Mesaview Senior Assisted Living

Allegation investigated: Staff did not safeguard the resident's belongings

LPA Amy Rodgers conducted an unannounced complaint visit to investigate and deliver findings regarding the above-mentioned allegations. LPA Rodgers was greeted by Administrator Genoveva Guerrero, who identified herself and was informed of the purpose of the visit. The Department’s investigation consisted of reviewing records and interviewing internal and external sources as well as staff. On August 3, 2026, Community Care Licensing (CCL) received a complaint alleging that staff did not safeguard resident #1 (R1)’s personal belongings and were not providing a comfortable environment for R1. R1 reported people have stolen some items but does not know who. A complaint investigation conducted on August 18, 2025, regarding safeguarding R1’s belongings revealed similar concerns consistent with statements from the day program. A Physician’s Report dated 2/21/2026, states R1 is diagnosed with schizophrenia with a history of auditory hallucinations as well as dementia with depression. Interviews with the reporting party confirmed R1 attends a day program and has a history of behavioral health symptoms including persecutory delusions.Department interviews with R1 indicate they expressed general persecutory concerns but were unable to provide any specific examples. Multiple resident and staff interviews revealed no concerns related to missing items or thef. Based on interviews and observations, a preponderance of evidence does not exist to support the allegations. Therefore, the allegations are UNSUBSTANTIED. An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 7, 2026 · control 08-AS-20260803103209

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Rodgers was welcomed by, identified herself to, and discussed the purpose of the visit with Genovea Guerrero. According to the facility’s license, the facility has a maximum capacity of forty (40) residents, ages 60 years and over, all of whom may be non-ambulatory and five (5) of whom may be bedridden. A hospice waiver for eight (8) residents has been approved. LPA, accompanied by licensee’s staff, 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. Doors, windows and 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’s ambient internal temperature and hot water temperature at taps accessible to clients were all compliant. There was 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. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. 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 multiple staff and clients. LPA reviewed multiple staff and client records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. No Citations were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Guerrero, to whom a copy of this report were provided during the visit.the state’s words, verbatim · CDSS document, Aug 7, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) conducted an announced Case Management visit. LPA disclosed the purpose the visit to Administrator Genoveva Guerrero and was allowed entry into the facility. The facility requested a change of capacity from 30 (thirty) non-ambulatory clients of which five(5) can be bedridden to a maximum capacity of fourty (40) residents, ages 60 years and over, all of whom may be non-ambulatory and five (5) of whom may be bedridden. The facility currently and will continue to have a hospice waiver for eight (8) residents. The Fire Clearance Inspection Report (STD850) was completed by the local fire authority and received in the San Diego Regional Office (SDRO) on July 22, 2026. LPA reviewed the facility’s new facility sketch, which matches the STD 850. LPA also conducted a brief tour of the facility. The Change of Capacity request will be forwarded to the SDRO management team for approval. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Genoveva Guerrero, 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, Jul 23, 2026

Allegation investigated: Staff hits resident.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to investigate and deliver findings regarding the above complaint allegations. The investigation included interviews with the residents, staff and an outside source, as well as a review of facility records. On July 15, 2026, the Community Care Licensing Division (CCLD) received a complaint alleging that Resident #1 (R1) was hit on legs and body while staff #1(S1) was changing R1 brief. The departments records review and interviews revealed R1 has a history of reporting imagining situations. The department interview with R1 confirmed R1's account of information may not be reliable and R1's reports interactions with staff as positive other then said incident. The department's interviews with the outside source(OS1) revealed that R1 has a history of memory impairment and is not always a reliable historian especially around the time of their simi-annual mental and physical status check by said outside source. OS1 interview revealed no concerns regarding the resident’s care and confirmed that the facility communicates regularly with POA and R1's comprehensive elder care service agency. Staff interviews confirm R1 expressed concerns to staff and they addressed R1’s concerns, but no one could verify the alleged incident. Based on interviews and records review, the preponderance of evidence standard was not met; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Genoveva Guerrero and a copy of this report along with Licensee/Appeal Rights (LIC 9058) was provided at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 22, 2026 · control 08-AS-20260715213715

Allegation investigated: Resident missed medication Staff do not follow physicians orders.

