St. Paul's Villa

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Allegation investigated: Lack of supervision resulting in resident getting violent with another resident(s).

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit with Executive Director, LaTressa Downing. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, and outside sources, and a review of records. On 9/2/25, it was alleged that there was a lack of supervision resulting in a resident getting violent with another resident. (Continued on LIC9099C) Unsubstantiated (Continued from LIC9099) Facility staff were interviewed and consistently reported reporting requirements, including timelines for notifying the Department, responsible parties, and other agencies when appropriate. Staff stated that all incidents are documented immediately and submitted to the Department within the required time frame. The incident reports reviewed were properly addressed. There was no evidence of lack of supervision during the resident to resident incident. The facility staff followed the policy in place regarding resident to resident inappropriate interaction. Residents interviewed revealed that they feel safe at the facility. There were no complaints of lack of staff from residents. LPA interviewed residents regarding their experiences with staff availability, safety, and communication. Residents reported that they feel safe living at the facility and stated that staff are present, approachable, and responsive. Residents did not report any concerns regarding a lack of staffing or delays in staff response. No resident expressed concerns related to incident reporting or staff oversight. LPA interviewed outside sources, who confirmed they receive incident notifications from the facility promptly when required. Outside sources reported no issues with communication and described the facility as consistent and proactive when incidents occur. There were no complaints of insufficient staffing or supervision from outside contacts. LPA reviewed the facility’s incident reports for the period of 8/1/25 through 9/1/25, including incident logs, LIC 624s, internal documentation, and communication records. All unusual incidents were found to have been reported to the Department and other required agencies per regulatory timelines. Reports were complete, included required details, and aligned with internal documentation. Outside sources were informed of the incidents when they occurred with no delays. Based on interviews, LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with the Executive Director to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 19, 2026 · control 08-AS-20250902151440

Allegation investigated: Staff communicated inappropriately to resident Staff threw an object at the resident

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to LaTressa Downing, Executive Director. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. On 6/8/26, it was alleged that staff communicated inappropriately with a resident. Staff interviewed denied speaking to residents in an inappropriate, disrespectful, or unprofessional manner. Staff were able to describe expected communication practices and reported that they are trained to interact with residents using supportive and person‑centered language. Continue on LIC9099C Unsubstantiated Continued from LIC9099 Residents interviewed did not report being spoken to in a rude, aggressive, or improper way by any staff member. Outside sources who have regular contact with the resident also denied witnessing or receiving reports of inappropriate communication from staff. During the Department’s visit(s), LPA observed interactions between staff and residents and did not observe any concerning communication, tone, or behavior. A review of facility records, including staff training logs and incident reports, did not reveal any information indicating issues related to inappropriate verbal interactions. On 6/8/26, it was alleged that staff threw an object at the resident. Staff interviewed denied ever throwing objects at residents or witnessing any staff engage in such behavior. Staff reported that they are trained to follow proper de-escalation techniques and maintain safe, respectful interactions at all times. Residents interviewed did not report seeing staff throw objects or behave aggressively toward residents. Outside sources who have regular contact with the facility also denied observing or receiving any credible information indicating that staff engaged in this type of conduct. During the Department’s visits, LPA observed staff interacting appropriately with residents and did not observe any concerning behaviors. A review of facility records, including incident reports and staff training documentation, did not reveal any information supporting the allegation. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation(s) are UNSUBSTANTIATED. An exit interview was conducted with the Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 08-AS-20260608111302

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Director of Nursing Divina Salinas. According to the facility’s license, the facility has a maximum capacity of 200 residents, of whom 80 may be non-ambulatory on entire second floor. This facility is approved for locked dementia unit with delayed egress doors. Hospice waiver is approved for 12 residents. During today’s inspection, there were 112 residents in care. LPA, accompanied by Divina Salinas, toured the interior and exterior of the facility. Pathways were free of obstruction and slip hazards. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant. There was at least 2 days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to residents. Medications were labeled, as required, and stored in locked areas. (Cont. on LIC 809-C) (Cont. from LIC 809) No pools or bodies of water on the premises. Per Divina Salinas, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present and serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and residents, and reviewed multiple staff and resident records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Director of Nursing Divina Salinas to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 8, 2026

Allegation investigated: Neglect/Lack of Supervision resulting in serious bodily injuries. Neglect resulting in delayed medical care. Neglect resulting in UTI/Sepsis.

