Orcutt Board and Care Home

Type of visit: Case Management - Other

At 7:30am on 04/15/2026, Licensing Program Analyst (LPA) Jeffries arrived to the facility and knocked on door and rang doorbell to no answered. LPA noted that on the door of the facility was a posted notice of extermination, building is safe to reenter on 04/09/2026. LPA noted that the window was partially unobstructed in the south east bedroom and LPA viewed a completely empty bedroom. With the observation of the extermination notice, no answer to the door knock and electronic door bell, and the observed empty bedroom, shows some evidence that the facility no longer has any clients. Additionally, LPA did a second visit at 1:30pm with no changes to the observations above. LPA will advise LPM on the closure of the facility.the state’s words, verbatim · CDSS document, Apr 15, 2026

Type of visit: Collateral

At 12:30pm on 02/25/2026, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility as a collateral visit to request documentation to a subsequent complaint at a different facility (Complaint # 29-ACS-20251203154853). LPA met with Care Giver, Mario Dechavez (S1) announced who he is and the reason for the visit. LPA attempted to contact the Administrator, with no answer and not able to leave voicemail. LPA requested S1 provide documentation for Resident 1 (R1). LPA noted that R1 was admitted to this facility on 11/01/2025. LPA also noted that the pre-admissions appraisal was completed and dated on 02/19/2026, LPA noted that a citation was issued for the lack of pre admission appraisal for R1 dated approximately 4 months after the R1's admission date (87457(a)). During this collateral visit LPA contacted the designated Administrator (DA), according to the current Administrator Annie Yague, (DA) Rea Stateresa by phone, who stated four times that, "there was no agreement to have me designated as the administrator while the current administrator was out of the country." Mrs.Stateresa stated, that they "drove down from San Jose last week to help buy groceries but only to help for the day, not to be the temporary administrator, we have no agreement.". LPA noted that a second citation for (87405(a)) When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility when current administrator has had a prolonged absence from the facility when being out of the country. At this time during this visit current administrator is said to be out of the country and Mrs. Stateresa who is located in San Jose stated that they are not the designated Administrator. LPA was able to collect the documentation requested on 01/28/2026 and 02/17/2026 during this collateral visit. Exit interview, report singed, citations issues, appeal rights and report provided.the state’s words, verbatim · CDSS document, Feb 25, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(a) · Plan of correction due date: Mar 11, 2026

87457 Pre-Admission Appraisal (a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. Based on the pre- appraisal provided to LPA dated 02/19/26 the pre-admission appraisal was not completed prior R1's admission to the facility which poses a potential risk to resident in care.the state’s words, verbatim · CDSS document, Feb 25, 2026

Plan of correction: LPA will follow up when Administrator returns to the United States on 02/28/2026 to develop this plan of corrections.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Mar 11, 2026

87405 Administrator - Qualifications and Duties ... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility. ... This requirement was not met by evidence of no administrator present or designated at the facility during collateral visit. This poses a potential danger to residents in care.the state’s words, verbatim · CDSS document, Feb 25, 2026

Plan of correction: LPA will follow up when Administrator returns to the United States on 02/28/2026 to develop this plan of corrections.

Allegation investigated: Facility is violating residents personal rights by locking them in their bedroom at night.

At 7:30am on 09/08/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the initial investigation to the allegation to this complaint. LPA met with Licensee/Administrator Annie Yague, announced who he is and the reason for the visit. LPA conducted a physical tour of the facility and interview with Licensee/Administrator and was able to determine final findings during this investigation visit. As to the allegation of, "Facility is violating resident personal rights by locking them in their bedroom at night." It was alleged that, facility is locking residents in their bedrooms at night. On 09/08/2025 LPA Jeffries arrived to the facility at 7:45am to discover Resident 2 (R2) in bedroom 2 with a screw lock door that was locked. Administrator used a dime to unlock bedroom 2 door, LPA observed R2 still in bed behind locked door. LPA observed screw lock doors on all resident bedrooms. On 09/08/2025, LPA conducted interview with Licensee/Administrator Annie Yague, who stated, "I know why your here, we just lock the doors so that (R1) doesn't go in other residents rooms." On 09/05/2025, LPA interviewed Family Member 1 (F1) who stated that R1 left facility due to being locked in the room during the night and morning. CONTINUED on LIC9099-C Substantiated Based on interviews, admission, and observation there is evidence to support the allegation of, "Facility is violating residents personal rights by locking residents in their bedroom at night." and is substantiated at this time.the state’s words, verbatim · CDSS document, Sep 8, 2025 · control 29-AS-20250904155314

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Sep 9, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents ...shall have the following personal rights:(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 does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, ..., with permission from the Department. This requirement was not met by evidence of admission and observation of resident rooms being locked in bedrooms which poses an imminent danger to residents in care.the state’s words, verbatim · CDSS document, Sep 8, 2025

Plan of correction: Administrator agrees to change the door knobs on all resident rooms to door knobs without locks that lock from the outside. Administrator also agrees to have all staff participate in 1 hour of personal rights training by an CCLD authorized vendor. Administrator will provided proof to LPA of class chosen by email no later than 09/09/2025, and have all training done as soon as possible.