LPA Amy Rodgers conducted an unannounced complaint visit via telephone to deliver findings to Assit. Manger Ileana Castro. On October 21, 2024, CCL received a complaint alleging Resident #1(R1) missed medication and that staff were not following physician’s orders. R1 specifically alleged eye drops were only given once daily instead of four times daily. The Department reviewed facility records and conducted staff and outside interviews. Records confirmed R1's physician’s orders for eye drops were four(4) times daily, and Medication Administration Records (MARs) and daily logs showed consistent administration as ordered. R1 also signs a daily medication log verifying they were given the eye drops and no noted discrepancies were documented. Department Interviews confirmed R1 has a documented mental health diagnosis and has made similar allegations in the past. No evidence was found to support that medications were missed or that staff failed to follow physician’s orders. Based on interviews 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 and a copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) were provided to Asministrator Guerrero via E-mail. An electronic E-mail read receipt confirms the documents were received. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 2, 2026 · control 08-AS-20241021144527

Allegation investigated: Staff abuse resulting in serious bodily injury

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced complaint visit to investigate and deliver findings regarding the above-mentioned allegations. The LPA was greeted by Administrator Genoveva Guerrero, who identified herself and disclosed the purpose of the visit. The Department’s investigation consisted of a review of records and interviews with internal and external sources. On July 31, 2025 Community Care Licensing (CCL) received a complaint alleging that the Reporting Party(RP) observed a bloody wound in Resident #1(R1) genital area, identified as a torn meatus, and indicated the injury may have resulted from improper handling by facility recommended hospitalization for further evaluation . (Continued on LIC9099C) Unsubstantiated (Continued from LIC9099) R1, was wheelchair-bound, required total assistance for all activities of daily living, followed a pureed diet, exhibited behavioral disturbances, and had a catheter in place incrementally. R1 was also was transported daily to a healthcare facility for insulin care. Department review of email correspondence reveals on June 6, 2025 the facility reported observing blood drops from the R1's genital area during a brief change and notified R1's clinic. On June 17, 2025, the facility emailed the clinic reporting a skin tear near the catheter site. The clinic responded with instructions to clean the area, adjust the catheter securement device to reduce tension, and monitor the resident, noting that the resident was on blood thinners. Department review of the facility’s Unusual Incident/Injury Report dated June 24, 2025, revealed on June 24, 2025, the resident attended a routine appointment at R1's clinic, the facility documented receiving a call from the clinic nurse stating that trauma related to the catheter was observed and the resident was sent to the hospital for further evaluation. Department review of hospital records dated June 24, 2025, revealed the resident was examined for a genital injury and diagnosed with erosion of the urethra related to catheter use. The documentation does not reference external trauma or abuse. Department review of Training Log dated, 05/29/2024 revealed staff had training on Skin care and pressure ulcer training and staff also received instruction on proper catheter care procedures and communication protocols to ensure compliance with care standards. Facility records show staff communicated with clinic and family regarding catheter care, followed instructions provided, and reported the incident to CCLD as required. Based on interviews and document review a preponderance of evidence does not exist to support the allegation that staff abused a resident resulting in serious bodily injury. The allegation is therefore unsubstantiated. An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 08-AS-20250624155723

Allegation investigated: Staff member abused resident

Licensing Program Analyst (LPA), Amy Domingo, conducted an unannounced complaint visit to investigate and deliver findings regarding the above-mentioned allegation. The LPA was greeted by Administrator Genoveva Guerrero, who identified herself and disclosed the purpose of the visit. The Department’s investigation consisted of a review of records and interviews with internal and external sources. On September 5, 2024, Community Care Licensing (CCL) received a complaint alleging that a staff member abused a resident. During the investigation, interviews were conducted with multiple residents and staff. The interviews reveal they have no concerns with how staff care for the residents. Multiple staff and resident interviews also reveal that all interviewed parties denied witnessing or experiencing any form of abuse. Residents stated staff treat them respectfully, knock before entering rooms, and provide care in a professional manner. No resident reported physical, verbal, or emotional abuse. Unsubstantiated 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 is UNSUBSTANTIATED. An exit interview was conducted with Genoveva Guerrero, 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 9, 2026 · control 08-AS-20240905160722

Allegation investigated: Staff pushed resident Staff did not safeguard residents personal belongings

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to invistigate and deliver findings regarding the above complaint allegations. The investigation included interviews with the residents, staff and outiside sources, as well as a review of facility records. On January 28, 2026, the Community Care Licensing Division (CCLD) received a complaint alleging that staff pushed Resident #1 (R1) and used profanity, and that staff failed to safeguard R1’s personal belongings. The departments records review revealed R1 has a history of reporting missing items as well as imagining situations. The department interview with R1 confirmed R1's account of information may not be reliable and R1 did not recall any missing money and revealed interactions with staff as positive. The department's interviews with the outside sources revealed that R1 has a history of memory impairment and is not always a reliable historian. Both outside sources reported no concerns regarding the resident’s care and confirmed that the facility communicates regularly and safeguards valuables per R1's request. Staff interviews confirm they addressed R1’s concerns, but no one could verify the alleged incidents. Based on interviews and records review, the preponderance of evidence standard was not met; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Genoveva Guerrero and a copy of this report along with Licensee/Appeal Rights (LIC 9058) was provided at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 3, 2026 · control 08-AS-20260128105503

