La Costa Heights Assisted Living

Allegation investigated: Neglect resulting in resident developing multiple pressure injuries

On 2/24/2026, LPA Amy Rodgers conducted a subsequent visit to deliver findings regarding the above-mentioned allegation. LPA spoke with Administrator Lindu Napitupular and explained the purpose of the visit. During the investigation, staff members and outisde sources were interviewed, and records were reviewed. Regarding the allegation of Neglect resulting in resident developing multiple pressure injuries, Resident (R1) sustained an open wound caused by lying on a catheter cord, staff failed to reposition R1 resulting in the development of open wound. R1 is bedridden and requires full assistance with ADLs. R1 is provided additional care from home health. Per statements from staff and home health nurse (HH), R1 requires brief checks and repositioning every two hours to avoid pressure injuries. (Continued from LIC9099C) Substantiated (Continued from LIC9099) Caregiver (S1) cared for R1 on 2/8/2025 and 2/9/2025. On 2/8/2025, around 8:30 AM, S1 and S2 changed R1s brief. There was no wound on R1s back upper left thigh at that time. HH also visited R1 at the facility on 2/8/2025, around 10:00 AM, and did not document any new injuries. S1 said he/she checked on R1 the remainder of the shift on 2/8/2025, as well as throughout 2/9/2025. R1 did not do any brief change. S1 left at the end of the shift on 2/9/2025, around 6:30 PM and S2 took over. On 2/10/202, around 8:00 – 9:00 AM, S2 and S3 rolled R1 to his/her side to change the brief. S2 noticed that R1s catheter cord was positioned under R1s left thigh and when S2 removed the cord, S2 observed a large open cut where the cord had been placed. S2 said he/she did not have a co-worker the evening of 2/9/2025 into the morning of 2/10/2025 therefore S2 did not reposition R1 in bed. Based on the interviews, R1s brief was last changed on 2/8/2025, around 8:30 AM. It’s not noted when the last time S1 repositioned R1 before ending the shift on the evening of 2/9/2025, at 6:30 PM. However, S2 did not reposition R1 when S2 took over R1s care on 2/9/202, at 6:30 PM until S2 changed R1 on 2/20/2025, around 8:00 – 9:00 AM, around fourteen hours later. Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D. The Department has determined this violation resulted in a developed of an open wound due to lack of care and supervision. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM. Currently, according to Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted with Administrator Lindu Napitupula, and a Plan of Correction was jointly developed. A copy of this report, LIC 9099-D, LIC421IM and the Licensee/Appeal Rights (LIC 9058) were provided to Administrator Lindu Napitupula, signature on this form confirms receipt of documents. (Continued from LIC9099) According to HH, R1 was exhibiting symptoms of a UTI the week prior to going to the hospital on 2/10/2025, and a urine sample was taken for testing. The preliminary finding of UTI was delivered to home health on 2/7/2025 and the final finding of a UTI was delivered on 2/10/2025. HH2 added that R1 would have been prescribed antibiotics, however, R1 had been transported to the hospital before the prescription could be ordered. Based on interviews and records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Lindu Napitupular, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 24, 2026 · control 08-AS-20250213153409

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87564(f)(1) · Plan of correction due date: Feb 25, 2026

87464(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This was not met as evidenced by: Based on interviews and records review, R1 was not repositioned every two hours and developed an open wound due to lack of care and supervision which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: The immediate threat was resolved: R1 was sent by emergency service to hospital and no longer residends at faciliy. LIcensee staff agreed to schedule basic services/ Care and Supervision training to all staff, by 3/25/2026 Training will be completed and submitted to LPA Rodgers with sign-in sheet and training topic clearly noted via email by 3/25/2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Licensee Lindu Napitupulu. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, ages 60 and above with a Hospice waiver for four (4). During today’s inspection there were six (6) residents in care. LPA and Licensee Lindu Napitupulu toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. 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. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Licensee Lindu Napitupulu, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were 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 clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview and Plan of Correction was jointly developed with the licensee Lindu Napitupulu, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Nacole Patterson and Arian Golbakhsh conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by and discussed the purpose of the visit to Licensee Lindu Napitupulu. The facility's license shows a maximum capacity of six (6) ambulatory and non-ambulatory residents, ages 60 and over, with a hospice waiver for three (3) residents. During today’s inspection there were 6 residents in care. LPAs and Licensee Lindu Napitupulu toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards, and client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. 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. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, which were all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Licensee Lindu Napitupulu, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were 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. LPAs interviewed staff and clients, and reviewed facility records. The files reviewed by LPAs contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Licensee Lindu Napitupulu to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 6, 2024

