St. Paul's Plaza

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 did not maintain the facility clean Staff did not meet resident's hygiene needs Staff did not receive required training

On October 29, 2025, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced complaint visit to deliver investigative findings for the allegations listed above. LPA met with Executive Director Kim Stratman to present the investigative findings. The Department’s investigation included a facility tour, record review, and interviews with staff and external sources. On December 6, 2023, Community Care Licensing (CCL) received a complaint alleging that staff did not maintain the facility in a clean condition. Specifically, it was alleged that staff failed to clean Resident 1’s (R1’s) bathroom, which had feces on the floor and toilet, and that R1 tracked the feces from the bathroom into other areas of the room. Specific details regarding the date and time of the incident were not disclosed during the investigation. (Continue at LIC9099C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 29, 2025 · control 08-AS-20231206111416

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 did not follow infection control protocols.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to investigate and deliver findings on the above allegation. LPA met with Resident Clinical Specialist Chardonnay Blue and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, resident and outside sources. It was alleged that facility staff did not follow infection control protocols. It was reported that Resident 1 (R1) had an infectious skin condition (scabies) and was not isolated in their room in the memory care unit. It was also reported that facility staff were not following infection control protocols including the use of personal protective equipment (PPE). LPA reviewed R1's physician's report dated March 5, 2025. R1 has a diagnosis of vascular dementia with behavior disturbance and R1 is confused and disoriented at times. R1's cathe state’s words, verbatim · CDSS document, Jul 17, 2025 · control 08-AS-20250522163321

Allegation investigated: Lack of supervision resulted in resident sustaining injury

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Director Maria Sano and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observation, records review, interviews with staff, residents and outside sources. It was alleged that lack of supervision resulted in Resident 1 (R1) sustaining an injury. It was reported that R1 was pushed to the ground by Resident 2 (R2) resulting in a hematoma on their head. LPA conducted a records review on April 11, 2025. Review of R1's physician's report revealed that R1 had a primary diagnosis of severe dementia with agitation, R1 was not able to leave the facility unassisted and R1 was both confused and disoriented at times. Review of R1's care plan revealed that R1 had a history of falls and as a result, facility interventions wethe state’s words, verbatim · CDSS document, May 12, 2025 · control 08-AS-20250404172519

Allegation investigated: Staff did not prevent a resident from eloping out of a window while in care

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Director Maria Sano and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observation, records review, interviews with staff, outside sources and outside agency. It was alleged that facility staff did not prevent a resident from eloping out of a window. It was reported that Resident 1 (R1) fell from a bedroom window in the memory care unit. It was further reported that the fall was approximately eight feet and R1 sustained minor injuries. Substantiatedthe state’s words, verbatim · CDSS document, Apr 24, 2025 · control 08-AS-20250324154907

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 did not ensure toxic chemical was inaccessible to resident

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Assistant Administrator Maria Sano and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff and clients It was reported to CCL that staff did not ensure toxic chemical was inaccessible to resident. Regarding the allegation, it was reported that resident (R1) mistakenly put nail polish remover in the mouth and immediately spit it out. It was reported that staff were unaware of how the resident got the nail polish remover. [Continued on 9099-C] Substantiatedthe state’s words, verbatim · CDSS document, Dec 12, 2024 · control 08-AS-20241016172046

Allegation investigated: Illegal evicion

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Assistant Administrator Maria Sa and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that facility issued an illegal eviction. Regarding the allegation, it was reported that a resident (R1) was not allowed to return to the facility and facility did not go through the proper eviction procedure. A review of records availed no record of an eviction given to R1. [Continued on 9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 12, 2024 · control 08-AS-20241120143445

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.