Type of visit: Case Management - Licensee Initiated

Licensing Program Analyst (LPA) Amy Rodgers conducted a case management - Licensee Initiated visit regarding Resident #1, who is presenting as a fall risk.LPA was greeted by, identified himself to, and discussed the purpose of the visit with Genoveva Guerrero. LPA A. Rodgers discussed fall prevention strategies and reviewed the resident’s current care plan to ensure appropriate interventions are in place. Recommendations included: Assessment Review: Confirm that the resident’s fall risk assessment is current and accurately reflects their condition. Environmental Safety: Ensure clear walkways, adequate lighting, and removal of tripping hazards in the resident’s living area. Assistive Devices: Verify that the resident has access to and is using appropriate assistive devices (e.g., walker, grab bars).Staff Monitoring: Reinforce staff awareness and monitoring protocols, especially during transfers and ambulation.Care Plan Updates: Incorporate fall prevention measures into the resident’s care plan and communicate changes to all staff. An exit interview was conducted with Administrator Genoveva Guerrero and a copy of this report along with Licensee/Appeal Rights (LIC 9058) was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 3, 2026

Allegation investigated: Staff are not ensuring that a resident's hygiene needs are being met

Licensing Program Analyst (LPA) Amy Domingo conducted an announced visit to deliver findings regarding the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Ileana Castro Assistant Manager. CCLD’s investigation involved unannounced facility tour/welfare checks and review of facility care and medical records. The Department also interviewed relevant staff, clients, and outside sources. On 6/6/24, it was alleged that staff are not ensuring that a resident's hygiene needs are not being met. LPA interviewed three (3) staff members, including caregivers assigned to the resident in question. Staff stated that the resident receives assistance with bathing three (3) times per week and as needed. (Continue on LIC9099C) Unsubstantiated Continued from LIC9099 Staff also reported assisting the resident with grooming and dressing daily. Records review of the resident’s care plan confirmed that hygiene assistance is part of the resident’s individualized care plan. Bathing logs and staff notes documented regular hygiene care. LPA interviewed three (3) residents, Resident 2 stated, staff help me with showers and getting dressed. They’re respectful and come when I ask. Other residents interviewed also reported receiving hygiene assistance as needed and expressed satisfaction with the care provided. LPA interviewed three (3) outside sources who reported that the residents appear well cared for and that staff communicate effectively regarding the resident’s condition and needs. No concerns were raised about the facility’s ability to meet the resident’s needs. During the visit, LPA observed residents to be clean, appropriately dressed, and well-groomed. No odors or signs of neglect were noted. Staff were observed assisting residents in a timely and respectful manner. The Department has investigated a complaint with the above allegation. The Department has found that although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted with Ileana Castro Assistant Manager, 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, 2025 · control 08-AS-20240606101125

Allegation investigated: Staff neglect leading to a resident sustaining a pressure injury

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above-mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Ileana Castro, Assistant Manager. During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents, and outside sources. On June 10, 2024, the department received a complaint alleging staff neglect, leading to a resident sustaining a pressure injury. (Continue on LIC9099C) Substantiated (Continued from LIC9099) During the interview, staff indicated that multiple facsimile transmissions were sent to the medical organization responsible for managing Resident 1’s healthcare, informing them of the resident’s skin condition. The staff was awaiting direction from the medical team. Outside Source 1 (OS1) reported that pressure ulcers were identified during a routine visit. OS1 stated they had not been informed of any skin integrity concerns before the visit, nor had they received any documentation indicating that Resident 1 (R1) was experiencing skin issues.. Review of facility records revealed that a physician’s report dated February 26, 2024, documented that Resident 1 (R1) was non-ambulatory, diagnosed with dementia, and required total assistance with all activities of daily living. No family member or responsible party was listed. The first facsimile to R1’s health management team, describing the resident’s skin condition, was sent on May 28, 2024. Subsequent facsimiles were sent on May 29, June 3, June 5, and June 7, 2024. Facility records do not indicate any response received from the health management team regarding these communications. The facility policy states that if the facility is unable to care for a resident because of a change of condition the resident should be sent to the hospital for evaluation and treatment. There was no indication in R1’s care plans that the resident was receiving treatment for any skin-related conditions. Additionally, the care plans did not include interventions for repositioning while the resident was in bed or seated in a wheelchair to alleviate pressure and prevent further skin breakdown. The Department has investigated a complaint with the above allegation. The Department has found that there is a preponderance of evidence to prove that the alleged violation did occur; therefore, the allegations are substantiated. An exit interview was conducted with Ileana Castro, Assistant Manager, 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, 2025 · control 08-AS-20240610135841

