Mydor's Open Guest Homes, Inc. V

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin arrived at 9:22 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator Amelita Antonio and Juanito Pasion 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: Physical Plant & Environment Safety: The fire extinguisher was last charged and inspected on 2/25/26. The facility has 4 resident bedrooms and 2 bathrooms currently occupying 2 residents. The facility has smoke and carbon monoxide detectors which were tested and working at time of visit. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid flooring. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant and cleaning solutions are inaccessible to residents in care and locked in laundry room cupboards. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Operational Requirements: The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 12/30/26. The facility is approved for a capacity of 6. The fire clearance is granted for 6 Non-Ambulatory of which 2 may be bedridden. Hospice is approved for 4. Staffing, Records & Training: The facility currently employs 1 full-time and 2 Administrators and has additional on call staff if needed. Staff records are kept confidential. Files reviewed had current 1st Aid, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Current Administrator Certificates will expire 08/02/27 and 03/22/28. Staff have annual training completed for all subjects/topics and hours for 2025. Continued 809-C 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 2 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, 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. All food is covered, stored and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. 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 a 2 residents’ medications, no labels were altered, and all medications were kept in their original containers. Caregiver was able to clearly explain the process, all records are clear, and update to date. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills and monthly fire drills. 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 accepts dementia residents in care. The facility has 1 gate on the side of the home. The facility currently has 1 resident with dementia. All door and gate alarms were operational. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Mar 12, 2026

Allegation investigated: Staff handled resident roughly resulting in injury Staff do not have required training for transferring residents

Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegations. LPA was accompanied by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Miquel Magana. LPA identified themselves and met with administrator Juanito Pasion, to discuss the purpose of the visit and elements of the complaint. During the visit LPA collected relevant documentation, including training, physician report, staff and resident rosters, and interviewed two (2) care staff, and one (1) administrator. During the investigation LPA also conducted a phone interview and a collateral visit to a day program to interview relevant witnesses. On the allegation: Staff handled resident roughly resulting in injury It was alleged that on 8/15/25 Resident 1 (R1) showed a witness their arm, and a bruise was observed on R1’s left arm. The witness was told that staff had rubbed R1’s arm with a cloth and it was believed this caused R1 to have a bruise. On 8/26/25 staff was observed assisting R1 with sitting up and getting to the edge of R1’s bed, continued on 9099-C Unsubstantiated it was alleged that staff grabbed R1’s left arm with staff’s right hand, and with staff’s left hand, staff grabbed the back of R1 neck and pulled R1’s head forward, pushing R1’s body forward by R1’s arm and neck, to pull R1’s body towards the end of the bed. The use of R1’s neck to move them was alleged to be forceful and unnecessary. Interview with staff was conducted, staff demonstrated transfer assistance techniques used and discussed injury to the arm. Staff explained that injury is believed to be caused when R1 was leaning against a safety rail that is on the toilet. Staff stated that the injury resulted in a bruise, but did not state any blood was present. Staff explained that they rubbed the area where the indent and bruise occurred, stating they rubbed with their gloved hand, but did not use a cloth. Incident reports reviewed stated that on 8/15/25 program observed the bruise to the left arm below the elbow and to the side of the arm, program stated that R1 was unclear when this happened and why there was a bruise. Incident report provided by facility stated that on 8/11/25 R1 was on the toilet for 15 minutes, when staff noticed that R1’s left elbow was learning against the safety rail and staff observed a small blister on the left lateral elbow. Images of the safety rail with a nut at the end of a screw were provided to Community Care Licensing. The screw was on the inner parts of the safety rail in the front portion of the rail, it appeared that this was part of the design of the rails, not the facilities creation. The facility also provided images of replacement toilet safety rails with no protruding attachments to ensure this did not occur again. LPA spoke with R1, LPA also took a photo of the area where the injury occurred. A red mark in the upper/outer part of the left arm is still present. It is plausible that the injury occurred when the resident was leaning against the bar due to the position of the mark, and the location of the bold that is on the toilet safety rail. It is unclear if a cloth was used as there is conflicting information to that point. LPA observed that R1’s skin is very soft and thin, when LPA took the image of the arm. R1 has been a resident of the facility for 10 years, R1 stated to LPA and QAS that they are safe, that there was no issue with the help given during transfers, R1 stated they are able to do many movements on their own, this was confirmed with discussions done with staff at the collateral visit who stated R1 does much of the transfers to and from toileting on their own, with staff standby assist. Based on interviews and documentation it is believed that a bruise was caused on or about 8/11/25. Based on interviews, it is unclear if the injury is due to staff rubbing the arm with a cloth, or the resident leaning against a safety rail. The allegation may have happened or is valid but there is insufficient evidence to support that, therefore, the allegation is deemed Unsubstantiated at this time. Continued on 9099-C On the allegation: Staff do not have required training for transferring residents It was alleged that on 8/26/25 it was observed that staff assisted R1 with sitting up and getting to the edge of R1’s bed, staff grabbed R1’s left arm with staff’s right hand, and with staff’s left hand, staff grabbed the back of R1 neck and pulled R1’s head forward, pushing R1’s body forward by R1’s arm and neck, to pull R1’s body towards the end of the bed. It is alleged that staff have not been trained. LPA requested documentation of all training provided to staff regarding the positioning, transferring, and assistance used for residents. Training documents were provided, LPA noted that current staff is listed on the training dated 7/20/24. Additional transfer training is scheduled for this afternoon by a nursing consultant. Credentials and training of the consultant were reviewed by the LPA to be appropriate regarding both education and various forms of experience and skills. LPA asked staff to show QAS and LPA how they assist and transfer R1. LPA and QAS observed staff explain their techniques. The explanation of both staff and the administrator provide that staff are aware that the neck should not be used for repositioning. The administrator stated that the consultant will come today and observe staff technique to ensure all skills are refined and reenforced. Based on interviews, observations, and training documentation the allegation is unsubstantiated as records were provided, and the facility quickly scheduled additional training when asked by the Long-Term Care Ombudsman to ensure the confidence and safety of the resident. Exit interview conducted and copy of the report provided.the state’s words, verbatim · CDSS document, Sep 5, 2025 · control 29-AS-20250829142554

