Villa Gardens

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 9:25 am to conducted a 1 year annual visit to the facility above. LPA met with Licensee/Administrator Janelyn Castaniaga 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 a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer and visiting hours. The bathrooms have toilet paper, hand dryer, 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 when and if needed. Physical Plant & Environmental Safety: The facility is a 5 bedroom home. Three double bedrooms with 2 on suite bathrooms and 1 common area restroom are dedicated for residents use. There are 2 bedrooms dedicated to live in staff and 2 cleared family members.The facility has 3 residents in care and employs 6 staff, 1 administrator and back up staff on call when needed. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. The kitchen has a gate to make the range inaccessible to dementia residents, and it does not lock. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents locked in the laundry room and locked garage. The facility has sufficient space inside and outside for activities and visiting. Continued 809-C Continued: The facility has a back/side yards for resident use with furniture and plenty of shade. Telephone and internet service is provided for resident use. The facility has a working washer and dryer. Water was tested and measured 109.5 in resident bathroom. Fire Extinguishers were last inspected on 05/07/2026. Operational Requirements: The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance expires 05/01/2027. The facility is approved for a capacity of 6 Non-Ambulatory and has a Hospice waiver approved for 4. Staffing: The facility employes 6 staff, 1 Administrator and back up staff when needed. Staff records are kept confidential. LPA reviewed 4 staff files for Application, finger print clearance, transfer or exemptions and Health screening with TB results. LPA verified administrator file for Administrator Certificate expires 10/22/2027 and renewal with CEU certifications. Personnel Records & Training: The facility keeps confidential files for each staff member. 4 staff files were reviewed for initial and annual training requirements. 4/4 staff files had current 1stAid/CPR/AED certification on file. Initial training records on file. The facility employes LVN's, CNA's and regular caregivers. 4/4 files reviewed did not have annual 2026 training on file. Resident Rights & Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license is posted. CCL reports are posted. Internet is provided to residents in care, confidentiality and privacy are given. Planned Activities: The facility has supplies for activities. The residents currently in care watch TV, go for walks, have discussions with staff and exercise a few days a week. The residents get to do what they want to do. 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. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. Continued 809-C Incidental Medical and Dental: Facility provides 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). Medications for all resident in care are centrally stored. LPA reviewed medications and records. No medication labels were altered, no medications were expired, and all medication was stored in the original containers. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Three 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. Pre-Admission appraisals and functional capabilities assessments are conducted on perspective residents before accepting them into care. The facility does not handle cash resources for any of the residents in care. Facility does submit incident reports to the department when required. 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. Facility has emergency food and water supply, flash lights with batteries, and a cooler with ice packs for medications. The facility has several evacuation sites. The facility has a back up generator if needed. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have any current resident on oxygen. The facility does not currently have any resident receiving hospice services. The facility has no residents currently receiving home health services. Hospice and Home Health care plans are kept on file and up to date with any residents with those services. The facility does not have any delayed egress. The facility has alarmed exiting doors. There are no bodies of water on the premises. LPA conducted interviews with 2 staff and 1 resident. Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Licensee/Administrator by request.the state’s words, verbatim · CDSS document, Aug 24, 2026

The state marks this report as 25 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Staff did not meet resident’s needs Facility is unsanitary