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced subsequent complaint visit regarding the above-mentioned allegations. LPA was met by, identified herself to, and discussed the purpose of the visit with Director of Nursing Divina Salinas. The Department's investigation consisted of records reviews and interviews with staff and outside sources. It was alleged that St. Paul’s Villa (facility) staff had neglect and lack of supervision that resulted in serious bodily injuries for Resident (R1). It was also alleged that there was staff neglect in delayed medical care and that licensee did not provide incontinent care. Based on records reviews and interviews, R1 sustained injuries from an unwitnessed fall at approximately 7:00pm on 08/20/24 during an altercation with another resident (R2). The residents were in front of the nursing station room where staff were working. The charge nurse immediately assessed R1 who complained of pain to the back of the head and buttocks. Staff called paramedics and notified R1’s Durable Power of Attorney (DPOA). The DPOA came onsite when the paramedics were at the facility and signed a release to deny transfer of R1 by paramedics to the hospital. Unsubstantiated DPOA instructed staff to monitor R1 and if the pain worsens to give Tylenol and then if needed, the DPOA would take R1 to the hospital in the morning. On 8/21/24 at 7:00am, R1 had an unwitnessed fall in the dining room where R1 slipped out of a chair while sitting down to eat breakfast. Staff were in dining room and assisted R1 off the floor. According to records reviews, this type of fall of slipping out of a bed or chair was not uncommon for R1, however this time R1 complained of pain and was not able to bear weight without assistance. R1’s DPOA was onsite at the facility at that time and drove R1 to the hospital. R1 was diagnosed with a closed fractured sacrum and a closed fracture to the left ischium. ER doctor prescribed Tylenol for R1's pain and R1 returned to facility. Based on records reviews and interviews, there is not substantial evidence to support the allegation that staff had neglect and lack of supervision that resulted in serious bodily injuries for R1, therefore this allegation is unsubstantiated. It was alleged that the staff did not seek timely medical care for R1. Based on records reviews and interviews, staff called paramedics to transfer R1 to the hospital after the fall on 8/20/24. R1’s DPOA signed a paramedic release form denying transport of R1 by paramedics to the hospital. DPOA then instructed staff to monitor R1 and if the pain worsened, the DPOA would take R1 to the hospital in the morning. DPOA was notified in the morning of 08/21/25 that R1 slipped out of chair while sitting down for breakfast. This type of slipping fall was not uncommon for R1, however this time R1 complained of pain and was not able to bear weight without assistance. Shortly after the incident, the DPOA drove R1 to the hospital emergency room. R1 was diagnosed with a closed fractured sacrum and a closed fracture to the left ischium. The ER doctor prescribed Tylenol for R1's pain and R1 returned to facility. Based on records reviews and interviews, there is not substantial evidence to support the allegation that staff did not seek timely medical care for R1. It was alleged that licensee did not provide R1 incontinence care. Records reviews and interviews indicated that R1 was paying $700/month additional to the monthly payment rate since admission to facility on 06/19/24. R1’s Incontinence Care Plan stated that staff would assist R1 with all toileting needs. Facility staff and nurses used a 24-hour charting system that documented toileting. The charting was available for incoming staff to checked at the beginning of shifts. Examples of entries during a shift are: On 07/30/24 staff assisted R1 with toileting, staff changed his clothes, and staff escorted R1 to breakfast at 06:45am. On 08/15/24, resident was awake at 1:28am and staff assisted him to the restroom and back to bed. 08/16/24, R1 urinated on door right after staff had changed resident. Staff changed R1 again and changed bed sheets. Based on record review, there is not substantial evidence to support the allegation that staff did not provide incontinence care, therefore this allegation is unsubstantiated. An exit interview was conducted with Divina Salinas, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Her signature on this form acknowledges receipt of these rights.the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 08-AS-20241003144505

Allegation investigated: Staff mismanaged resident's medication.

Program Analyst (LPA) Juliana Barfield conducted an unannounced complaint visit regarding the above-mentioned allegation. LPA was met by, identified herself to, and discussed the purpose of the visit with . Nursing Director Divina Salinas. The Department’s investigation consisted of records reviews and interviews with staff and outside sources. It was alleged that the staff mismanaged resident’s medication. Based on records reviews and interviews, Resident one (R1) and Resident two (R2) were at the nursing station to receive their medications on 03/13/2025. Medication Technician (Med Tech) had both of their medications separated in different souffle cups held in one hand. Med Tech used the other hand to get water. Med Tech handed R1 medication first, looked down and realized the dispensed medication was for R2. Med Tech told R1, “Wait, don’t take that yet,” and R1 replied that R1 had already taken the medication. Interviews revealed that R1 swallowed R2’s medication. R1 was monitored closely for any adverse signs. All vital signs were normal. Substantiated The Department has investigated the above-mentioned allegation. Based on records reviews and interviews, the Department has found that a preponderance of evidence exists to support the allegation that staff mismanaged resident’s medication. Therefore, the allegation is deemed substantiated One deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Divina Salinas, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 08-AS-20250317091651

