Baron's Loving Care - UC

Allegation investigated: Staff did not administer medications as prescribed

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and was allowed entry into the facility by Staff, Medenio Villar. Staff, Esther Villar arrived during the visit and discussed the allegation. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff did not administer medications as prescribed. It was reported staff were crushing medications and placing them in pudding. A review of medication orders for Resident #1 (R1) indicated only six (6) out of nine (9) medications were allowed to be crushed. Staff confirmed 8 eight (8) out of nine (9) medications were being crushed, due to R1 requesting all medications be crushed. Staff admitted they were aware there was no order on file to crush all medications but it was crushed due to R1 insisting. The facility did not have a Medication Administration Record on file for R1. Continued on LIC 9099C. Substantiated It was also alleged that staff did not keep the facility clean. It was reported the toilet was not kept clean. On 08/30/26, an outside source reported they observed the restrooms at the facility to be clean, including the toilets. On 09/08/26, LPA observed the bathrooms and toilets were clean. In addition, resident interviews revealed the bathrooms and toilets were kept clean. Today, LPA observed lunch being cooked, which consisted on beef stew with green beans, mashed potatoes and ice cream for dessert. During the course of the investigation, interviews were conducted, and records were reviewed. The allegations may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Staff, Esther Villar whose signature below confirms receipt of these rights. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 was cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Staff, Esther Villar whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Sep 8, 2026 · control 08-AS-20260831141810

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 15, 2026

Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not administer medications as prescribed for 1 out of 5 residents [R1], which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 8, 2026

Plan of correction: All staff that dispense medications will attend medication training through a vendor and provide proof of training by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Deficiencies visit. LPA identified herself and was allowed entry into the facility by Staff, Medenio Villar. Staff, Esther Villar arrived during. LPA was at the facility to conduct a complaint investigation and observed deficiencies. Upon arrival, LPA observed the garage that stored chemicals had a padlock, that was unlocked, making it accessible. Staff were inside the facility and the garage was unattended. A review of the facility's freezer reflected a package of meat that had torn plastic, allowing air exposure to the meat. The meat had freezer burn from the exposure. There were other meat products not in their original packaging without labels or dates to indicate what the items were. Resident #1 (R1) had some unusual incidents that occurred at the facility to include, a medical condition requiring attention. Staff contacted 911 but R1 refused transport. The paramedics were also contacted a week later for the same medical condition, which R1 refused again. On a different day, R1 was transported by their Power of Attorney to the hospital. In addition, R1 wandered outside of the facility and down the street, staff had line of sight supervision. R1's Physician's Report dated 07/17/26, indicated R1 was not allowed to leave the facility unassisted. However, none of the incidents involving R1 was reported to Community Care Licensing. LPA requested the Medication Administration Records (MARs) for R1. However, staff did not have any for R1. LPA requested to review the MARs for the other residents. Staff brought the MARs for August 2026. LPA requested the current MARs for September 2026 for the other residents. Staff was taking a prolonged period of time to provide the records. Therefore, LPA went to inquire about the delay and observed staff completing the MARs for September by initialing their name in the boxes. Staff stated medications were administered for September 2026 but they did not complete the MARs when they administered the medications. Staff initialed the boxes for September with the assumption all the previous medications were dispensed due to not completing the MARs when the medications were actually dispensed. Continued on LIC 809C. In addition, a review of R1's Physician's Report dated 07/17/26, indicated R1 was ambulatory but did not have the capacity for self care, regarding bathing, dressing/grooming, feeding, toileting, cash resources, and medication management which was a prohibited health condition. The licensee did not submit an exception request prior to admitting R1 to the facility. In addition, the report reflected R1 was unable to follow directions, and unable to communicate, and it did not have a primary diagnosis. Deficiencies were observed and cited on the attached LIC 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Staff, Esther Villar whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Sep 8, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Sep 15, 2026

Storage Space and Access. Except as specified...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...and other similar items which could pose a danger...locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observations, the licensee did not ensure cleaning solutions were locked and/or unattended for 5 out 5 residents [R1-R5], which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 8, 2026