Type of visit: Required - 1 Year

At 8:00am on 06/23/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facility annual inspection. LPA met with Administrator, Annie Yague, announced who he is and the reason for the visit. LPA and Licensee conducted a physical tour of the facility and the facility grounds. This facility is a 8 bedroom 4 bathroom (6 resident bedrooms and 2 staff bedrooms), 2 living rooms, kitchen, dining room, indoor patio, side yard and back yard. There are chairs and umbrella on the side yard for resident, visitor and staff use. LPA observed resident bedrooms to be furnished and stocked in compliance with regulation standards. LPA observed facility restrooms to have liquid soap, paper towels, and Non slip mats. LPA observed the facility to be clean and in good repair. LPA tested water at two different bathrooms in the facility to be within regulation temperatures (105*-120*(f)). LPA noted that the medications storage is located in a lockable cabinet to the left of the refrigerator. There is a complete 1st Aide Kit in the same locked storage in the kitchen. Staff and Resident files are located in a locked file cabinet between the kitchen and the dining room. Fire and Carbon Monoxide detectors are working throughout the facility. LPA observed a fire extinguisher in the kitchen primed and in the green. LPA observed the facility has at least 2 days of perishable foods and at least 7 days of Non perishable foods on hand for 6 residents and staff. LPA observed at least 72 hours or emergency water. LPA noted that all passageways, door ways and exits were free and clear of obstacles. LPA did not observe any noticeable regulation violations during the walk through at this time. LPA and Licensee conducted a full review of the annual care tools modules. LPA noted that there were no violations or citations issued as a result of the annual care tools review and no violations or citations issued as a result of this annual inspection. Exit interview, report singed and report emailed.the state’s words, verbatim · CDSS document, Jun 23, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

At 2:05pm on 03/13/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct a Case Management visit pertaining to cross report of form SOC 341 for resident 1 (R1) dated 03/16/2025. LPA met with Licensee Annie Yague, announce who he is and the reason for the visit. LPA conducted a health and welfare check of R1. LPA requested R1’s physicians report (LIC602), Hospice Care contract, Medication Administration Record (MAR) and Centrally Stored Medication Record. (CSMR) LPA conducted interviews of staff, residents and family members. LPA noted that the Family member 1 (F1) was present during the case management visit and is the Power of Attorney for R1 and noted that the care at the facility was excellent and was noted in interview LIC812. LPA noted that he was informed that the Santa Barbara County Sheriffs (SBCOS) were at the facility on 03/11/2025 for same SOC 341 cross report. LPA will obtain SBCOS case number at a later date. LPA had no significant findings during the visit. . Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Mar 13, 2025