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Nov 20, 2025

Facilities must ensure a plan for medical care, and residents receive the necessary medical care for their conditions and needs of residents. This requirement was not met as evidence by; Based on observations, interviews and records reviewed that one (1) out of twenty-eight (28) the licensee did not receive the necessary medical care for their conditionthe state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: The Facility agrees to conduct a training on Incidental medical care by a CCLD verified vendor by the agreed date of 11/20/25

Allegation investigated: Staff did not prevent resident from engaging in inappropriate behaviors Staff are not providing a comfortable environment for resident Staff did not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced complaint visit to investigate and deliver findings regarding the above-mentioned allegations. The LPA was greeted by Administrator Genoveva Guerrero, who identified herself and disclosed the purpose of the visit. The Department’s investigation consisted of reviewing records and interviewing internal and external sources as well as staff. On August 11, 2025, Community Care Licensing (CCL) received a complaint alleging the above-allegations. The Department’s investigation consisted of staff and client interviews, record reviews and investigative observation and outside sources interviews. (Continued on LIC9099) Unsubstantiated (Continued from LIC9099) It was alleged that staff did not prevent residents from engaging in inappropriate behaviors and were not providing a comfortable environment for resident #1(R1). More specifically, R1 reported during an interview that they feel people at the facility are threatening them and that they feel uncomfortable due to weird looks. Physician’s Report dated March 31, 2025, states (R1) is diagnosed with schizophrenia with a history auditory hallucinations. R1 has been a client at the facility since June 30, 2023. Interviews with the reporting party confirm that R1 frequents a day program and has been observed reacting to feelings of being watched and becoming upset when they perceive others are not friendly toward them. They further noted R1 has a cognitive impairment and a history of misinterpreting social interactions The Long term care ombudsman interview revealed they are not aware of any incidents involving threats or mistreatment at the facility and expressed no current concerns regarding R1’s safety. Interviews with R1 denied any physical contact and stated others at the facility made them feel uncomfortable. Interviews with staff deny that residents threaten each other. It was also alleged that staff did not safeguard R1's personal belongings. More specifically, R1 reported during an interview that someone stole clothes a few years ago at the facility. Multiple residents and staff interviews were conducted. The interviews reveal they have no concerns with items missing from residents' rooms. Multiple staff and client interviews also reveal they have no concerns over theft in the facility. Based on interviews and observations a preponderance of evidence does not exist to support the above allegations. The allegations is therefore unsubstantiated. An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 08-AS-20250811095128

