Welcome Home II (RCFE)

Allegation investigated: Staff do not administer resident’s medication as prescribed. Staff do not provide accurate dosage of medication to resident. Staff did not provide proper supervision, had resident watch another resident in care.

Licensing Program Analyst (LPA) De Leon conducted a Subsequent Complaint visit at the facility above. LPA met with Back up to Administrator Edwin Ingan explained the purpose of the visit. LPA interviewed staff around 2:30pm and resident around 5:15pm. LPA reviewed and requested records. LPA conducted an audit of R1's medications and conducted a pill count on the medications Quetiapine and Lorazepam. On the allegation: Staff do not administer resident’s medication as prescribed. LPA reviewed R1’s Medication lists dated 05/18/2026 and 07/20/2026, Medication Administrator Record (MAR) dated July 2026, Centrally Stored Medication and Destruct Record (CSMDR) for 2026, PRN and One-Time Medication Records for June-July 2026, conducted an audit of pill counts for Quetiapine and Lorazepam medications for June and July 2026. The records and pill counts matched with correct count of medications as of 07/30/2026 when LPA audited the medications and records. Continued 9099-C Substantiated LPA reviewed R1’s medication records which revealed R1 was physician ordered the medication Quetiapine 25mg was to be given 1 time a day at bedtime then on 07/20/2026 prescription was changed to 50mg at 3pm for sundowning, may advance to100 mg daily after 2 weeks if continuing to have disruptive sundowning. The new medication was listed on the CSMDR and on the MAR according to the orders. The start dates of the old and new medication orders for each bottle were listed and the pill counts of medication at the facility matched the records. LPA reviewed records for Lorazepam Medications the new order from the doctor 07/20/2026 was 0.5mg tab PO BID PRN, to be given by mouth 2x per day as needed, based on the record review the facility never used over the prescribed PRN dosage. LPA’S interview with witnesses revealed on a visit in the late morning to the facility on 07/23/2026 to assess R1, the staff could not provide correct paperwork or details about medications and R1 seemed to not be at R1’s normal baseline and seemed out of it. Witness stated witness does not know how R1 normally is after receiving medications in the late afternoon or evenings. LPA interviewed staff 1 (S1) that stated last week it was around the 23rd of July, Staff was not at the facility and said everything should have been documented on the MAR, Staff said R1 had gotten agitated and started displaying sundowning symptoms around 11:00am and it was probably due to R1 not sleeping very well the night before, medication Quetiapine dosage had been increased at the last doctor’s appointment on 07/20/2026 from 25mg to 50mg to help with the new behaviors but on this morning instead of S1 assisting R1 with the medication at 3pm assisted at 11:00am. Staff stated only 25mg was given and per the new order another 25mg could be given later if needed, the new order does say 3pm. Staff had also assisted R1 with medication Lorazepam .05mg ½ tablet at 2:45am and ½ tablet at 1:25pm on 07/23/2026, and that is a PRN as needed from the doctor. S1 said S1 did not call the doctor to get an authorization to assist R1 with medication at 11:00am instead of 3pm, therefore this allegation is Substantiated at this time. On the allegation: Staff did not provide proper supervision, had resident watch another resident in care. LPA received a statement from a witness that stated on 07/21/2026 on a visit to the facility 3 residents in care were observed, Resident 1 (R1) was in the room with Resident 2 (R2), R2 informed the witness that the caregiver had asked the Resident to oversee R1 while the staff were tending to the needs of another resident in care and had to shut the door for privacy leaving R1 and R2 alone together. Continued 