Type of visit: Required - 1 Year

On 07/22/2024 Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct a required annual site inspection visit at the facility above. When the LPA arrived, they were greeted by Direct Support Staff Members MaryLou Reyes and Mario DeChavez as the Administrator/Licensee was not available, and informed them of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE) with a fire clearance capacity of Six (6) clients. The facility has approval for (Six) 6 non-ambulatory residents, (One) 1 of which may be bedridden. The Bedridden resident must be housed in bedroom 1 or bedroom 2 of the facility. The facility has an approved hospice waiver for (Four) 4 residents. KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food. Additional perishable food items were maintained on a shelf and/or an extra freezer. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation. The Kitchen area was observed by LPA to be somewhat disorganized/disheveled, but no violations of Licensing regulations were observed, and all kitchen equipment/appliances were observed to be in good/operating condition. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food. The Kitchen are also serves as the storage area for Resident Records, Staff member records, Medication Administration Records (MARS), and the Centrally Stored Medications themselves. All these documents and medications are stored in locked and secure cabinets away from perishable food items and kitchen utensils/kitchen microwave, oven, etc. Contd. on 809-C COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in fair to moderate condition. Quality of furnishings were not damaged to the extent they were not functional (i.e. dresser is shabby, but operational vs. one that is broken and non-functional; a tear in the seat of a chair vs. exposed springs). There were no signs of neglect; furnishings were not broken and would not cause injury if used. There is a fireplace in the living room, which is covered and inaccessible. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were fully charged and serviced annually. All exits from the facility were locked and operational at the time of the visit. The LPA observed required postings throughout the common space. There was a storage linen closet with extra towels and fresh linens for residents. There is a dining room with a table capable of seating all six (6) residents as well as a living room with a television and furniture for resident use. All inclines in common areas in the facility have accessibility ramps for residents. There are activity supplies and equipment, including reading materials for the clients. All window screens were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and well-lit. The facility common areas were observed by LPA to have signs of wear and tear as well as disorganization, but the conditions of the common areas were not indicative of an overall deterioration of the facility; or the failure to implement the plan of operation which includes maintenance and housekeeping. BACKYARD/GARAGE/ETC: The backyard area has an indoor patio area/sunroom equipped with furniture for resident use. There were no bodies of water noted. All exits from the facility are locked, which the LPA checked to make sure the locks were engaged. There is a separate laundry room where cleaning products are stored, which is kept locked. The laundry room is accessible through the garage where 2 staff rooms are also located. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. There was emergency food and water in a storage room/area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to clients are kept in areas inaccessible to clients. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. In the front of the facility, the LPA noted that the outdoor front area of the facility was observed to be clean and landscaped, with no signs of neglect or lack of maintenance. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are six (6) designated resident rooms. All the resident rooms have an individual bed for one resident. Continued on 809-C Each closet in all the client rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any client assistive device such as a wheelchair or a walker. Each room has at the least a chair, nightstand, chest of drawers, and sufficient lighting. RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are four (4) total resident restrooms, with 2 of these restrooms containing a shower/tub for the washing and bathing of residents. All restrooms inspected had assistive equipment for clients including grab bars and/or non-skid surfaces. The bathrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations. Nightlights are installed in the hallways outside of the common area restrooms. RECORDS: The facility keeps confidential storage of personnel records and resident records on-site at the facility. Personnel records reviews were reviewed for, but not limited to Personnel records, Health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, Employee Rights, Criminal record Statements, Criminal record clearances, First aid/CPR certification that is not expired, and the appropriate training documentation. All staff member personnel records had the appropriate documentation with no expiration of any training. The administrator of the facility has a pending renewal of an Active Administrator Certification with an expiration date of 12/29/2025. Resident records were reviewed for Pre-Admission/Placement appraisals, Admission Agreements, Physicians Reports, Consent Forms, Personal Rights for Residents, Emergency Information, Release of Medical Information, Needs and Services Plan (ANS), Resident Assessments, Self-management of medications if applicable, Medication Orders, and Medication Logs. All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information. MEDICATIONS: Medications were reviewed in the Medication Administration Record (MARS) for each resident. Medications for all residents are in a centrally stored and locked cabinet in the kitchen. The LPA observed the Licensee demonstrate the locking and unlocking of the centrally stored medication cabinet. The LPA observed and audited the medications of residents, including bubble packs, powders, and liquids. All medications are labeled appropriately according to the pharmacy and physician. There were no signs of missed medications or medication irregularities according to the LPA upon the audit of the MARS and the actual medications. Continued on 809-C INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and a sanitation station. The staff members keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. FACILITY DOCUMENTATION: The facility keeps hard copies of the Application for an RCFE, Applicant Information, Designation of Facility Responsibility, LIC 500 Personnel Report, LIC 501 Personnel Record, LIC 503 Health Screening Reports, LIC 610E Emergency Disaster Plan for Residential Care Facilities For the Elderly, LIC 9282 Infection Control Plan, Fire Safety Clearance, and Facility Sketch. The facility has a Plan of Operation, Control of Property, Staff Job Descriptions, Personnel Policy, In-Service Training for Staff, Facility Program Description, Rules of Discipline/Personal Rights, Admission Agreement for Residents, Theft & Loss Policy, Neighborhood Complaint Policy, Hazard Assessment, and Job Description for the Administrator. The facility has a Dementia Care Plan document as well as Hospice Care Waiver. The Hospice Care Waiver states the maximum number of Hospice Patients is four (4). During this annual facility site inspection no deficiencies were cited. Technical violations were issued due to the facility previously having no medical reappraisal for injuries to a resident, no continuing record of a resident's injuries/medical care and no incident reports submitted to Licensing by facility for a resident's hospitalization on 08/11/2023 or 10/27/2023. On 10/27/2023, the licensee notified the resident's representative that the resident was hospitalized due to passing out at the dining room table. However, the licensee did not notify resident's representative of resident's 10/26/2023 fall at the facility. On 06/12/2024, LPA conducted a case management-deficiencies visit. Licensee agreed to a Plan of Correction that Licensee would submit a plan describing how facility would ensure reporting requirements were followed. Proof was submitted to LPA. LPA observed areas of the facility that appeared to be disorganized and/or cluttered. However, this was not observed by LPA to be a risk to the health and safety of residents in care. There is no widespread neglect regarding maintenance of the facility, and on-going corrective action to prevent overall deterioration of the Physical Plant is being maintained by the facility. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 22, 2024

Allegation investigated: Staff mismanaged resident’s medication.

Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Phillips met with Licensee/Administrator Annie Yague and explained the reason for the visit. On 12/01/2023, the Department received a complaint alleging facility staff mismanaged Resident #1’s (R1’s) medications by over-medicating R1. On 12/05/2023, from 10:00am to 4:00pm, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct an initial complaint visit. LPA Phillips met with licensee/administrator Annie Yague and announced the purpose of the visit. The LPA conducted a physical tour, requested documents, LPA observed and photographed facility food supply, resident bedrooms, and common areas (kitchen, dining room, living room, bathrooms). The LPA determined further investigation was needed prior to issuing findings. Continued on 9099-C Substantiated On the allegation: Staff mismanaged resident’s medication. According to R1’s physician report, signed and dated 03/30/2023, the primary diagnosis was listed as dementia. R1 was not identified with motor impairment or paralysis. R1 was identified as being confused/disoriented, with wandering behavior, sundowning behavior, but was listed as being able to follow instructions and communicate needs. R1 was listed as ambulatory and could independently transfer to and from bed. The report documented R1 was able to dress, groom, feed self, and care for own toileting needs. The resident appraisal information, dated 03/30/2023, indicated R1 had moderate dementia, used a walker, was listed as non-ambulatory, but did not need help transferring in and out of bed or chair. Facility records indicated R1 was admitted to the facility on 04/01/2023. R1’s Centrally Stored Medication Record (CSMR) was reviewed. The record lists three (3) dates filled (04/07/2023, 04/22/2023, and 05/06/2023) for the medication Quetiapine 50 mg. The instructions on the record are listed as “take 1-2 tabs at bedtime as needed”. “As needed” indicates that this medication was prescribed as a PRN (Pro re nata). The facility did not have a specific order for an exact dosage for R1’s PRN (as needed) Quetiapine medication and should have clarified the order with R1’s physician. A review of the facility’s “As Needed Medication Record” dated 04/07/2023, revealed that R1 was being given a dose of Quetiapine 50 mg routinely every night at bedtime, and not as prescribed on an “as needed” basis. Some of the entries are listed with doses of 50 mg, other dates and doses indicate 100 mg was given. The record listed the Quetiapine as being given routinely at every bedtime, with an “effectiveness” consistently noted as “calm” or “sleeping”. These records are dated from 04/07/2023 through 07/27/2023. This indicates that during this time period, the facility staff gave R1 a PRN Quetiapine as a routine daily medication and not as ordered as a PRN, which should have only been given on an as needed basis. Later, R1’s physician changed the Quetiapine dosage to 75 mg, citing that 100mg (2 tabs) was too much for the resident and causing them to be to sleepy. Based on the information obtained, there was sufficient evidence to show R1’s medication was not given as prescribed. Therefore, the allegation is deemed Substantiated at this time. Exit interview, deficiencies cited on 9099-D, report given, appeal rights given. The LPA conducted a physical tour, requested documents, LPA observed and photographed facility food supply, resident bedrooms, and common areas (kitchen, dining room, living room, bathrooms). The LPA determined further investigation was needed prior to issuing findings. Investigator Real conducted interviews on 12/15/2023, at approximately 3:30pm, with Resident #1’s (R1’s) resident representative; on 01/08/2024, from approximately 4:10pm to 7:10pm, with facility staff and residents; and on 02/05/2024, at approximately 12:00pm, with the administrator. In addition, the investigator reviewed medical records from Marian Regional Medical Center, American Medical Response (AMR) ambulance, and facility file documents related to R1. According to R1’s physician report, signed and dated 03/30/2023, the primary diagnosis was listed as Dementia. R1 was not identified with motor impairment or paralysis. R1 was identified as being confused/disoriented, with wandering behavior, sundowning behavior, but was listed as being able to follow instructions and communicate needs. R1 was listed as ambulatory and could independently transfer to and from bed. The report documented R1 was able to dress, groom, feed self, and care for own toileting needs. The resident appraisal information, dated 03/30/2023, indicated R1 had moderate dementia, used a walker, was listed as non-ambulatory, but did not need help transferring in and out of bed or chair. Facility records indicated R1 was admitted to the facility on 04/01/2023. On the allegation: Staff neglect led to resident sustaining fractures while in care. R1’s medical records indicated R1 was admitted to Marian Regional Medical Center on 07/31/2023 after an unwitnessed fall. R1 sustained a laceration to the right front orbital region. No acute fractures were identified. A CT scan of the spine revealed severe degenerative changes and it was noted R1 had multiple chronic cervical spine compression fractures. Osteoarthritis was also noted in the records. A chest x-ray showed possible pneumonia, that was addressed with antibiotics, and R1 was discharged back to the facility. On 08/11/2023, R1 returned to the hospital for complaint of back pain. A CT scan of R1’s spine revealed a previously unidentified spinal fracture from 01/22/2023. On 10/26/2023, R1 had a witnessed fall that resulted in no visible injuries and R1 denied any injuries or pain. The following day, 10/27/2023, R1 was sent to the hospital after loss of consciousness at the dining table. At the hospital R1 was initially diagnosed with a UTI and on 10/31/2023 was found to have a periprosthetic femur fracture. On 11/01/2023, R1’s resident representative declined surgical intervention and R1 was placed on hospice and discharged to a skilled nursing facility. Continued on 9099-C The investigation included a review pertaining to periprosthetic femur fractures. According to the National Institutes of Health (NIH), the fractures usually occur as a result of minor trauma, and people with osteoporosis are at risk. Some fractures present with pain and inability to ambulate, while some present with vague thigh pain but are able to ambulate. The investigation further revealed R1’s resident representative did not witness any neglect or harm by any of the facility staff. The residents had no neglect concerns and felt the staff provided an appropriate level of care and supervision. The staff and the licensee denied providing inadequate care that led to the fracture. Based on interviews and records review, the Department does not have sufficient evidence to determine that there was negligence or lack of supervision on behalf of the facility staff. Although R1 did sustain fractures while in care, there is insufficient evidence to conclude that it was due to neglect on the part of facility staff. Therefore, the allegation “Staff neglect led to resident sustaining fractures while in care” is deemed Unsubstantiated at this time. On the allegation: Due to neglect resident sustained UTI while in care. On 10/26/2023, R1 had a witnessed fall that resulted in no visible injuries and R1 denied any injuries or pain. The following day, 10/27/2023, R1 