Allegation investigated: Staff did not ensure resident's care needs were met. Staff did not provide adequate food service to residents. Staff did not administer resident's medication as prescribed. Staff did not provide resident with clean linen. Staff did not treat resident(s) with dignity. Licensee did not comply with terms of the admission agreement.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Licensees Lindu and Mildred Napitupulu. On 2/1/24 it was alleged that staff did not ensure resident's care needs were met, staff did not provide adequate food service to residents, staff did not administer resident's medication as prescribed, staff did not provide resident with clean linen, staff did not treat resident(s) with dignity, and Licensee did not comply with terms of the admission agreement. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, records review, and LPA observations. (Continued on LIC9099-C p.2) Unsubstantiated (Continued from LIC9099 p.1) Regarding the allegation, "Staff did not ensure resident's care needs were met", it was alleged that staff did not respond to Resident 1 (R1)'s call at night, and did not assist them with incontinence care. Staff interviews revealed that R1 lived at the facility for two (2) days, and staff checked on R1 each night, including responding to their calls. Staff interview further revealed that staff and Hospice monitored R1's incontinence care system on both days R1 lived at the facility, and it was changed both days, once by an Outside Individual (OI) related to R1 on 1/23/24, and then by Hospice on 1/24/24. The Licensee informed that they personally checked the system the day R1 moved in, on 1/23/24. R1 moved out the morning of 1/25/24. Resident interviews did not corroborate the allegation, residents informed that staff assisted them with all care needs. No resident informed that staff did not assist them with incontinence care. Outside source interviews did not corroborate the allegation. One outside source had not received any concerns about incontinence needs not being met at the facility, and did not observe any concerning issues during past visits. Interview with a second outside source confirmed that R1 was at the facility for 2 days, and that the Hospice agency changed the incontinence care system during one of the visits. Review of charting notes on 1/23/24 at 11:30am showed that the resident's incontinence care system was checked upon admission, corroborating staff statements that staff were monitoring it. R1 was unable to be interviewed due to no longer living at the facility. Regarding the allegation, "Staff did not provide adequate food service to residents", it was alleged that staff did not offer resident(s) fresh food. Staff interview revealed that the facility consistently kept a number of fresh fruits on hand such as bananas, apples, honeydew, strawberries, watermelon, cantaloupe, and grapes. Staff interview revealed that staff ask residents what they would like to eat each meal, and then prepare it fresh. Staff interview revealed that R1 refused to eat most of the time they lived at the facility and informed staff that they wanted to go home, refusing to eat. (Continued on LIC9099-C p.3) (Continued from LIC9099-C p.2) Resident interviews corroborated staff statements that fresh fruits and vegetables were offered to residents. Residents stated that they got to choose what they would like to eat during the day and enjoyed eating cereal, puffy omelets, bananas, and oatmeal. Resident interviews further revealed that while some residents chose not to eat fresh fruit, staff still offered it to them and other residents were observed eating fresh fruit. Outside source interviews did not corroborate the allegation. Outside sources had not observed or been informed of residents being denied fresh food at the facility. No records were found to support the allegation. LPA directly observed fresh fruits and vegetables at the facility during unannounced facility visits. During a visit on 2/7/24, LPA observed watermelon, strawberries, grapes, apples, onions, cucumbers, tomatoes, and pasta salad in the refrigerator. LPA conducted a Required Annual Inspection on 11/22/23 and observed the facility to have more than the required amount of 2 days perishable food and 7 days non-perishable food, all properly stored and within expiration dates. Regarding the allegation, "Staff did not administer resident's medication as prescribed", it was alleged that staff did not provide R1 with a medication at night. Staff interview revealed that the medication in question was a pro re nata (PRN) "as needed" prescription for pain, which R1 asked for and was given both nights they lived at the facility. Resident interviews did not corroborate the allegation, residents stated that their medications were given accurately and on time with no issues. Outside source interviews did not corroborate the allegation, informing that they had not observed medication errors at the facility and had not been notified of errors. (Continued