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin arrived at 11:25 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator Amelita Antonio and Juanito Pasion 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: Physical Plant & Environment Safety: The fire extinguisher was last charged and inspected on 01/13/25. The facility has 4 resident bedrooms and 2 bathrooms currently occupying 5 residents. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats/flooring. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant and cleaning solutions are inaccessible to residents in care and locked in laundry room cupboards. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Operational Requirements: The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 01/30/26. The facility is approved for a capacity of 6. The fire clearance is granted for 6 Non-Ambulatory of which 2 may be bedridden. Hospice is approved for 4. Staffing: The facility currently employs 3 full time and 1 Administrators and has additional on call staff if needed. Staff records are kept confidential. Files reviewed had current 1st Aid, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Current Administrator Certificate will expire 08/02/25. Continued 809-C Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for all subjects/topics and hours for 2024. Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible. 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. All food is covered, stored and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. 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 a sample of residents’ medications, no labels were altered, no medications were expired and all medications were kept in their original containers. Caregiver was able to clearly explain the process, all records are clear, and update to date. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. 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 accepts dementia residents in care. The facility has 1 gate on the side of the home. Facility does have one resident currently on oxygen. The facility currently has 3 hospice residents in care. The facility currently has 1 resident receiving Home Health services. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Mar 12, 2025

The state marks this report as 7 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Miller arrived at 10:00 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator Amelita Antonio 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 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. 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 January 22, 2024. The facility has 4 resident bedrooms and 2 bathrooms currently occupying 5 residents. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. 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 and cleaning solutions are inaccessible to residents in care and locked in laundry room cupboards. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard 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 January 30, 2025. The facility is approved for a capacity of 6. The fire clearance is granted for 6 Non-Ambulatory of which 2 may be bedridden. Hospice is approved for 4. Staffing: The facility currently employs 3 full time and 3 on-call staff and 2 Administrators. Staff records are kept confidential. Files reviewed had current 1st Aid, 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 that will expire August 2, 2025. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for all 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 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, 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. 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 residents medications, no labels were altered, no medications were expired and all medications were kept in their original containers. Continued 809-C Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. 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 accepts dementia residents in care. The facility has 1 gate on side of the home. Facility does not currently have anyone on oxygen . The facility currently has 3 hospice residents in care. The facility currently has 1 resident receiving Home Health services. Exit door alarms are working. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Mar 8, 2024