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 inappropriately handled a resident in care

Licensing Program Analyst (LPA)Daniel Pena conducted an unannounced complaint visit to the facility to deliver an investigative finding on the above-mentioned allegation. LPA gained access to the facility, identified himself, and met with Assistant Administrator, Maria Sano to discuss the purpose of the visit. On 4/25/23, the Department received this complaint alleging staff inappropriately handled a resident in care. The Department’s investigation consisted of LPA observation, interviews with pertinent residents and staff, and review of resident and facility records. Interviews revealed an incident that took place at the facility on or around April 14, 2023. Resident 1 (R1) was eating lunch in the pub when another resident (R2) came in and sat down at a table near R1. R1 told the server (Staff 1) staff should not feed R2 because R2 did not have their cane. S1 was confused by the remarks and thought maybe it was an inside joke between R1 and R2. S1 approached R2 and Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 22, 2024 · control 08-AS-20230425104104

Allegation investigated: Facility staff did not properly assist resident causing resident to fall and sustain an injury(ries). Facility staff handled resident in a rough manner causing an injury(ries). Facility staff did not provide incontinence care resulting in skin breakdown Resident sustained unexplained injuries. Facility staff did not serve resident dinner.

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings. LPA was allowed entry by the Maria Sano, Assistant Administrator. LPA identified herself and disclosed the purpose of the visit and elements of the findings to the Assistant Administrator. On December 08, 2022, The Department investigated the above-listed complaint allegations. The investigation consisted of a facility tour, interviews with staff and outside sources, and a records review. Allegation 1: On March 25, 2019, Resident 1 (R1) was assisted by Staff 1 (S1) due to a fall. Immediate response was initiated, and R1 was immediately transported to a hospital via a 911 call, sutures were placed onto a two-inch laceration at R1's eyebrow. The complainant was interviewed regarding this fall. The complainant reported that they did not have a problem with this particular fall, or the staff’s response to the fall. The complainant reported that they included the fall on the complaint referral tothe state’s words, verbatim · CDSS document, Feb 7, 2024 · control 08-AS-20221208135517

Allegation investigated: Facility staff yells at resident Facility staff did not assist resident with toileting needs

Licensing Program Analyst Becky Kennedy concluded the investigation which began on 1/29/2021. LPA Kennedy made an unannounced visit to the above facility today and met with Maria Sano, Assistant Administrator. LPA advised her of the reason for today's visit and delivered the investigation findings on the above allegations. The investigation into the above allegations consisted of interviews with internal sources, records reviews, and a tour of the facility. It was alleged that Staff Member 1 (S1) (A list of confidential names was provided to the facility) yelled at Resident 1 (R1) and that S1 did not provide toileting assistance to R1. The investigation revealed that S1 admitted that they get frustrated with R1. In interactions with R1, S1 would talk loudly. Some staff members that overheard these interactions reported that S1 yelled at R1. Substantiatedthe state’s words, verbatim · CDSS document, Jan 24, 2024 · control 08-AS-20210120145516

Allegation investigated: Licensee did not administer medication as prescribed. Licensee did not meet resident's needs.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above allegations. LPA introduced herself and disclosed the purpose of the visit to Assistant Administrator Maria Sano. On 12/11/23 it was alleged that the Licensee did not administer medication as prescribed, and did not meet a resident's (R1) needs. The Department’s investigation consisted of an unannounced facility visit, review of relevant records, interviews with facility staff, residents, outside sources, and LPA direct observations. Regarding the allegation, "Licensee did not administer medication as prescribed", it was alleged that the Licensee did not provide a medication to R1 within a specific timeframe. Staff interview revealed that the medication in question was a pro re nata (PRN) medication that was to be administered as needed based on R1's pain levels. Records review revealed that the resident was given the medicationthe state’s words, verbatim · CDSS document, Dec 19, 2023 · control 08-AS-20231211141521

Allegation investigated: Facility retained resident involuntarily

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA met with Community Manager, Maria Sano and shared findings. The Department investigated the above-listed complaint allegation. The investigation consisted of staff interviews and a detailed review of relevant records. On September 25, 2023, Community Care Licensing (CCL) received a complaint alleging that Resident #1 (R1) was retained at the facility involuntarily. Facility staff were provided with Confidential Names Form (LIC 811) in order to identify R1. A review of facility records indicated that R1’s Admissions Agreement was signed on March 30, 2019, by their Durable Power of Attorney (DPOA)/responsible party. R1’s physician’s report and care plan indicated that R1 was diagnosed with dementia and required assistance with activities of daily living and medication management. In addition, records disclosed that R1 was conserved. R1 passed away on September 2,the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 08-AS-20230925091541