Casa De Castro

Allegation investigated: Staff did not prevent resident from wandering from facility.

On 02/21/2026, LPA Janet Ngallo conducted a subsequesnt visit to deliver findings regarding the above-mentioned allegation. LPA spoke with Caregiver Fransisco Tullas and explained the purpose of the visit. Regarding the allegation of Staff did not prevent resident from wandering from facility, Resident (R1) was able to leave the facility unassisted During the investigation, staff members were interviewed, and records were reviewed. On 9/9/2024, R1 was able to leave the facility unassisted. Staff took a break and did not notice that R1 was missing from the facility. It was not clear how long R1 was missing. Based on records review, R1 is not able to leave the facility unassisted. (Cont. on LIC 9099-C) Substantiatedthe state’s words, verbatim · CDSS document, Feb 21, 2026 · control 08-AS-20240910143605

Allegation investigated: Licensee financially abused a resident while in care.

Licensing Program Analyst (LPA) Liliana Silveira completed a complaint investigation and delivered findings via phone call with the Licensee Cheryl Castro. The Department’s investigation consisted of interviews and a records review. On April 6, 2022, it was alleged that the Licensee financially abused a resident while in care. Specifically, it was alleged that the Licensee was forging checks and taking Resident #1 (R1’s) money. The Department conducted a records review which revealed that R1 moved into the facility on February 16, 2018. A review of R1’s Physician’s Report, dated 02/12/2018, revealed that R1's physical health status was fair. R1’s was assessed as being able to follow instructions and able to communicate needs with occasional confusion. Regarding capacity for self-care, R1 was assessed as not being able to manage their own cash resources. Resident records indicated that R1’s money was managed by both R1 and their Responsible Relative (RR). (CONTINUED ON NEXT PAGE, LIC 90the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 08-AS-20220406152357

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident sustained unstageable pressure injury due to staff neglect

On 11/10/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Administrator Celeste Castro and explained the purpose of the call. Regarding the allegation resident (R1) sustained unstageable pressure injury due to staff neglect, R1 was brought to the hospital and had unstageable pressure injury. During the investigation, staff members were interviewed, and records were reviewed. R1 was under hospice upon admission to the facility under hospice. Per records, the facility submitted an incident report to the department regarding R1s hospitalization on 2/22/2025. R1 had started to develop pressure sores and the administrator recommended to the hospice nurse for a wound specialist. Hospice nurse (HN) mentioned that he/she is the wound specialist. HN also said that there is no issue with the facility as every time HN visits, R1 is changed properly, diapers are always dry. Based on interviews and records review, the department has determthe state’s words, verbatim · CDSS document, Nov 10, 2025 · control 08-AS-20250224165747

Allegation investigated: Staff took resident's phone away.

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced visit to continue a complaint investigation visit and to deliver findings. LPA Silveira introduced themselves, disclosed the purpose of the visit and was granted entry into the facility by caregiver Josefina “Josie” Wilkins. Licensee Cheryl Castro arrived a short time after. The Department’s investigation consisted of interviews and a records review. On June 23, 2025, it was alleged that staff took Resident #2’s (R2’s) phone away. A Department interview with Resident #2 (R2) revealed that Staff #1 (S1) had taken R2’s cell phone away. R2 stated that they would ask staff to charge the cell phone often. R2 also admitted that the phone would go “missing” because R2 was confused and would misplace it. An interview with S1 revealed that due to health issues, R2 was continuously dropping their cell phone and losing it. S1 stated that they held the phone for R2 to keep it safe and there were no intentions to take the phothe state’s words, verbatim · CDSS document, Oct 15, 2025 · control 08-AS-20250623154810

Allegation investigated: Staff do not ensure that resident's incontinence needs are met. Staff do not assist resident with ambulation. Staff do not answer facility phone when resident's responsible party calls. Licensee accepted resident #1 into facility even though resident required higher level of care. Administrator is not present at facility a sufficient amount of hours to manage facility.

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced complaint investigation visit to deliver findings for a complaint investigation. LPA Silveira introduced themselves, disclosed the purpose of the visit and was granted entry into the facility by caregiver Josefina “Josie” Wilkins. Licensee Cheryl Castro arrived shortly after. The Department’s investigation consisted of observations, interviews and a records review. On August 29, 2025, it was alleged that staff do not ensure that Resident #1 (R1’s) incontinence needs are being met. Specifically, it was alleged that R1’s incontinence briefs were not being changed in the evenings. The Department conducted an unannounced visit to the facility on October 8, 2025 and observed that R1’s incontinence briefs and bedding were clean. A Department interview with R1 revealed that R1 stated that the facility caregivers were “really good” about diaper changes, and also stated that, at the moment, R1 felt clean and had no concerthe state’s words, verbatim · CDSS document, Oct 14, 2025 · control 08-AS-20250929095042

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff not treating resident with dignity

Licensing Program Manager (LPM) Lizzette Tellez conducted an unannounced complaint visit to deliver findings on the above-mentioned allegation. LPM was met by Caregiver, Edna Francia, and was allowed entry into the facility. LPM spoke with Licensee/Administrator, Cheryl Castro, by phone to discuss the purpose of the visit. Investigation consisted of interviews with residents, staff, outside sources, and a tour of the facility. It was alleged that staff did not treat Resident #1 (R1) with dignity, specifically that Staff #1 (S1) provided showers to R1 in the backyard area. Interviews with staff and outside sources revealed that staff provided showers to R1 on the back porch, with the use of a shower chair. Interviews with S1 revealed that staff occasionally do this due to fear of R1 falling, and due to needing help to get R1 into the tub. Interview with R1 yielded contradictory statements. During a tour of the facility, a shower chair and sheet were observed on the back porch. The Departhe state’s words, verbatim · CDSS document, Sep 22, 2023 · control 08-AS-20210831162033