Allegation investigated: The resident developed a pressure injury while in care. Staff did not seek medical attention for the resident in a timely manner.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to the Assistant Manager, Ileana Castro. The Department’s investigation consisted of a review of facility and outside records, as well as interviews with staff, residents, and outside sources. On May 17, 2024, it was alleged that a resident developed a pressure injury while in care, and staff did not seek medical attention for the resident in a timely manner. Resident 1 (R1) was diagnosed with COVID-19 on May 6, 2024. R1 was quarantined to their room and spent most of their time recovering. On May 11, 2024, a pressure injury was discovered on R1’s right ankle during a shower. The pressure injury was reported to Staff 1 (S1), who called R1’s Primary Care (This is an amended report from 8/18/25, the correction is on the third page of the LIC9099C) Substantiated (Continued from LIC9099 2 of 3) physician. The front desk for the office was closed due to it being a Saturday, and according to S1, they left a message for the Physician requesting a return call to discuss R1’s pressure injury. Three different staff members observed R1’s pressure injury, and they all provided different descriptions of it. Although a body check form is required when a pressure injury is discovered on a resident, there was not one done. Staff 2 (S2) said they checked R1’s pressure injury on May 12, 2024, and May 13, 2024, and stated the pressure injury had not improved or worsened, there was no documentation, or information provided by other staff that R1’s pressure injury was monitored. In addition, no one from Mesaview called the Physician’s office on Monday, May 13, 2024, to follow up about R1’s pressure injury. R1 was transported from the facility to the medical office on May 14, 2024, for a follow-up appointment referencing their May 6, 2024, COVID-19 diagnoses. During the visit, the medical office staff discovered R1’s right ankle pressure injury, and the sock they were wearing was stuck to their skin due to the fluid oozing from the pressure injury. R1 was evaluated by the medical office’s staff, who diagnosed R1’s pressure injury as an unstageable pressure injury due to the injury being covered with slough and being unable to see the depth of the wound. R1 was transported to the Hospital where they were admitted and administered antibiotics to treat their pressure injury. On May 17, 2024, it was alleged that a resident developed a pressure injury, and staff did not seek medical attention for the resident in a timely manner. S2 was interviewed and stated they discovered R1’s pressure injury on May 11, 2024, in the early morning while changing R1. S2 described the pressure injury as being a circle about the size of a quarter, with redness and an outer red ring around the pressure injury. S2 stated on May 11, 2024, that they reported R1’s pressure injury to the medical office by leaving a message. On Monday, May 13, 2024, Mesaview staff did not receive a call from the medical office related to R1’s pressure injury, and no one from Mesaview called the office to follow up about R1’s pressure injury. Staff 4 (S4) was interviewed, and they stated they discovered R1’s pressure injury on May 12, 2024, while changing R1. S4 described R1’s pressure injury as a “boil, a little red and a little wet.” During an interview with OS1, they stated that R1’s sock was stuck to their skin due to the fluid oozing from the pressure injury. OS1, as well as two physicians at the medical office, diagnosed the pressure injury as an unstageable pressure injury. (Continued on LIC9099) (Continued from LIC9099 3 of 3) OS1 said the wound was diagnosed as unstageable due to it being covered with slough and their inability to see how deep the wound was. OS1 had R1 transferred to the Hospital to be further evaluation and treatment. Staff 4 (S4) was interviewed, and they stated they discovered R1’s pressure injury on May 12, 2024, while changing R1. S4 described R1’s pressure injury as a “boil, a little red and a little wet.” During an interview with OS1, they stated that R1’s sock was stuck to their skin due to the fluid oozing from the pressure injury. OS1, as well as two physicians at the medical office, diagnosed the pressure injury as an unstageable pressure injury. OS1 said the wound was diagnosed as unstageable due to it being covered with slough and their inability to see how deep the wound was. OS1 had R1 transferred to the Hospital to be further evaluation and treatment. OS1 said the first stage of the pressure injury would have been redness, which should have been immediately reported. The staff should have monitored the area closely and rotated the patient to prevent the pressure injury from worsening. By the time R1 was examined at the medical office on May 14, 2024, their pressure injury was open, oozing, and stuck to their sock from the fluid covering the pressure injury. Although S1 stated they checked R1’s pressure injury on May 12, 2024, and May 13, 2024, and stated the pressure injury had not improved or worsened, there was no documentation or information provided by other staff that R1’s pressure injury was monitored. OS1 said they found no record of Mesaview staff calling the medical office on May 11, 2024, or any other time to report R1’s pressure injury. OS1 confirmed the clinic’s front office is closed during the weekend; however, Mesaview is also provided with a 24-hour emergency number for these calls so the staff can respond to them immediately. The Department investigated the above allegations, and the preponderance of the evidence standard was met. Therefore, the above allegations are substantiated. Pursuant to the California Code of Regulations, Title 22, Division 6 deficiencies were cited on the attached 9099-D. An immediate civil penalty of $1000 was assessed during today's visit for the facility's neglect.lack of care and supervision resulting in a resident's pressure injury and hospitalization. At this time, per Health and Safety Code Section 1569.2(c), an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with the Assistant Manager, Ileana Castro, and a plan of correction was jointly developed. A copy of these reports, along with Licensee/Appeal Rights (LIC 9058 03/22), was provided after the visit.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 08-AS-20240517083953

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Aug 18, 2025

Observation of the Resident, staff must observe residents for changes in condition and respond appropriately. (The licensee shall ensure that residents are regularly observed for changes in physical,mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any) This requirement was not met, as evidenced by: Based on records review and interviews, the licensee did not observe the resident for changes in 1 out of 30 residents. This posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: The plan of correction was cleared on today’s date. The facility also conducted an in-service on skin care, pressure ulcers, and reporting. The facility has implemented a new skin assessment sheet to address the deficiency and has provided the LPA with the documentation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Aug 18, 2025

Incidental Medical Care -The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health.. This requirement was not met, as evidenced by: Based on records review and interviews, the licensee did not accord incidental medical care to 1 out of 30 residents. This posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: The plan of correction was cleared on today’s date. The facility also conducted an in-service on skin care, pressure ulcers, and reporting. The facility has implemented a new skin assessment sheet to address the deficiency and has provided the LPA with the documentation.