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 19, 2025

A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following: The licensee shall assist residents with self-administered medications as needed. Based on records reviews and interviews, LPA found there was a preponderance of evidence that supported the allegation of staff mismanaged resident's medication. This allegation is substantiated.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: Director of Nursing stated she will train Med Techs with the proper medication process when administering medication to residents. POC was cleared today, 06/19/25 with the submittal of medication training already completed by staff with DON.

Allegation investigated: Staff did not ensure that resident was adminstered their medication as prescribed.

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced complaint visit regarding the above-mentioned allegation. LPA was met by, identified herself to, and discussed the purpose of the visit with Nursing Director Divina Salinas. LPA and Ms.Salinas briefly toured the facility. The Department's investigation consisted of record review and interviews with outside sources and staff. It was alleged that the facility staff did not ensure that a resident was adminstered their medication as prescribed. A resident was prescribed a course of medication for five days however, the staff input an incorrect time for the receipt of the medication into their electronic medication administration system. This resulted in the wrong dose being given to the resident on the first day of administration. No dose of medication was given on the second day. The correct dose was given on the third day before the staff became aware that the the overall administation course of the medication was incorrect. (Continued on 9099-C page) Substantiated (Continued from LIC9099-C) LPA’s record review and interviews confirmed that the resident was not administered their medication as prescribed in regards to the proper time and in the correct dosage. The Department has investigated the above-mentioned allegation and has found that a preponderance of evidence exists to support the allegation. Therefore, the allegation is deemed substantiated. One deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Ms. Salinas, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 08-AS-20250313130008

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 20, 2025

A plan for incidental medical and dental care shall be developed...The plan shall encourage routine medical and dental care and provide for assistance...by compliance with the following: The licensee shall assist residents with self-administered medications as needed.the state’s words, verbatim · CDSS document, Mar 20, 2025

Plan of correction: Director of Nursing stated she created an Antibiotic Login Sheet and trained LVNs and Med Techs on it's use. DON also reviewed the proper inputting of prescriptions into the electronic MAR system. Confirmation of training with employee signatures is due to licensing by POC date 04/03/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director LaTressa Downing and Director of Nursing Divina Salina. According to the facility’s license, the facility has a maximum capacity of 200 residents, of whom 80 may be non-ambulatory on entire second floor. This facility is approved for locked dementia unit with delayed egress doors. Hospice waiver is approved for 12 residents. During today’s inspection, there were 112 residents in care. LPA, accompanied by Divina Salina, toured the interior and exterior of the facility. Pathways were free of obstruction and slip hazards. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per LaTressa Downing, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. Required licensing postings were observed in visible areas of the facility. Confidential records were stored in locked areas. LaTressa Downing also presented proof of current/active business liability insurance. An exit interview was conducted with LaTressa Downing and Divina Salina. A copy of this report and Licensee Appeal Rights (LIC 9058 01/16) were provided to LaTressa Downing and Divina Salinathe state’s words, verbatim · CDSS document, Jan 22, 2025

Allegation investigated: Unlawful eviction. Licensee did not report changes in resident’s condition to physician.

Licensing Program Analysts (LPAs) Amy Rodgers and Angelica Boyles conducted an unannounced visit to the facility to deliver investigative findings regarding the above-mentioned allegation. LPAs identified themselves, explained the purpose of the visit and nature of the complaint to LatTressa Downing, Executive Director. On 5/26/2021, the Department received this complaint which alleged, the facility illegally evicted Resident #1 (R1) [LIC 811 Confidential Names List was provided to identify the client.] and did not ensure changes in R1’s condition were reported to R1’s physician. The Department’s investigation included, facility tour, record reviews and interview with an outside source. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Regarding allegation of facility illegally evicting R1, records revealed R1 had a history of aggressive behavior, which R1’s physician was aware of. On 5/17/21 due to aggressive behaviors R1’s physician recommended R1 go to a hospital for psychological evaluation and medication review. As evidenced by records, while R1 was at UCSD Hospital, social worker recommended to facility that R1 be placed in a locked facility. Evidence further the indicated facilities Resident Service Coordinator evaluated R1 at UCSD Hospital and conducted a Resident Appraisal noting a higher level of care, which R1’s responsible party signed. R1 did not return to the facility from UCSD Hospital. Regarding the allegation of not ensuring changes in R1’s condition were reported to R1’s physician, records obtained confirmed through emails, clinical notes, and physician communication that leading up to R1’s hospitalization R1’s physician was aware of changes. Further evidence reveals facility staff attempted to schedule a care conference with R1’s responsible party and R1’s physician prior to hospitalization. The Department has investigated the allegations that the facility illegally evicted a resident and staff did not ensure changes in resident’s conditions were reported to a physician. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. An exit interview was conducted with LaTressa Downing, Executive Director, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 08-AS-20210526114412