Plan of correction: Staff locked the garage during the visit, removing the immediate threat. In addition, staff will attend training on ensuring chemicals and items that can pose a danger are inaccessible to residents. Proof of training will be submitted by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(9) · Plan of correction due date: Sep 15, 2026

General Food Service Requirements. Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by: Based on observations, the licensee did not ensure food was properly stored for 5 out 5 residents [R1-R5], which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 8, 2026

Plan of correction: Staff disposed of meat that was freezer burned due to air exposure. In addition, all staff will attend training on food storage and provide proof of training by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 15, 2026

Reporting Requirements. A written report...within seven days of the occurrence...(A) through (D) below. This report...and disposition of the case. Any incident...resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not submit incident reports involving 1 out of 5 residents [R1], which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 8, 2026

Plan of correction: Administrator and staff will attend training regarding reporting requirements and submit proof of training by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Sep 15, 2026

Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not ensure records were accurately maintained for 5 out 5 residents [R1-R5], which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 8, 2026

Plan of correction: Administrator and staff that assist with record keeping will attend training and provide proof of training by POC due date.

Type of visit: Prelicensing

Licensing Program Analyst (LPA), Natasha Persaud conducted a Prelicensing inspection. An initial application to operate a Residential Care Facility for the Elderly was received on 10/01/25. The facility was approved to care for six (6) Non-Ambulatory, of whom one (1) may be bedridden in room #1. LPA was greeted and allowed entry into the facility by Staff, Esther Villar and Applicant, Agnieszka Norton. Structure- The facility is a single story structure with 7 bedrooms and 2 bathrooms. There is an outdoor covered area for resident use. No bodies of water were observed. Bedrooms Residents- Rooms #1-#6 may be used for Non-Ambulatory. Bedridden, room #1 only. Bedrooms Staff- There is 1 staff room, bedroom #7. Bathrooms- All bathrooms have a working toilet, sink, grab bars and tub/showers with non-skid mats. Linens & Hygiene Supplies- Adequate supply. Emergency Phone Numbers, Exit Plan and Required Postings- Posted. Smoke Detectors and Carbon Monoxide Detectors- Interconnected and hardwired. Appliances- Stove burners, oven, microwave, washer, and dryer working. Toxins- Stored in a locked cabinet. Water Temperature- Measured at 118 degrees F. Medications- Centrally stored and locked in a cabinet. First-Aid Kit- Stored in a locked cabinet. Resident & Staff Files- Located in the office and in a locked cabinet. Activities- Adequate supplies to include exercising, games, and puzzles for resident's use. Fire clearance- Approved on 10/28/25. Component III- Conducted at the Pre-Licensing visit. Information provided about how to operate the facility within substantial compliance. All items reviewed during the visit are in compliance. Prelicensing is complete and this facility has no deficiencies. Facility appears to be ready for licensure pending final review. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Applicant, Agnieszka Norton whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jun 11, 2026

Type of visit: Prelicensing

Licensing Program Analyst (LPA), Natasha Persaud conducted a Prelicensing inspection. An initial application to operate a Residential Care Facility for the Elderly was received on 10/01/2025. LPA was greeted and allowed entry into the facility by Staff, Esther Villar and Applicant, Agnieszka Norton. During today’s visit, LPA, accompanied by the applicant, toured the interior and exterior of the facility and inspected each room. There were items which must be corrected for the facility to comply with regulations. The applicant did not pass the pre-licensing inspection, and a return visit will be required. In addition, the applicant was made aware additional time will be spent at the next visit to assist the applicant with Title 22 Regulations and basic facility knowledge, as the administrator was not aware of new law changes within licensing. Pre-Licensing is incomplete with deficiencies to be resolved by 06/04/26. A follow up Pre-licensure LIC809 will be generated upon resolution of deficiencies." An exit interview was conducted with the applicant 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, May 26, 2026

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 5 COMP II Participants: Agnieszka Norton, Owner/Administrator Interview Method: Telephone interview On May 13, 2026, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, May 13, 2026