Licensing Program Analyst (LPA) De Leon conducted a 10 day complaint visit to the facility above. LPA met with Lizeth Tunac, Assitant Administrator/LVN and explained the purpose of the visit. LPA toured the facility and spoke with all 4 residents and 2 staff from 10:30am-11:00am. LPA requested a staff roster, resident roster, All 4 residents care plans and LIC 602A medical assessments, and staff Schedule for June 2026. LPA called Licensee/Administrator, no one answered, LPA left a text message for Licnesee to return call. On the allegation: Facility is unsanitary. LPA interviewed witnesses which revealed a resident had a soiled washcloth left by the resident’s head after staff cleaned up resident in bed. Witness also stated a hospice aide came to bathe a resident in care and when going to the resident’s drawer to get clean briefs found a soiled brief with clean briefs in drawer. Continued 9099-C Substantiated LPA observed facility to be clean at the time of visit but the hallway to the resident’s room had an odor of urine. Witnesses also stated a resident’s bed linens have not been changed for several weeks. LPA observed all residents’ beds, several of them did not have the required linens in place and 2 of the beds had dirty blankets and linens. Based on the evidence this allegation is Substantiated at this time. On the allegation: Staff did not meet resident’s needs. LPA interviewed Witness which revealed witness came to visit and found R1 in bed in the flat laying position with a sandwich in hand and no staff present. LPA interviewed staff member which revealed R1 does need assistance with feeding. LPA observed staff feeding R1 at lunch time, R1 was up in wheelchair in the patio area at lunch time. LPA reviewed Resident 1 (R1) records which revealed R1 is on hospice services, needs 2 person assist, according the R1’s LIC 602A dated 01/21/2026 R1 is not able to bath, dress or groom self, is incontinent in bladder and bowels, requires assistance with repositioning and transfers, on a special diet due to Dysphagia, and able to feed self but needs staff monitoring. Based on the evidence this allegation is Substantiated at this time. Exit interview completed, deficiencies cited and copy of report printed for Assistant Administrator/LVN. Another resident stated the meals are good, the staff help with re-positing and turning in bed, staff help residents with cleaning up and wiping down, the staff are the residents’ favorite people and LPA observed the resident was changed and cleaned up by staff member and brought out in wheelchair to eat lunch on the patio and was feed by staff. Another resident could not answer LPA questions due to dementia diagnosis. LPA observed the resident, was clean and groomed properly, walking around facility, watching TV, playing with a hand towel and eating lunch at the dining room table. A hospice resident was in bed, said resident was doing fine and had no problems, thank you for checking, resident was changed and cleaned up, put in wheelchair by staff and brought out to lunch at the dining room table. LPA observed 2 staff working at the facility upon arrival. One staff member was providing resident care, filling in for the Administrator for a few weeks while out of town and provided LPA with all the requested resident records. The other staff member cleaned the kitchen, was prepping and cooking food for lunch and serving lunch to the residents in care. Staff stated they help each other when residents are needing transfers or repositioning in bed. Staff stated the facility has several other staff to work shifts. According to the LIC 500 dated June 2026 the facility has a total of 1 Administrator/ LVN works weekday 7am-7pm shifts, 1 Assistant Administrator/LVN works weekday shifts 7am-7pm , 1 Housekeeper/Cook/Aide works weekday 7am-7pm shifts, 1 CNA works weekend shifts 7am-7pm, 1 awake caregiver for weekday 7pm-7am shifts, 1 RN works weekend Sat/Sun 7am-7pm shifts, 1 awake caregiver works Sat/Sun 7pm-7am. According to the staff present this is a good schedule for what the staff is currently working at the facility. A witness stated the facility is not properly staffed with enough staffing that is knowledgeable and able to care for others. There is a staff member present that is only supposed to do housekeeping and cooking with no resident care provided but feels this staff is doing caregiving at the facility and is worried about the residents in care. The Witness stated an LVN staff is working at the facility and provides good care but also has another job so not sure of the working hours but was told by the Administrator the LVN would be covering shifts while Administrator was out of town. The Administrator has left the facility to go out of town due to being overwhelmed. The Witness does not know what staff is covering overnight shifts and does not know if the facility is providing awake staff overnight coverage.. Based on the lack of evidence this allegation is Unsubstantiated at this time. Continued 9099-C On the allegation: Facility does not have designee for Administrator. LPA interviewed LVN/Assistant Administrator which revealed the administrator is out of town on vacation and is covering the administrator day shifts while administrator is gone for 2 weeks. Facility documents did not reveal LIC. 308 Designation on file for the staff member covering the administrator on record. The staff covering for Administrator was able to provide LPA will all the records requested. The covering staff is on the LIC 500 Personnel Report listed as Assistant Administrator/LVN working Monday -Friday 7am-7pm, therefore this allegation is Unsubstantiated at this time. On the allegation: Staff locked resident in their room. LPA toured the facility and took photographs of the resident’s three bedroom doors, only room 3 has a lock on the door, and it is placed correctly that the residents can lock the room and unlock the room from the inside and cannot be locked in the room from the outside, the room is a double room occupying 2 residents in care, and both residents are verbal, 1 of tne resident in Non-Ambulatory and has a wheelchair, the other resident is Ambulatory and able to move around the facility. Witness interview revealed the resident in room 3 was able to go out the sliding glass door on to the patio but went to Room 1 patio door and knocked, a family member was present with resident in Room 3 and opened the door for the other resident, when the resident entered the room the resident laid down in another residents bed and had to be redirected by staff. The residents were not locked in rooms, 2 residents can move freely around the facility while the other 2 residents need transfers to wheelchairs to be able to move around the facility. LPA observed staff doing transfers and bringing both residents out of rooms for lunch. Based on the lack of evidence this allegation is Unsubstantiated at this time. Exit interview conducted and copy of report printed for Assistant Administrator/LVN.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 29-AS-20260617080150