was sent to the hospital after loss of consciousness at the dining table. The hospital records noted the chief complaint as a syncopal episode while in wheelchair. At the hospital R1 was diagnosed with a UTI. The medical records reviewed did not indicate any signs of neglect. The investigation further revealed R1’s resident representative visited R1 in the facility and observed the facility staff interaction with the residents and denied seeing any intentional harm or neglect by the staff. Per documents reviewed, R1 did not require staff assistance with toileting. Based on interviews and records review, there is insufficient evidence to prove the alleged violation occurred. Although R1 sustained a UTI while in care, there is insufficient evidence to conclude that the UTI was a result of staff negligence. Therefore, the allegation “Due to neglect resident sustained UTI while in care” is deemed Unsubstantiated at this time. On the allegation: Staff did not make sure resident's room was kept clean. It was alleged a resident’s room was not clean, as there were spiders in the room. LPA toured the facility on 12/5/2023 and took photographs. LPA did not observe any spiders or that the facility was unclean. Residents interviewed indicated the facility was clean. During the visit, LPA also observed facility staff cleaning. Continued on 9099-C Based on the information obtained, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff did not provide adequate food service. It was alleged staff served juice instead of water, only served processed foods, served cold food, and did not serve food in a timely manner. On 12/5/2023, LPA observed the facility food supply. LPA observed a supply of fresh fruit on the counter accessible to residents, and a water dispenser. In the refrigerator, LPA observed an adequate amount of food including milk, juice, coffee creamer, fruit, bread, cheese, lunchmeat, vegetables, meat, and condiments. In the freezer, LPA observed ice cream, tempura shrimp, frozen meals, fries, frozen vegetables, and frozen meat. The facility also had an adequate supply of nonperishable foods. Through interviews with Staff, LPA was told the facility follows a documented daily menu for residents, unless a substitution regarding recipes and/or ingredients needs to be made. This includes providing water to a resident instead of juice, coffee, milk, etc. as stated on the facility daily menu. LPA requested and received a copy of the facility daily menu which provided a weekly schedule of meals for breakfast, lunch, and dinner. The facility daily meal menu provides different foods for each meal of the day and provides different foods daily to residents. The daily menu provides meals that are not processed foods and meals that are served warm/hot. All residents interviewed by LPA had no corroborative statements about the food service at the facility. No resident interviewed stated that water was not served, the facility only served processed foods, only served cold food, and did not serve food in a timely manner. Based on interviews, records review, and LPA observations, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation “Staff did not provide adequate food service.” is deemed Unsubstantiated at this time. On the allegation: Staff did not comply with resident's admission agreement. It was alleged that although Resident 1 (R1)’s admission agreement stated it would be a private room and bathroom, other residents used R1’s bathroom. LPA requested and received signed copies of R1’s admission agreement and the facility house rules. Through record review, the dated and signed admission agreement of R1 does not mention anything about a private bathroom. The admission agreement states that the lodging is a private, non-ambulatory room, with no mention of a private bathroom for R1. LPA observed two (2) resident bathrooms in the facility. Both bathrooms were in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. Continued on 9099-C Through Staff interviews, LPA was told that the resident restrooms are communal as the facility has six (6) residents in care, so therefore residents have to share bathrooms. One of the bathrooms in the facility has 2 doors on either side and is a "jack and jill style" restroom so residents can enter the restroom from either side. One of the doors on this bathroom is connected to a resident bedroom, but the other door of the bathroom is connected to a different room in the facility. Therefore, a resident can enter that bathroom from their bedroom and other residents can enter the bathroom from the other side when it is unoccupied. There is no evidence that any resident invaded R1’s personal space by entering the communal restroom through the door in R1’s private bedroom. Based on interviews, records review, and LPA observations, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation “Staff did not comply with resident's admission agreement” is deemed Unsubstantiated at this time. On the allegation: Facility is in disrepair. It was alleged the facility had a ramp that was not installed properly which caused a resident to trip. LPA observed a ramp in the facility from the hallway to a living room. The ramp is carpeted, but the carpet was not tight and had ripples in it. LPA observed a second ramp from the hallway into the dining room/kitchen area of the facility. This ramp was also carpeted, and LPA did not observe any ripples in the carpet. All Staff interviewed by LPA denied that any residents have ever tripped on the uneven carpet. LPA interviewed residents about the use and safety of the carpet on the ramp(s), but no resident told LPA that they had personally tripped on either of the ramps or witnessed any other resident trip on the carpet of the ramp. Staff agreed to a request by LPA to adjust the carpet of the ramp from the hallway into a living room, so the ripples aren’t there. Based on interviews and LPA observations, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation “facility is in disrepair” is deemed Unsubstantiated at this time. On the allegation: Staff did not provide activities for residents. It was alleged the facility did not provide any activities. LPA observed activities in the facility including puzzles, games, and residents watching television. Residents interviewed by LPA indicated that they liked activities in the facility including watching television shows with other residents, playing crossword puzzles at the dining room table, and reading books. Continued on 9099-C LPA requested and received copies of the facility admission agreement and the facility house rules. The facility admission agreement states there are planned activity programs for residents, and the facility house rules states that residents are allowed televisions and/or radios in their own bedrooms as well as a shared television available for viewing in the living room of the facility. Staff interviews by LPA indicated that residents are provided crossword puzzles, reading materials, and a television in the living room that residents watch together. Residents are also provided jigsaw puzzles to complete alone or with other residents under the supervision of Staff. Based on interviews, records review, and LPA observations, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation “Staff did not provide activities for residents” is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Jun 12, 2024 · control 29-AS-20231201163837