Allegation investigated: Staff did not safeguard resident’s belongings

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced complaint visit to invistigate and deliver findings regarding the above-mentioned allegations. The LPA was greeted by Administrator Genoveva Guerrero, who identified herself and disclosed the purpose of the visit. The Department’s investigation consisted of a review of records and interviews with internal and external sources. On July 31, Community Care Licensing (CCL) received a complaint alleging that a bottle of perfume went missing approximately two years ago and recently a blue robe is missing from Resident #1(R1) room. Reporting Party did state that R1 has issues with cognition thinking and grew irritated when pressed for further details. An interview with the responsible party reveals they are not sure if the resident has ever owned a robe and do not recall seeing a robe. They are aware of the reported missing bottle of perfume; however, after talking to R1, they are unclear if the resident used up the contents of the bottle or misplaced it. (continued on LIC9099) Unsubstantiated (Continued from LIC9099) During the investigation, interviews were conducted with multiple residents and staff. The interviews reveal they have no concerns with items missing from residents rooms. Multiple staff and client interviews also reveal they have no concerns over theft in the facility. Interviews with Administrator reveal belongings of any value are kept in a basket in a locked cabinet, accessible to residents upon request. Interview with R1 reveals they cannot confirm timelines nor did they mention any staff or other residents taking items, only that the two items were not in their possession. Based on interviews and observations a preponderance of evidence does not exist to support the allegation that staff did not safeguard resident’s belongings. The allegation is therefore unsubstantiated. An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 4, 2025 · control 08-AS-20250731164958

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Rodgers was welcomed by, identified herself to, and discussed the purpose of the visit with Genovea Guerrero. According to the facility’s license, the facility has a maximum capacity of thirty (30) residents, ages 60 years and over, all of whom may be non-ambulatory and five (5) of whom may be bedridden. A hospice waiver for eight (8) residents has been approved. LPA, accompanied by licensee’s staff, 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. Doors, windows and 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’s ambient internal temperature and hot water temperature at taps accessible to clients were all compliant. There was 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. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. 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 multiple staff and clients. LPA reviewed multiple staff and client records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. No Citations were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Guerrero, to whom a copy of this report were provided during the visit.the state’s words, verbatim · CDSS document, Aug 4, 2025

Type of visit: Collateral

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced collateral visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Genoveva Guerrero, Administrator. This visit is to Amend a visit with Resident 1. The administrator informed LPA that the Resident was currently out in the community. LPA Domingo thanked the administrator for her time and did not conduct a tour or any interviews at this time. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22) were left with the Executive Director, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Dec 3, 2024

Allegation investigated: Staff are not attending to resident's hygiene needs

Licensing Program Manager (LPM) Simon Jacob and Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings in the above complaint allegation. LPM and LPA identified themselveself and discussed the purpose of the visit with Ileana Castro Vasquez, Assistant Manager. On May 23, 2024, Community Care Licensing (CCL) received a complaint alleging that staff are not attending to resident's hygiene needs. During the investigation, LPA Domingo conducted a facility tour, collected pertinent records, and conducted interviews. (Continued on LIC9099C) Substantiated Continued from LIC9099 It was alleged that staff are not attending to resident's hygiene needs. Resident 1 (R1), (Please refer to the LIC811 confidential names), who reported to Outside Source 1 (OS1), that on Wednesdays and Thursdays the night shift does not attend to R1's hygiene needs. R1's records were reviewed and the Physician's Report LIC602 documented that R1 was able to make decisions with no cognitive deficits. R1 was interviewed and R1 stated that only during the month of May 2024, the night time staff did not respond to R1's call light for a request to assist with hygiene needs. R1 stated that waiting for over an hour was not acceptable. Outside source 1 (OS1) was interviewed and stated that R1's allegation was reviewed with management and staff and was confirmed to be a valid complaint. Outside Source 2 (OS2) stated that R1 discussed R1's concerns with the night time staff for the month of May 2024 and OS2 confirmed that staff were not addressing R1's hygiene needs due to the call light system was not functioning. Staff 1 (S1) and Staff 2 (S2) was interviewed and confirmed that R1's complaint of not attending to resident's hygiene needs were valid for the month of May 2024 due to the call light was not working. Based review of records and interviews a preponderance of evidence exists to support the allegation that staff are not attending to resident's hygiene needs. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Ileana Castro Assistant Manager, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Ileana Castro Assistant Manager.the state’s words, verbatim · CDSS document, Oct 28, 2024 · control 08-AS-20240523154148

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Nov 27, 2024

Basic Services. The facility shall be responsible for meeting the resident's needs, as specified in Section 87457, Pre-admission Appraisal and providing the other basic services…This requirement was not met as evidenced by: Based on record review and interviews, Licensee did not provide basic services, as specified in Section 87457, for 1 of 28 residents in care [R1]. This posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2024

Plan of correction: Licensee agreed to arrange vendor training for all staff, specifically related to resident post-dialysis treatment hygiene, clothing and bandage changes. Licensee to forward written proof training has been scheduled and completed to CCLD by 11/27/2024.