9099-C Resident interview revealed resident was upset the staff asked the resident to keep an eye on the resident while going in the other room and shutting the door. R1 is afraid of R2 and did not like being left alone like that. Staff interviews revealed Resident 3 (R3) needs 2 person assist with Hoyer lift so staff told the 2 residents that were in the room together that the staff were going into the other room to take care of R3 and would need to shut the door to R3’s room so if R1 & R2 needed anything the staff would be in R3’s room, Staff stated when staff said that staff did not mean R1 had to watch R2. Based on evidence this allegation is Substantiated at this time. On the allegations: Staff do not provide accurate dosage of medication to resident. LPA reviewed R1’s Medication lists dated 05/18/2026 and 07/20/2026, Medication Administrator Record (MAR) dated July 2026, Centrally Stored Medication and Destruct Record (CSMDR) for 2026, PRN and One-Time Medication Records for June-July 2026, conducted an audit of pill counts for Quetiapine and Lorazepam medications for June and July 2026. The records and pill counts matched with correct count of medications as of 07/30/2026 when LPA audited the medications and records. LPA reviewed R1’s medication records which revealed R1’s physician ordered medication Quetiapine 25mg was to be given 1 time a day at bedtime then on 07/20/2026 prescription was changed to 50mg to be given at 3pm for sundowning, may advance to100 mg daily after 2 weeks if continuing to have disruptive sundowning. The new medication was listed on the CSMDR and on the MAR according to the orders. The start dates of the old and new medication orders for each bottle were listed and the pill counts of medication at the facility matched the records. LPA reviewed records for Lorazepam Medications the new order from the doctor 07/20/2026 was 0.5mg tab PO BID PRN, to be given by mouth 2x per day as needed, based on the record review the facility never used over the prescribed PRN dosage. LPA interviews with staff indicated the prescribed medication being given at 11:00am instead of the prescribed time of 3:00pm, the dosage given was 25mg as the staff was using up the remainder of the previous order for 25mg tablets before starting the 50 mg tablets, and felt another 25mg could be given at 3pm if needed, as it would still not go over the 50mg currently prescribed, the new ordered was ordered on 07/20/2026, it was filled by the pharmacy and was written on the CSMDR with a start date of 07/29/2026, the MAR indicates 2x 25mg tablets were given on 27th and the 28th finishing the old bottle and starting the new bottle on the 07/29/2026. LPA interviews with Witnesses felt R1 was out of it and not normal self on a visit to see R1 later in the morning on 07/23/2026. Records review do not show the staff gave R1 more than the prescribed dosages of medications. Based on the doctor orders the 50mg should have started when the order was filled 07/21/2027 and on 07/23/2026 only 25mg had been given which was under the required dosage but should not have been given at 11:00am and should have been given at 3:00pm therefore this allegation is Substantiated. This will not be cited due to duplication of the same deficiency being issued. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Back up to Administrator. LPA reviewed Resident 1 (R1)’s records which revealed Pre-Placement Appraisal, Functional Capabilities Assessment, LIC. 602A Physicians Report of a visit date of 12/10/2025 with updates and signed on 04/16/2026, Medication list dated 05/18/2026, another LIC. 602 Physicians Report dated 07/20/2026 with a new mediation list dated 07/20/2026 (Due to change in condition) and a signed Admission Agreement dated 04/17/2026. Based on the evidence this allegation is Unsubstantiated at this time. Exit interview conducted, copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 29-AS-20260724130920