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jun 13, 2024

87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above when staff gave R1 PRN Quetiapine as a routine daily medication and not as ordered, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: Licensee will submit a plan how you will ensure medication is given according to the physician's directions. Submit to CCL by 6/13/2024

Type of visit: Case Management - Deficiencies

On 06/12/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a case management-deficiencies visit. During the complaint investigation of complaint # 29-AS-20231201163837, the following deficiencies were observed: There were no incident reports submitted for R1’s hospitalization on 08/11/2023 or 10/27/2023. On 10/27/2023, the licensee notified R1’s resident representative that R1 was hospitalized due to passing out at the dining room table. However, the licensee did not notify R1’s representative of R1’s 10/26/2023 fall at the facility. Exit interview, deficiencies cited, report given, appeal rights given.the state’s words, verbatim · CDSS document, Jun 12, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(1)(B) · Plan of correction due date: Jul 10, 2024

87211(1)(B) Reporting Requirements. Licensee shall furnish to licensing agency reports...including following…(1) Written report submitted to agency and responsible person...seven days of occurrence of events (A) through (D)...(B)... injury determined by physician...under facility supervision. Requirement not met as evidenced by: Based on interviews and records review, licensee did not comply by not submitting incident reports for R1 on 08/11/2023, 10/27/2023 nor notifying representative of R1 on 10/26/2023, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: The licensee will submit a plan describing how facility will ensure reporting requirements are followed. Submit proof to CCL by 7/10/2024.

Allegation investigated: Staff restrained resident. Staff left resident in soiled clothing. Due to staff neglect, resident developed pressure injury while in care.