Allegation investigated: Staff restrained a resident

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Administrator Genoveva Guerrero. On April 12, 2024 Community Care Licensing (CCL) received a complaint alleging staff restrained a resident. During the investigation, LPA Domingo conducted a facility inspection, collected pertinent records, and conducted interviews. According to allegations received, Outside Source 1 (OS1), (Please refer to LIC811 confidential names list), observed Resident 1 (R1) with a gait belt wrapped around R1's wheelchair and around the resident to prevent the resident from getting out of the wheelchair. Continue on LIC9099C Substantiated Continued from LIC9099 On April 18, 2024 LPA Domingo interviewed Staff 1 (S1) and S1 stated that S1 does not recall the gait belt wrapping around R1's wheelchair including R1's body. S1 stated that the gait belt is used to help reposition and transfer R1 and is sometimes left on R1's waist because R1 has a history of bending down to remove anything on his feet (Socks, shoes, and slippers). S1 verified that S1 did participate in the care plan meeting on April 12, 2024. On May 6, 2024 LPA Domingo interviewed Outside Source 2 (OS2) and OS2 stated that there was not a gait belt wrapped around R1's wheelchair and body the day of the care plan meeting on April 12, 2024. On May 6, 2024 LPA Domingo interviewed Outside Source 3, (OS3) and OS3 stated that OS3 did observe the gait belt wrapped around the wheelchair and waist of R1. OS3 stated that prior to the meetings conclusion OS3 completed a training with the people present at the care plan meeting and reviewed the health and safety reasons to not wrap a gait belt around a person and the wheelchair to prevent the person from falling. On May 7, 2024 LPA Domingo interviewed Outside Source 4 (OS4) and OS4 verified that there was a gait belt wrapped around the wheelchair and waist of R1. OS4 concurred with OS3 that a training with the staff present at the care plan conference to review the health and safety reasons to not use the gait belt as a restraint. LPA Domingo attempted to interview other residents in care, but due to their limited cognitive ability no credible information could be attained. Based on interviews and observations a preponderance of evidence exists to support the allegation that staff restrained a resident. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Administrator Genoveva Guerrerothe state’s words, verbatim · CDSS document, May 8, 2024 · control 08-AS-20240412163346

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(3) · Plan of correction due date: May 8, 2024

Personal Rights. Each clients has the right to be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement is not met as evidenced by: On 4/12/24 1 out of 29 residents was observed with a gait belt around the wheelchair and body. The gait belt around the wheelchair and body was a restraint and a violation of the resident's personal rights. This poses a potential safety risk to clients in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: The licensee scheduled an in service on how to use a gait belt. Which was held on 4/24/24 The training material and sign in sheet was provided to CCLD on 5/8/24

Allegation investigated: Staff did not meet resident's needs

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Administrator Genoveva Guerrero. On May 1, 2024 Community Care Licensing (CCL) received a complaint alleging staff restrained a resident. During the investigation, LPA Domingo conducted a facility inspection, collected pertinent records, and conducted interviews. On May 8, 2024 LPA interviewed Resident 1 (R1) and R1 stated that R1 feels that staff do meet resident's needs. R1 stated that the facility staff address R1 needs in a timely manner. R1 stated that R1 has challening days but that does not reflect the care the facility staff provide for R1 or other residents. R1 stated that the facility has a communication log that assist with understanding R1's needs and R1 agrees that the communication log works well. Unsubstantiated Continued from LIC9099 On May 8, 2024 Resident 1 (R1) was interviewed and R1 stated that there was a possibility that R1 may have broken the call light in R1's room but verbalized that R1 prefers to not have a call light. S1 and R1 both agreed to have a smart button that R1 has on her person to alert staff if R1 needs staff assistance. R1 is the only resident with a smart button the other residents have a call light in the rooms to alert staff if there is a need for assistance. LPA Domingo attempted to interview other residents in care, but due to their limited cognitive ability no credible information could be attained. Based on interviews and observations a preponderance of evidence does exists to support the allegation that residents call light did not work. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Continued from LIC9099 Staff 1 (S1) was interviewed and S1 provided the care plans that the staff are working on to provide better assistance with R1's needs. S1 provided the staff schedule and there is appropriate staffing for the residents needs. Outside Source 1 (OS1) was interviewed and there has not been any complaints regarding residents needs are not being met. Outside Source 2 (OS2) was interviewed and OS2 has not observed residents needs not being attended to. LPA Domingo attempted to interview other residents in care, but due to their limited cognitive ability no credible information could be attained. Based on interviews and observations a preponderance of evidence does exists to support the allegation that staff are not meeting residents needs. The allegation is therefore unsubstantiated. An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 8, 2024 · control 08-AS-20240502165909

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1) · Plan of correction due date: Jun 7, 2024