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(e) · Plan of correction due date: Aug 11, 2026

(e)For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank,...This requirement was not met as evidenced by: Based on interviews and record review the Licensee did not comply with the regulation above in S1 gave R1 medication Quetiapine at 11:00 am without a dated written order from R1’s physician for the okay to give the 3pm medication at 11:00am which possess a potential Health, Safety and Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Administrator agreed to train all staff on regulation 87465 each residents medications, make sure the facility has signed dated and written orders for all residents medications by physicians, make sure all medication written on the (Cont. below) CSMDR and MAR match the written orders and provide proof of training, staff signatures and an up-to-date LIC 500 to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 11, 2026

(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 requirement was not met as evidenced by: Based on interviews the Licensee did not comply with the regulation above, staff left R1 & R2 alone together in one resident’s room while tending to R3 when R2’s needs require staff supervision which possess a potential Health, Safety and Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Administrator agreed to train all staff in regulation 87464 and facility policy and procedures for care and supervision of each resident in care and follow the resident’s appraisal needs and services plans. Provide additional supervising R1 when the regular staff are busy.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 12:00pm to conducted a 1 year annual visit to the facility above. LPA met with Back up to Administrator Edwin Ingan and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has an Infection Control Plan on file. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. The staff take infection control training annually. Physical Plant & Environment Safety: The facility is a 3 bedroom and 2 bathroom home currently occupying 4 residents and 2 full-time staff with 6 relief staff and additional Administrators. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The gates are self closing and self latching. The facility has table and chairs available outside with shaded area for resident use. Laundry room has working washer and dryer. Operational Requirements: The Facility is operating in compliance with fire clearance. The facility provided current up to date liability insurance. All Dementia requirements are being met. Hospice wavier granted for 3. The facility has 1 residents on home health services. The facility currently has 2 hospice residents. Facility currently had 1 resident on oxygen, signs are posted on the front door and bedroom wall. Personnel Records & Training: The facility keeps confidential files on each staff member. Training records were up to date for 2025-2026 annual training requirements. Continued on 809-C Staffing: The facility employes 6 staff and staff records are kept confidential. Staff records were reviewed for 4 current staff. Staff records had finger print clearance and associations with criminal record statements, personnel record or application, First Aid and CPR certificates and Health screening with TB results. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Facility does submit incident reports to the department when required. Resident Rights Information: All require posting for residents were posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, CCL Complaint poster, and LTCO poster. Nondiscrimination notice, and Signed Admission Agreements. Planned Activities: The facility offers activities to all residents in care. Activities include books, magazines, newspapers, TV watching, daily walks, group discussions and communications, arts and crafts. The facility has sufficient space to allow for activities indoors and outdoors. Interviews with residents revealed they do what they want to do for their leisure. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. Food, snacks and drinks are available when the residents want them. Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed facility uses both Medication Administration Records (MAR) and Centrally Stored Medication and Destruct Records (CSMDR). All medications were in original containers, Prescription labels were not altered, and none of the medication were expired. The doctors orders were present and dispensing instructions were followed. Disaster Preparedness: The current emergency disaster forms were posted and up to date. The facility provided copies of quarterly disaster drills. The fire extinguishers were charged and last inspected on 10/24/2025. The dual smoke and carbon detectors are present and hard wired throughout the facility with sprinkler system. Residents with Special Health Needs: The facility has dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility has a license for 1 bedridden in room #2 only. The facility does not have any delayed egress. LPA conducted interviews with 2 Resident and 2 Staff. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Apr 17, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 9:45pm to conducted a 1 year annual visit to the facility above. LPA met with Administrator Evelyn Florentino and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has an Infection Control Plan on file. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. The staff take infection control training annually. Physical Plant & Environment Safety: The facility is a 3 bedroom and 2 bathroom home currently occupying 4 residents and 2 full-time staff with 6 relief staff and Administrator. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The gates are self closing and self latching. The facility has table and chairs available outside with shaded area for resident use. Laundry room has working washer and dryer. Operational Requirements: The Facility is operating in compliance with fire clearance. The facility provided current up to date liability insurance. All Dementia requirements are being met. Hospice wavier granted for 3. The facility has 2 residents on home health services. The facility does not currently have any hospice residents. Facility currently had 1 resident on oxygen, signs are on the front door and bedroom Personnel Records & Training: The facility keeps confidential files on each staff member. Training records were up to date for 2024-2025 annual training requirements. Continued on 809-C Staffing: The facility employes 8 staff and staff records are kept confidential. Staff records were reviewed for 4 current staff. Staff records had finger print clearance and associations with criminal record statements, personnel record or application, First Aid and CPR certificates and Health screening with TB results. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four Files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), Immunization records, TB results, Personal Rights, and Safeguard for personal property and valuables. Facility does submit incident reports to the department when required. Resident Rights Information: All require posting for residents were posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, CCL Complaint poster, and LTCO poster. Nondiscrimination notice, and Signed Admission Agreements. Planned Activities: The facility offers activities to all residents in care. Activities include books, magazines,newspapers, TV watching, daily walks, group discussions and communications, arts and crafts. The facility has sufficient space to allow for activities indoors and outdoors. Interviews with residents revealed they do what they want to do for their leisure. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. Food, snacks and drinks are available when the residents want them. Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for all 4 residents in care both Medication Administration Records (MAR) and Centrally Stored Medication and Destruct Records (CSMDR) were current and up to date. LPA completed a full audit on one residents medication, all medications were in original containers, Prescription labels were not altered, and none of the medication were expired. The doctors orders were present and dispensing instructions were followed. Disaster Preparedness: The current emergency disaster forms were posted and up to date. The facility provided copies of quarterly disaster drills. The fire extinguishers were charged and last inspected on11/04/2024. The dual smoke and carbon detectors are present and hard wired throughout the facility. The facility has a sprinkler system. Residents with Special Health Needs: The facility has dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility has a license for 1 bedridden on room 2. The facility does not have any delayed egress. The facility does have a current resident with oxygen. LPA conducted interviews with 2 Resident and 2 Staff. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, May 19, 2025

Allegation investigated: Staff did not provide assistance to resident in care in a timely manner. Staff did not provide medical assistance/PT as needed to resident in care in a timely manner.

Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit on March 6, 2024. On June 5, 2024, LPA issued final findings on the allegations above. During the investigation, LPA, Miller, toured the facility and interviewed staff on March 6, 2024, from 1:00 p.m. to 3:00 p.m. LPA also obtained and reviewed relevant documents. LPA met with Evelyn Florentino, administrator and explained the purpose of the visit. On the allegation: Staff did not provide assistance to resident in care in a timely manner. Resident 1 (R1) reported that they fell three days ago while transferring to wheelchair. R1 reported that they were on the floor between 2 to 4 hours waiting for assistance. R1 stated that Staff provided a blanket and pillow, but Staff refused to call the fire department "because they would investigate". R1 stated to the Ombudsman that while getting out of bed they slipped to the floor. This occurred when it was dark outside. It was daylight when two males came to assist R1 off the floor. (Cont.9099-C) Unsubstantiated Staff stated that R1 was admitted to the facility on January 10, 2024, and stayed for nine days. Staff stated that on or about January 12, 2024, R1, called with a notification bell at approximately 7:15 a.m. Staff found R1 sitting in bed and required changing and toileting. R1 attempted to use their standing pole to transfer from bed to wheelchair, but R1 lost their balance. Staff could not support R1’s weight and advised R1 to slide slowly to the floor. R1 requested Staff call 911. Staff determined it was not necessary as R1 had no bruises or bumps and did not complain of any pain. R1 only required to be cleaned up and lifted off floor. Staff cleaned up R1 and provided R1 with a blanket and pillow. After cleaning up R1, Staff called for assistance from another caregiver at 7:45 a.m. R1 was moved into wheelchair by 8:10 a.m. R1 stated that they were okay and had no complaints of injury. There was no evidence of any injury to R1. Administrators and staff collectively dispute that R1 fell from their bed on January 12, 2024 or that R1 was on the floor for an inordinate amount of time after sliding on to floor. On January 14, 2024, a law enforcement officer conducted a welfare check on R1. Staff stated that R1 told the officer they were fine. A police report was not filed, and the officer did not leave a business card. 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 allegation is Unsubstantiated. On the allegation: Staff did not provide medical attention/physical therapy as needed to resident in care. It was alleged that R1 was not receiving necessary physical therapy. Staff stated that Mission Home Health of Central Coast visited the facility and provided R1 with physical therapy on two occasions. In addition, a nurse visited twice to assist with R1 wound care. R1 only resided in the facility for a total of nine days. Staff claimed that the physical therapist advised that R1’s knee was too swollen to perform exercise. Physical therapist advised staff to ensure that R1 perform 5 repetitions of sitting to standing from wheelchair each morning. Staff advised there is no written documentation of these instructions at the facility. Witness 2 (W2) confirmed that a nurse conducted an initial visit of R1 on January 13, 2024, and performed a subsequent visit on January 18, 2024. A physical therapist and occupational therapist conducted evaluations on January 14, 2024, and January 15, 2024, respectively. (Cont. 9099-C) W2 stated that there is no evidence of an exercise plan because R1 was hospitalized effective January 19, 2024. W2 further stated that clinicians were concerned that R1 required a higher level of care. R1 was ultimately moved into a skilled nursing facility. W2 advised that before admissions into facility, R1 was recovering from a left hip fracture that was surgically repaired. 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 allegation is Unsubstantiated. Exit interview conducted, copy of report issued.the state’s words, verbatim · CDSS document, Jun 5, 2024 · control 29-AS-20240301164343

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA Miller) arrived at 10:11 am to conduct a one-year annual visit to the facility above. LPA met with Administrator Evelyn Florentino and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectant sprays and cleaners. The facility has a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environment Safety: The fire extinguisher was last charged and inspected on November 7, 2023. All trash cans and wastebaskets have tight fitting covers. The facility has 3 resident bedrooms and 2 bathrooms currently occupying 3 residents. LPA was authorized to enter and inspect the facility. The facility has a smoke and carbon monoxide detector that was tested. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions are inaccessible to residents in care as they are locked and stored in the garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use and a front patio for client use, with plenty of shade. The facility has telephone and internet service for resident use. Continued 809-C Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on October 18, 2024. The facility is approved for a capacity of 6. The fire clearance is granted for 6 non-Ambulatory, of which 1 may be bedridden in bedroom #2. Hospice is approved for 3. Staffing: The facility currently employs 2 full time staff, 3 part time staff and 1 administrator. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Administrator Certificate expires July 15, 2025. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 3 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians reports, Pre-appraisals, Appraisals Needs and Services Plans, Emergency and ID forms, all forms were legible and records are kept confidential. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. Continued 809-C Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed resident medications; no labels were altered. However, resident medication of Metformin was expired effective 9/16/23 and Administrator immediately called family to get a current refill. In addition, three (PRN) medications for another resident were logged in the CSMR, but not logged in the MAR. Administrator advised the medications were properly given, but not recorded. Administrator will notate the file. Disaster Preparedness: The current emergency disaster forms were posted. The facility last conducted a quarterly disaster drill April 1, 2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility has 2 self latching gates on side of the home. The facility currently has 1 hospice residents in care. The facility currently has 3 residents receiving Home Health services. The facility does not have delayed egress, locked doors or gates. Exit door alarms are working. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, May 22, 2024

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.