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jun 19, 2026

(f)... (4)Personal assistance and care as needed by the resident...with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications,...This requirement was not met as evidenced by: Based on interviews the Licensee did not comply with the regulation above in R1 was not monitored while eating which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Administrator is to make sure all R1’s forms are up to date to give a full account of R1’s current needs and services, provide a letter of understanding of R1’s needs and how the facility will meet R1’s needs. Train staff on regulation 87464 and provide proof of training to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 24, 2026

(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interviews and observation the Licensee did not comply with the regulation above a dirty washcloth was left on residents bed, a dirty brief was left in the drawer with clean briefs, the bed linens were not clean and the facility had a odor of urine in the hallway which possess a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Administrator agreed to clean and disinfect the residents rooms, have a trash can and a laundry hamper aviable for dirty items, provide clean linens on each bed,all linens meeting regulation requirements. Train all staff on regulations 87303 and 87470 and provide proof of training to CCL.

Allegation investigated: Staff are locking residents in rooms Staff are sleeping while on duty Staff are not trained to use the hoyer lift Licensee does not ensure residents have toilet paper in the bathrooms Licensee does not ensure all toilets are clean

Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Jane Castaniaga Administrator/Licensee and explained the purpose of the visit. LPA toured the facility, reviewed records, interviewed administrator at 10:35am, staff around 11:15am and resident at 11:30am. On the allegation: Staff are locking residents in rooms. Witness statement stated the lock is on the opposite side of the door and it was locked with a person inside. Witness also stated the residents had been locked out on the patio before. LPA interviewed Administrator which revealed the lock on the door was turned around because the resident started to exit seek at night. LPA spoke to the staff which revealed the resident would get out at night so they changed the lock. LPA looked at all bedroom doorknobs and locks which revealed room 5 had a lock on the outside of the door which provides the opportunity for a resident to be locked in, Continued 9099-C Substantiated The current resident in room 5 was in the common area the door was opened and not locked on LPA visit. LPA took a photograph of the lock on the outside of the door. Based on the evidence this allegation is Substantiated at this time. On the allegation: Staff are sleeping while on duty. LPA interviewed Administrator which revealed a residents family felt the staff was sleeping because she was laying on the couch with the staff eyes closed and she talked with the staff an explained staff can not do so that while working on shift. Staff interviewed stated staff was resting and just had eyes closed but was not sleeping. Witness interview stated the staff was asleep on the couch during the day while residents in care were awake and at the facility. Based on the evidence this allegation is Substantiated at this time. On the allegation: Staff are not trained to use the hoyer lift. LPA interviewed Administrator which revealed the staff that work at the facility have prior caregiving experience and staff know how to use the Hoyer Lift with resident in care, facility did not train any staff in the hoyer lift and facility does not have any records of training on the hoyer lift. Staff interviewed revealed the staff knows how to use the hoyer lift and worked in caregiving prior and had learned how to use it then. Witness stated the staff was not trained on using the hoyer lift with a resident in care. Due to the facility's lack of training records or documentation this allegation is Substantiated at this time. On the allegation: Licensee does not ensure residents have toilet paper in the bathrooms. Witness statement revealed