Facilities shall have signal systems...All facilities licensed for 16 or more...shall have a signal system which shall: Operate from each resident's living unit. Transmit a visual and/or auditory signal to a central staffed location...loud enough to summon staff. This requirement was not met as evidenced by: Based on LPA direct observation the licensee did not have a functional signal system for 27 of 28 persons in care which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee agreed to do "Call light checks" every week and will conduct a management training regarding Call light system and will provide proof of training to LPA by POC due date of 6/7/24

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Genovea Guerrero. According to the facility’s license, the facility has a maximum capacity of thirty (30) residents. During today’s inspection, there were a total of twenty nine (29) residents in care. The facility is licensed to serve 30 residents, ages 60 years and over, all of whom may be non-ambulatory and five (5) of whom may be bedridden. A hospice waiver for eight (8) residents has been approved. The facility currently has six (6) resident receiving hospice care. LPA, accompanied by licensee’s staff, 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 and 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’s ambient internal temperature was 71 degrees F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 113 degrees F, Bathroom #1 sink was 113 degrees F, and Bathroom #2 sink was 113 degrees F. Refrigerator temperature was 40 F and freezer temperature was -2 F. There was 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. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the licensee's staff, 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. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs 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 required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Genoveva Guerrero, 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, Mar 20, 2024

Allegation investigated: -Licensee did not meet the needs of a resident, resulting in dehydration -Staff are retaliating against the resident

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the investigation regarding the above mentioned allegations. LPA met with Assistant Manager, Ileana Castro. During the investigation, records were reviewed, and interviews were conducted with staff and outside sources. It was alleged that the licensee did not meet the needs of Resident #1(R1), resulting in dehydration. R1’s Physician’s Report dated 11/19/19 indicated R1 had a Major Neurocognitive Disorder, Ambulatory but uses an assistive device, and able to dress/groom, toilet and feed themselves. R1’s Resident Appraisal dated 07/20/20 indicated services needed with transfers, bathing, dressing/grooming, help with moving about the facility, reminders with eating, toileting, medication management, and night supervision needed for fall risk, and wandering. It also indicated R1 refuses assistance with those services needed. R1’s medical records reflected on 10/04/20 R1 was transported to the hospital and diagnosed with dehydration and fecal impaction and returned to the facility the same day. Continued on the LIC 9099C. Unsubstantiated Outside source interviews revealed R1 reported they are drinking 3 oz of water daily. The outside source confirmed R1 was forgetful due to their medical condition but able to determine if they drank water, just not the accurate amounts. The facility’s Hydration Log dated 09/21/20 through 10/07/20 confirmed R1 was drinking water, coffee, milk and refusing fluids on multiple occasions. Staff interviews confirmed R1 was offered water multiple times a day but refused at times and requested milk or coffee. Further staff interviews revealed two (2) bottles of water were kept on R1’s night stand next to their bed and R1 was capable of drinking on their own. It was also alleged staff are retaliating against R1. It was reported staff are calling 911 for R1, which was unnecessary and costly, and not allowing visitation. Outside source interviews revealed it’s costly when the facility contacts 911 for R1. Outside sources also indicated they believe it was unnecessary and the facility was purposely contacting 911 so that R1 will incur costs. Staff interviews showed its facility policy if a resident complains of pain, hits their head and/or does not look well, they ensure the resident receives timely medical attention. On 09/28/20, R1 reported to staff they were not feeling well and very weak. Staff observed R1 was having difficulty bearing weight, so they had R1 sit down under the covered patio area and offered R1 a cup of water. The staff also recorded a video of R1 appearing lethargic and encouraging R1 to drink water. The facility provided R1’s responsible party with the video to show R1 was not well and required medical attention. Staff interviews revealed R1’s responsible party did not agree R1 required medical attention after reviewing the video. Outside source interviews identified R1’s responsible party believed staff should have placed R1 in an air-conditioned room and provided R1 with water, instead of contacting 911. Staff interviews confirmed R1 was in an air-conditioned room for many hours and provided water. Staff felt it necessary to send R1 out for evaluation as a precaution and ensure they meet R1’s needs. R1 was diagnosed at the hospital with dehydration. Therefore, the medical visit was necessary and not for retaliation purposes. Facility visitations were restricted during Covid-19 Pandemic. The facility had a visitation area that was enclosed, which allowed for only one (1) resident to visit their visitor at a time. A visitor came to visit R1 but R1 refused the visit. Also, one evening a visitor was visiting a resident when another visitor wanted to visit with another resident. However, the covid 19 restrictions for the facility allowed only one (1) visitor, which upset the other visitor. The visitor was not told they cannot visit, just needed to wait their turn. The facility followed Covid-19 visitation requirements. Continued on an LIC 9099C. During the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Assistant Manager, Ileana Castro whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Nov 17, 2023 · control 08-AS-20200928154706