On 01/23/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit to the facility above to issue final findings. LPA arrived at the facility, met with Administrator/Licensee Annie Yague, and announced the purpose of the visit. On the allegation: Staff restrained resident. It is alleged Resident #1 (R1) was found in their bed with bungee cords attached to each wrist, with cloth under the bungee cords. The bungee cords were attached from R1’s wrists to the bed frame, and R1 was allegedly restrained. It is alleged that two (2) Staff members were standing next to R1’s bed, “hovering over” R1. The allegation stated that the Staff members voiced R1 is combative, and Staff use the bungee cords so R1 cannot commit self-harm. It is alleged that bungee cords could also be seen hanging off the side of R1’s bed in each corner of the bed. It is alleged that the Staff members removed the bungee cords from R1’s wrists and took them out of R1’s bedroom with them, but that more bungee cords were seen located in R1’s bedroom drawer. Continued on 9099-C Unsubstantiated On 08/28/2023, LPA conducted an unannounced initial complaint visit to the facility above. LPA conducted thorough observation of each resident room including the room of R1. LPA also observed all storage areas in each resident bedroom as well as storage areas in the common areas of the facility such as cabinets, drawers, closets, storage room(s), etc. During the initial complaint visit on 08/28/2023, LPA did not observe bungee cords of any kind anywhere in the facility. LPA has frequently visited the facility including the dates of 07/18/2023, 08/14/2023, 08/28/2023, 10/12/2023, 12/05/2023, and 01/04/2024. At no point during any in-person visit to the facility by LPA were any bungee cords observed within the facility nor were any signs of trauma to R1’s wrists observed by LPA while R1 was in the facility. On 08/31/2023, LPA interviewed a Staff member from a Hospice Agency who had frequent contact with R1 on at least a weekly schedule within the past few months. Witness #1 (W1) stated that there was only one (1) individual who had allegedly observed all the allegations, and that W1 has been to the facility numerous times in the past few months and had not seen anything close to what the allegations are describing. W1 stated to LPA that they had visited the facility many times before with no concerns noted. LPA also spoke with other Staff from the Hospice Agency who have been into the facility in the recent months and no Staff member could corroborate seeing anything like what the allegations are describing. W1 was surprised to hear what the allegations described, as they have been in the facility on a consistent basis in recent months with no concerns regarding any restraints. According to W1, they went to see R1 on the afternoon of 08/24/2023, with no bungee cords seen in the resident's room. W1 checked the drawers in R1’s room and checked the closet but could not find any bungee cords at all. W1 stated to LPA that they had never observed signs of trauma to R1’s wrists or had any concerns with the care of R1. Other Hospice Agency Staff interviewed by LPA stated that R1 occasionally needed prompting and redirecting of negative behaviors such as lashing out and being upset at being woken up. However, they had never observed or heard of any Facility Staff members using any type of physical restraints on R1 or that R1 would self-harm. On 08/28/2023 and 10/12/2023, LPA interviewed Staff members of the facility about the allegation. No Staff member of the facility stated that any bungee cords were used on R1 at all. Staff members stated that R1 was on Hospice Care, medicated, and never physically restrained with anything. All Staff members interviewed stated that they did not restrain R1 with bungee cords to prevent R1 from committing self-harm. On 08/28/2023, LPA conducted record review of facility documentation for R1. Records reviewed for R1 included the Centrally Stored Medication and Destruction Record kept by the facility for all residents in care, physician’s notes for R1, Resident Appraisal for R1, Statements of Patient Advocates or Ombudsman, Physician Orders for R1 including Primary & Secondary diagnosis, Appraisal Needs & Services Plans (ANS), Physicians Reports for Residential Care Facilities for the Elderly (RCFE), and Emergency Information. Continued on 9099-C LPA also received Hospice Care documentation for R1 from R1’s Hospice Agency on 08/28/2023. LPA found no documented evidence that R1 was at risk for committing self-harm, nor any evidence of R1 needing physical restraints of any kind. Based on the information obtained, there was Insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff left Resident in soiled clothing. It is alleged that R1 was saturated in urine with a brief that weighed one (1) pound, incontinent of stool, and had had dried feces on their pillowcase and sheets. It is alleged that there was a strong odor of urine in the room of R1 and was concentrated. Allegedly urine went through R1’s clothing, sheets, and onto R1’s mattress. It is alleged R1 did not have hygienic cleaning wipes in their room, even though they had received a delivery that contained wipes from the Hospice Agency of R1. It is alleged that Staff of the facility had to bring in hygienic cleaning wipes from another resident’s room, but there was dried feces on the package. LPA has frequently visited the facility including the dates of 07/18/2023, 08/14/2023, 08/28/2023, 10/12/2023, 12/05/2023, and 01/04/2024. At no point during any physical visit to the facility did LPA observe any resident saturated with urine and/or feces anywhere in the facility. On 07/18/2023, LPA conducted a Required Annual Facility Evaluation Inspection and Report. The LPA observed all resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are six (6) designated resident rooms. All the resident rooms have an individual bed for one (1) resident. Each closet/storage area in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for residents. During multiple visits to the facility by the LPA on 07/18/2023, 08/14/2023, and 12/05/2023, LPA observed Staff members actively cleaning and sanitizing different rooms of the facility including restrooms and resident bedrooms. On 08/31/2023, LPA interviewed W1 who stated