the bathrooms do not have toilet paper for residents use. LPA toured the facility, the main bathroom did not have toilet paper, Room 3 bathroom did have toilet paper and room 4 & 5 have a shared bathroom that did have toilet paper. Resident interview said sometimes the bathroom has toilet paper and sometimes it does not, resident said if the resident asks the staff the staff will get the resident toilet paper. Administrator stated they were hiding the toilet paper from 1 resident due to the resident clogging up the toilet and it overflowing all over the bathroom and out into the living area causing a safety issue, the resident has clogged the toilet several times, staff told the resident to ask the staff for toilet paper if the resident needs it and the staff will bring it to the resident. LPA asked the Administrator if the facility had any doctor documentation that the resident can not have access to regular grooming and hygiene items, the Administrator stated no the facility did not. Based on evidence this allegation is Substantiated at this time. On the allegation: Licensee does not ensure all toilets are clean. Witness stated a toilet was dirty. LPA toured the facility and observed the main bathroom was clean and sanitary, residents bathroom 2 was clean and sanitary, shared resident bathroom 3 had a urine odor and was not clean and sanitary. Based on LPA observation this allegation is Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Administrator per request.the state’s words, verbatim · CDSS document, May 6, 2026 · control 29-AS-20260501093143

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: May 7, 2026

(a)... (6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night....This requirement was not met as evidenced by: Based on interview and observation the Licensee did not comply with the regulation above in the residents door has a lock placed on the outside of the door to be locked when a resident is in the room which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Administrator agreed to have the locked removed and the door knob to be re-installed with the lock on the inside of bedroom 5, statement from Licensee that residents will never be locked in rooms and training for all staff on regulation 87468.1 and 87468.2 provide proof of staff training with Lic. 500 to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 6, 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 in the staff on duty was on the couch with eyes closed looked to be sleeping with residents in care which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Administrator agreed to write a statement of understanding that staff can not sleep on the job and must be available and awake at all times for resident care. Train staff in 87464, 87705, 87706 and provide proof of training and an up to date LIC. 500 for staff to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: May 13, 2026

(d)All personnel shall be given on the job training...This training...shall provide...(3)Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by: Based on records the Licensee did not comply with the regulation above in the facility did not have on the job training for staff on resident in cares hoyer lift which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Administrator agreed to provide all staff training on residents hoyer lift, provide proof of training and up to date LIC. 500 to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: May 13, 2026

(a)...The following provisions shall apply: (3)Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident....(D)Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidenced by: Based on interviews and observation the Licensee did not comply with the regulation above in the Staff removed toilet paper from the restrooms so a resident would not continue to clog the toilets which poses a potential health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Administrator agreed to talk with residents doctor and get a update LIC 602A if it is a safety risk for resident to have personal grooming and hygiene items. Train all staff on regulation 87307 and provide proof of training and up to date LIC. 500 to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 13, 2026