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Director of Nursing Divina Salinas. Executive Director LaTressa Downing joined the visit shortly after. Today's visit was in response to two (2) LIC624 Incident Reports, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/23/2024), The first incident involving Resident #1 (R1) and Resident #2 (R2) and the second incident for Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report] During today’s visit, LPA performed a facility tour/welfare check and collected records and conducted interviews. No deficiencies were observed or cited during today's visit. An exit interview was conducted with LaTressa Downing, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 29, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Daniel Pena, conducted an unannounced Case Management Visit. LPA was greeted by and met with Director of Nursing, Divina Salinas to discuss the purpose of the visit. Today's visit is in response to a self-reported incident documenting a resident's unwitnessed fall. On 4/12/24, Resident 1 (R1) fell in the bathroom, striking their head. Emergency Medical Service (911) was called and R1 was transported to the hospital for evaluation and treatment. Per reporting, the resident sustained a hip fracture. LPA conducted interviews with staff and obtained and reviewed pertinent records. According to interviews with staff, R1 underwent surgery was transferred from the hospital to a skilled nursing facility. Director Salinas advised LPA that R1 will return to the facility after their rehabilitation. Based on LPA's investigation, no deficiencies were cited during today's visit. An exit interview was conducted with Director, Salinas, who was provided a copy of this report and Appeal Rights (LIC9056 03/22). Ms. Salinas' signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 3, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Daniel Pena, conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director, LaTressa Downing to discuss the purpose of the visit. Today's visit is in response to the self reported incident of Resident 1 (R1) who sustained an unwitnessed injury on 3/21/2024. Per reporting, interviews with R1 and record review, staff was alerted by R1 of a deep wound below the occipital region. 911 was called and R1 was transported to the hospital for evaluation and treatment. LPA conducted interviews with R1 and staff and collected records. LPA also conducted a health and safety check. Interviews revealed R1 received four (4) staples to close the wound. The facility has arranged for a mobile physician to remove the staples on 3/30/2024. LPA observed no health or safety issues. No deficiencies were cited during today's visit. An exit interview was conducted with Director, Downing, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Ms. Downing's signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 29, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers was granted entry into the facility by Administrator LaTressa Downing, after identifying herself and stating the purpose of the inspection. Facility is licensed for 200 residents, of whom 80 may be non-ambulatory on the entire second floor. Facility is approved for locked dementia unit with delayed egress doors on the second floor. Hospice waiver is approved for twelve (12) residents. LPA was accompanied by Administrator Downing, during a tour of the facility, which was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, outside grounds, and food storage areas. There is a fire system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted in January 2024 and conducted quarterly. Exterior and interior passageways were free from obstructions. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. No pools or bodies of water were observed on the premises. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with the required furnishings and appropriate lighting to ensure the comfort and safety of residents. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. There are non-skid mats or strips present in the showers. Resident’s room temperatures were within a comfortable range. Hot water temperature at taps accessible to clients were all compliant. Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. [Continued on 809-C] [Continued on 809] LPA observed an operational signal system. Medications are locked in carts, not accessible to residents. Carts are kept in the wellness room. Medications were labeled and kept in compliance with label instructions. LPA interview with staff indicates the facility arranges or assists in arranging medical and dental care appropriate to the conditions and needs of residents. This includes providing assistance with transportation or assisting in arranging transportation for incidental medical and dental appointments. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA conducted a review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. There are several areas used for activities such as: daily music, exercises, arts/crafts and outings. At the time of visit, LPA observed a small group activity, in which some residents were participating. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet residents’ needs. Based on today’s inspection, no deficiencies were observed in the areas evaluated. An exit interview was conducted with Executive Director Downing and a copy of this report and Licensee/Appeal Rights - LIC 9058 (rev. 01/16) were provided to Administrator Downing, whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jan 30, 2024