St. Paul's Villa

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 buttockRead the full finding— CDSS inspection report, June 19, 2025 · control 08-AS-20241003144505

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 cRead the full finding— CDSS inspection report, June 19, 2025 · control 08-AS-20250317091651

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 wasRead the full finding— CDSS inspection report, March 20, 2025 · control 08-AS-20250313130008

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) UnsubstantiatedRead the full finding— CDSS inspection report, December 19, 2024 · control 08-AS-20210526114412

On 10/10/2023, at about 2:30 PM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to the facility in order to initiate a complaint investigation. LPA was granted entry to the facility by Eleanor Downing, Administrator, after identifying himself and explaining the reason for the visit. On 10/5/2023, the Department received an allegation that the facility did not take necessary precautions to prevent an infectious disease outbreak. Allegedly, two residents were not treated for an infectious disease but the facility removed their clothing. Also, it was alleged that residents were placed into isolation but the families were not notified. Finally, it was alleged that two residents were isolated without clothing. The Department’s investigation consisted of LPA observations, review of facility records, and interviews with pertinet staff, residents and outside sources. On 10/10/2023, LPA’s visit included a walk-through of the facility, specifically the Memory Care UniRead the full finding— CDSS inspection report, October 10, 2023 · control 08-AS-20231005094127

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Eleanor “LaTressa” Downing. During today's visit, LPA observed residents in care, interviewed staff and residents, and obtained copies of facility records. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that staff yelled at a resident. Interviews and records review revealed that resident 1 (R1) had a diagnosis of mild cognitive impairment, was not confused or disoriented, was able to follow directions and communicate needs, and received assistance with medication administration. Continued on LIC9099-C page... UnsubstantiatedRead the full finding— CDSS inspection report, May 24, 2023 · control 08-AS-20220314163959

Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to the facility to deliver investigative findings regarding the above-mentioned allegation. LPA identified himself, explained the purpose of the visit and nature of the complaint to Administrator, LaTressa Downing. On 1/28/2021, the Department received this complaint which alleged, the facility restricted a resident's access to their physician. The Department’s investigation included, virtual and onsite physical plant tours, record reviews and interviews with residents, staff and outside sources. A review of facility records which included Resident 1’s (R1) Face Sheet, Admission Agreement, Resident Appraisal, Appraisal Need and Services Plan, Physician's Report, Record of Centrally Stored Medications and Hospice Contract. R1 was admitted into the facility on 1/2/2021 diagnosed with encephalopathy, pneumonia, COPD, pulmonary mycobacterial infection, sepsis and vitamin deficiency. R1's records noted two physiciansRead the full finding— CDSS inspection report, January 18, 2023 · control 08-AS-20210128122256