(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interviews and observation the Licensee did not comply with the regulation above room 5 bedroom bathroom had an odor of urine, the sink and floor were in need of cleaning which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Administrator agreed to clean the facility so no odor if urine is present make sure all sink and toilets are clean, safe and sanitary for the residents in care, train all staff in regulation 87303 and provide proof of training with an up to date LIC. 500 to CCL.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 10:00 am to conducted a 1 year annual visit to the facility above. LPA met with Licensee/Administrator Janelyn Castaniaga 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 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, hand dryer, 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 when and if needed. Physical Plant & Environmental Safety: The facility is a 5 bedroom home. Three double bedrooms with 2 on suite bathrooms and 1 common area restrooms dedicated for residents use. There is master bedroom and bath dedicated to a single resident and 1 other staff bedroom. The facility has 4 residents in care and employs 2 regular staff, 1 administrator and 2 back up staff on call when needed. The facility is clean, safe and sanitary. 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. The facility kitchen is clean, safe and sanitary. The kitchen has a gate to make the range inaccessible to dementia residents, and it does not lock. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents locked in the laundry room and locked garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a back/side yards for resident use with furniture and plenty of shade. Telephone and internet service is provided for resident use. The facility has a working washer and dryer. Continued 809-C Operational Requirements: The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance expires 05/01/2026. The facility is approved for a capacity of 6 Non-Ambulatory and a Hospice waiver approved for 4. Staffing: The facility employes 3 staff, 1 Administrator and 2 back up staff when needed. Staff records are kept confidential. LPA reviewed 4 staff files for Application, finger print clearance, transfer or exemptions and Health screening with TB results. LPA verified administrator file to have current 1st Aid/CPR. and Administrator Certificate expires 10/22/2025. Personnel Records & Training: The facility keeps confidential files for each staff member. 4 staff files were reviewed for initial and annual training requirements. Staff hired in 2025 had 40 plus hours of training meeting regulation requirements and staff hired prior to 2025 had 20 plus hours of annual training for 08/2024-08/2025 meeting regulation requirements. Resident Rights & Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license is posted. CCL reports are posted. Internet is provided to residents in care, confidentiality and privacy is given. Planned Activities: The facility has supplies for activities. The residents currently in care watch TV, go for walks, have discussions with staff and exercise a few days a week. The residents said they do what they want to do. 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. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. Continued 809-C Incidental Medical and Dental: Facility provides 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). Medications for all resident in care are centrally stored. LPA reviewed medications and records. No medications label were altered, no medications were expired, and all medication was stored in original containers. Medication are given as prescribed by physicians orders. 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), TB results, Personal Rights, and Safeguard for personal property and valuables. 1/4 residents was in need of an up to date Appraisal Needs and Services Plan (ANS) and all other forms were up to date. Pre-Admission appraisals and functional capabilities assessments are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources for any of the residents in care. Facility does submit incident reports to the department when required. 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. Facility has emergency food and water supply, flash lights with batteries, and a cooler with ice packs for medications. The facility has several evacuation sites. The facility has a back up generator if needed. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have any resident on oxygen. The facility currently has 1 resident receiving hospice services. The facility currently has no residents receiving home health services. Hospice care plans are kept on file and up to date. The facility does not have any delayed egress. The facility has alarmed exiting doors and gates. The facility has three self latching, self closing gates with alarms. There are no bodies of water on the premises. LPA conducted interviews with 1 staff and 1 resident. Exit interview conducted, deficiency cited, copy of report printed and appeal rights printed for Licensee/Administrator.the state’s words, verbatim · CDSS document, Aug 21, 2025

The state marks this report as 18 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Licensee is not ensuring that facility maintains a comfortable temperature for residents is care.

At 8:00am on 11/14/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to address the allegations to this complaint. LPA met with Licensee, Janelyn Castaniaga, announced the reason for the visit. Licensee and LPA conduced a tour of the facility. LPA conducted interviews of staff and residents, collected documentation and issued the final findings below. LPA noted that he temperature at time of visit read 68* (f). As to the allegation of, “Licensee is not ensuring that facility maintains a comfortable temperature for residents is care.” It was alleged that on 11/07/2024 at approximately 3:45pm, the facility interior temperature was 64 degrees Fahrenheit (*f). It was discovered through observation, reliable witness, and State issued, digital ambient temperature reading device that on 11/07/2024 at approximately 3:45pm, a reliable witness (person with license, or credentials indicating expertise training) (W1) made observations that the facility temperature was cold. At approximately 3:45pm on 11/07/2024, W1 used a State issued digital ambient temperature reading device to read the facilities temperature. W1 stated to LPA that device read 64*(f). W1 stated that 3 of 3 resident rooms were also 64*(f) or less. CONTINUED on LIC9099-C Substantiated Based on W1, observations, and State issued digital temperature reading device, there is enough evidence to support the allegation of, “Licensee is not ensuring that facility maintains a comfortable temperature for residents is care.” and is substantiated at this time. Exit interview, report read, citation issued, appeal rights, and report provided.the state’s words, verbatim · CDSS document, Nov 13, 2024 · control 29-AS-20241107163755