on LIC9099-C p. 4) (Continued from LIC9099-C p.3) Records Review corroborated staff statements that R1 was provided their PRN the evening of 1/23/24 and 1/24/24. R1 was unable to be interviewed due to no longer living at the facility. Regarding the allegation, "Staff did not provide resident with clean linen", it was alleged that the Licensee did not provide linens for R1's bed upon move in. Staff interviews revealed that R1's facility-provided bed was made up with linens upon admission, and when the Hospice bed was delivered, staff re-made the new bed with linens as well. Resident interviews revealed no concerns regarding clean linens, residents informed that their linens were cleaned regularly and/or upon request, including bed pads. Outside sources interviewed did not have concerns regarding the linens being changed regularly. Outside sources informed that it was customary for Hospice beds to be delivered without linens. Outside sources informed that the facility provided R1 with clean linens initially on the facility-provided bed, and the Hospice bed once it had arrived. No records were found to corroborate the allegation. During the facility visit LPA observed resident rooms to have the required bedding layers, which were clean and in good repair. LPA did not observe any stains, debris, or particles that would indicate that the linens had not been washed recently. LPA also did not observe any odors in the facility that would indicate that the linens were not washed regularly. During a facility visit on 2/7/24 LPA observed staff washing and folding laundry. R1 was unable to be interviewed due to no longer living at the facility. (Continued on LIC9099-C p.5) (Continued from LIC9099-C p.4) Regarding the allegation, "Staff did not treat resident(s) with dignity", it was alleged that staff spoke rudely to a resident. Staff interviews did not corroborate the allegation, staff informed that they had never heard another staff member speak rudely to a resident or yell at them. Staff informed that sometimes a specific resident had to be instructed back to their room during elevated behaviors, but staff did not speak rudely when doing so. Resident interviews did not corroborate the allegation, residents informed that staff were nice, respectful, and caring. No resident had heard staff speak rudely or yell at another resident. Resident interviews revealed that even when residents were rude to staff, staff respond respectfully and without yelling. Outside source interviews did not corroborate the allegation, having no concerns about staff treating residents with dignity. Outside sources had not been informed of, nor had they observed dignity issues at the facility. No records were found to corroborate the allegation. During unannounced facility visits, LPA observed staff engaging with residents in a calm, respectful manner. LPA did not observe any staff raise their voice or attempt to force a resident to do something outside of their will. Regarding the allegation, "Licensee did not comply with terms of the admission agreement", it was alleged that the Licensee did not issue R1 and their Responsible Party a refund for unused rent, per the admissions agreement. Staff interview revealed that the funds were not returned because R1 and their Responsible Party violated the signed admission agreement requiring residents to give a 30-day notice upon move out. Staff statements were corroborated by review of R1's admission agreement, which was initialed and signed by R1's Responsible Party. No records were found to support that R1 and/or their Responsible Party provided the 30 day notice to vacate the facility, as required. (Continued on LIC9099-C p.6) (Continued from LIC9099-C p.6) R1 was unable to be interviewed due to no longer living at the facility. Outside source interviews did not corroborate the allegation. One outside source had not received concerns regarding admission agreement violations by the Licensee. A second outside source confirmed that R1 and their Responsible Party violated their admission agreement by not providing a 30-day notice before moving R1 out of the facility. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Lindu and Mildred Napitupulu, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 26, 2024 · control 08-AS-20240201112810

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Licensee Lindu Napitupulu. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, During today’s inspection there were 6 residents in care. LPA and Licensee toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. 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. Facility contained at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. No toxic chemicals/poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were 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 clients, and reviewed staff and client records/files. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Licensee Lindu Napitupulu to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 22, 2023