (3) staff interviewed deny locking the facility doors to prevent residents from leaving. Five (5) resident interviews reveal they have not witnessed staff lock facility doors to prevent them from leaving. Regarding the allegation, staff insert suppositories to residents in care, three (3) staff interviewed deny inserting suppositories to residents in care. Five (5) resident interviews reveal they are not inserted with suppositories. Unsubstantiated Regarding the allegation, residents are not provided proper food service, interviews with three (3) staff and four (5) residents reveal dinner is served 4:00 p.m. and breakfast is served between 6:30 a.m. and 7:00 a.m. Hours between the third meal and last meal are within regulation. Five (5) resident interviews reveal they are provided breakfast, lunch, and dinner. Four (4) out of five (5) resident interviews reveal they are provided snacks between meals. Regarding the allegation, staff did not ensure resident’s diapering needs were met, three (3) staff interviewed deny not ensuring resident’s diapering needs were met. four (4) out of five (5) resident interviews reveal their diapering needs are met. Regarding the allegation, staff did not inform resident’s physician of resident’s change of condition, three (3) staff interviews reveal they will notify the resident's doctor or nurse of any changes of resident's condition. An exit interview was conducted where this report was discussed and copies with appeal rights were provided to Caregiver Salvatierra at the conclusion of the visit. LPA's record review reveals that S1 and S2 had health screenings conducted by the same doctor at the same medical office with the same evaluation results, but conducted years apart. Additionally, LPA conducted a health screening verification through the medical office on record, and the verification reveals that no medical record was found for S2. Regarding the allegation that staff did not maintain resident records, it was claimed that the facility did not have a current resident registry on file. LPA’s resident record review reveals that the facility did not have a resident registry available for LPA review. Based on pertinent record review and interviews with relevant parties, the allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where reports (LIC9099&LIC9099-D) were discussed and provided with appeal rights to Caregiver Salvatierra at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 10, 2025 · control 56-AS-20241121094816

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c)(1)(A) · Plan of correction due date: Jan 31, 2025

87412(c)Licensees shall maintain in the personnel records verification of required staff training...(1)The following staff training...shall be documented:(A)For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training made within 4 weeks of employment and at least four hours of training annually thereafter in one or more of the content areas...This requirement is not met as evidenced by: The Licensee did not comply with the section cited above by no annual staff training on file;Which poses a potential health,safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 10, 2025

Plan of correction: The Licensee/Administrator shall provide proof current job training for S1, S2, S3, and S4 to the Licensing Agency for review by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Jan 31, 2025

87207 No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility...This requirement is not met as evidence by: The Licensee did not comply with the section cited above by maintaining an invalid first aid certification for S1 and S4. By maintaining a nonverfiable health screening for S2 on file; Which poses a potential health,safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 10, 2025

Plan of correction: The Licensee shall provide verifiable first aid/CPR training for S1 and S4 and verifiable Health screening documentation for S2 by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87508(b) · Plan of correction due date: Jan 31, 2025

(b) Registers of residents shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Registers may be removed if necessary for copying...This requirement is not met as evidenced by: The Licensee did not comply with the section cited above by not having a resident registry on file for review; which poses a potential health,safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 10, 2025

Plan of correction: The Licensee/Administrator shall provide copy of registry to the licensing agency by POC due date.

Type of visit: Required - 1 Year

On 08/28/24, Licensing Program Analyst (LPA) Becky Mann and Magda Malcore arrived unannounced to conduct the required annual visit to the facility. LPAs met with Flordeliza Salvatierra and introduced and stated purpose of the visit. LPAs were informed that there are 7 clients who are in program. The facility has 6 bedrooms, 2 bathrooms, kitchen, dining area, living room, backyard, and attached garage. LPAs completed a walk through of the facility, review of records, and medication audit. 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 of 76 degrees fahrenheit. LPAs inspected clients' bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs inspected clients' bathrooms; bathrooms were clean and appliances were found functional. LPAs observed no non-slip mats in the bathroom. Water temperatures tested at 109 degrees fahrenheit. The facility is equipped with operational carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, facility license and CCL complaint poster were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to clients. There were 2 non-operable smoke detectors.There was a designated storage space for client/staff files. Medications was observed locked and inaccessible to clients. There is no firearms, ammunition, swimming pool or bodies of water in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. Facility did not have a first aid manual. Food Service: Non-perishable and perishable food supply is sufficient. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly. Yards/Outside: One shaded patio, side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPAs reviewed administrator and DSP files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. There was 3 staff who did not have up-to-date First Aid/CPR certifications. LPA reviewed 6 client files for admission agreements, updated physician reports, and needs and services plans. Medication was audited and did not match with MARs. LPA reviewed facility's file for fire drills, infection control plan, and emergency disaster plan. LPAs observed the facility did not have fire and/or earthquake drill logged. An exit interview was conducted where the reports of LIC809, LIC809C, and LIC809D were discussed and copies were provided to Flordeliza Salvatierra.the state’s words, verbatim · CDSS document, Aug 28, 2024

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.