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(1) · Plan of correction due date: Nov 28, 2024

87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68-degree F, (20 degrees C). This requirement was not met by evidence of W1 (reliable witness) recording facility livingroom and 3 of 3 residents rooms at a temperature of 64*(f) on 11/07/2024 which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2024

Plan of correction: Licensee agrees to document for 2 weeks, of two temperature checks per day at residents desired room temperature. Additionally, Licensee to have all Staff do 1 hour of personal rights training by independent State authorized vendor. Results due back to LPA by 11/28/2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 10:30 am to conducted a 1 year annual visit to the facility above. LPA met with Licensee/Administrator Janelyn Castaniaga 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 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, hand dryer, hand soap, and hand washing signs and paper towels. 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 when and if needed. All trash cans and waste baskets have tight fitting covers. Operational Requirements: The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance effective 05/01/2024. The facility is approved for a capacity of 6 Non-Ambulatory and a Hospice waiver approved for 4. Physical Plant & Environmental Safety: The facility is a 5 bedroom home with 3 double rooms dedicated for residents. The facility has 3 bathrooms to be used by residents and 1 staff bathroom currently occupying 2 residents and employs 2 staff and 2 administrators. The facility has 2 bedrooms for live-in staff. The facility is clean, safe and sanitary. 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. The facility kitchen is clean, safe and sanitary. The kitchen has a gate to make the range inaccessible to dementia residents, and it does not lock. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents are locked in the laundry room and locked garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for resident use with furniture and plenty of shade. Telephone and internet service is provided for resident use. The facility has a working washer and dryer. Continued 809-C Staffing: The facility employes 3 staff and 2 Administrators. Staff records are kept confidential. LPA reviewed staff folders, several staff work at the Licensee other facility and records are kept there, explained to Administrator that staff on the LIC 500 must have staff files available for review on visit. LPA verified each administrator to have current 1st Aid/CPR. Administrator Certificate expires 10/22/2025. Administrator will email LPA the remaining records. Personnel Records & Training: The facility keeps confidential files for each staff member at the other facility. LPA explained that all staff listed on the LIC. 500 must have training conducted annually and it must be available at the facility to verify annual training records. Resident Rights & Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license is posted. Internet is provided to residents in care, confidentiality and privacy is given. Planned Activities: The faciity has supplies for activities. The residents currently in care watch TV, go for walks, have discussions with staff and exercise a few days a week. 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. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff were observed for personal hygiene and food sanitation practices. Incidental Medical and Dental: Facility provides 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). Medications for all resident in care are centrally stored. LPA reviewed medications and records. No medications label were altered, no medications were expired, and all medication was stored in original containers. Medication are given as prescribed with physicians orders. Continued 809-C Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Two 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. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources for any of the residents in care. Facility does submit incident reports to the department when required. 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. Facility has emergency food and water supply, flash lights with batteries, and a cooler with ice packs for medications. The facility has several evacuation sites. The facility has generator. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have any resident on oxygen. The facility currently has 1 resident receiving hospice services. The facility currently has no residents receiving home health services. Hospice and Home Health care plans are kept on file and up to date. The facility does not have any delayed egress. The facility has alarmed exiting doors and gates. The facility has three self latching, self closing gates with alarms. There are no bodies of water on the premises. LPA conducted interviews with 1 staff and 1 resident. Exit interview conducted and copy of report printed and emailed to Licensee/Administratorthe state’s words, verbatim · CDSS document, Aug 22, 2024