that during the frequent visits to see R1 under the authority of an outside Agency, they have been in the facility many times before with no concerns noted about incontinence. W1 went to see R1 on 08/24/2023, and R1’s bed was clean & dry with no signs of feces anywhere in the bedroom and no observable odor of urine by W1. On 08/28/2023, LPA interviewed Staff members of the facility who stated that all residents are regularly cleaned/bathed, and checked according to a schedule if there are risks of incontinence. Staff stated that extra incontinence materials are stored in resident bedrooms and/or storage areas in the common areas of the facility. Continued on 9099-C All Staff members interviewed by LPA denied leaving R1 in urine-soaked clothing and/or bed, and all Staff members interviewed by LPA stated that no resident would be left in feces, nor would feces be on any item used to clean any resident. On 08/28/2023, LPA interviewed residents of the facility who all stated they had not seen feces being left in a bedroom or on anything in the facility. Residents interviewed by LPA all stated they are cleaned by Staff and/or checked on by Staff on a regular basis. Based on the information obtained, there was Insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Due to staff neglect, resident developed pressure injury while in care. It is alleged that R1 was observed with a pressure injury to R1’s bottom. It is alleged that the pressure injury to R1 was “0.5 pea size.” According to the allegation, the Reporting Party (RP) does not have details as to how R1 sustained their pressure injury. On 08/31/2023, LPA interviewed W1 and members of the Home Hospice Agency (HHA) that had contact with R1 and physically visited the facility. According to W1, the Home Hospice Agency (HHA) of R1 applied barrier cream onto coccyx area generously, where skin was reddened. W1 went to see R1 on 08/24/2023 and stated that R1 had a Stage 2 pressure injury to R1’s coccyx. On 08/28/2023, LPA conducted record review of facility documentation for R1. Records reviewed for R1 included the Centrally Stored Medication and Destruction Record kept by the facility for all residents in care, physician’s notes for R1, Resident Appraisal for R1, Statements of Patient Advocates or Ombudsman, Physician Orders for R1 including Primary & Secondary diagnosis, Appraisal Needs & Services Plans (ANS), Physicians Reports for Residential Care Facilities for the Elderly (RCFE), and Emergency Information. LPA also received Hospice Care documentation for R1 from R1’s Hospice Agency on 08/28/2023. R1 was admitted to Hospice Care with a Home Hospice Agency on 03/10/2023. On 08/28/2023, when interviewed by LPA, the Reporting Party (RP) did not have details as to how R1 sustained their pressure injury. On 08/28/2023, LPA interviewed Staff members of the facility about this allegation who all stated R1 was treated for a reddened area/wound on their bottom regularly by R1’s Home Hospice Agency (HHA) and had antibiotics (cream). R1 received a patch and routine cleaning from a Hospice nurse. The facility staff stated they would rotate R1 every 2 hours at minimum. Record Review of Hospice Care Agency documentation and interviews with Hospice Care Agency Staff indicated that R1 had redness/irritation/wound on their coccyx/tailbone area which was treated weekly by Hospice Agency providers. Continued on 9099-C According to HHA statements from a visit with R1 on 08/16/2023, the skin integrity of R1 was intact, however the skin around the coccyx area was reddened and inflamed which constituted a Stage 1 pressure injury. The HHA Staff applied barrier cream onto the coccyx area generously, where skin was reddened. According to HHA statements from a visit with R1 on 08/23/2023, R1 was observed with a Stage 2 pressure injury to their coccyx. Records show both the facility and Hospice Agency were providing care for the pressure injury to R1. Hospice Agency personnel interviews did not reveal any indications of facility Staff neglect. Facility staff interviewed indicated they regularly checked/turned R1 as per the Hospice Care Plan for R1. Hospice Agency personnel stated to LPA that R1 occasionally needed prompting and redirecting of negative behaviors such as lashing out and being upset at being woken up which was believed to cause friction of R1’s fragile skin rubbing against clothing or bedding, and traction (pulling or stretching of skin) from sliding down R1’s inclined bed. There is no evidence either through record review of Facility and HHA documentation or interviews with Staff members at either the facility or the HHA that R1 received the pressure injury due to Staff neglect. Based on the information obtained, there was Insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was issued to the facility.the state’s words, verbatim · CDSS document, Jan 23, 2024 · control 29-AS-20230824134837

Allegation investigated: Facility does not provide a safe environment for resident while in care.

On 01/04/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit to the facility above to issue final findings on the allegations above. LPA arrived at the facility, met with Licensee Nelson Yague, and announced the purpose of the visit. On the allegation: Facility does not provide a safe environment for resident while in care. It is alleged by the Reporting Party (RP) that Resident #1 (R1) has been put into a bedroom of the facility that has the only access to the back parking area of the facility. Allegedly R1 is not allowed to lock the bedroom door because it is the only access into the facility from the back lot, and R1 has multiple people entering and exiting the home through the bedroom of R1. On 10/12/2023, LPA conducted a complaint investigation visit to the facility above that included interviews with residents, staff, a record review of pertinent facility documentation, and a tour of the physical plant of the facility. Continued on 9099-C Substantiated Through LPA observation, record review of a Facility Sketch, and the facility LIC 610 Emergency Disaster Plan documentation, LPA identified facility exit locations at the front entrance door of the facility, sliding glass door in the living room of the facility, and back door(s) out of the facility located in two (2) separate resident bedrooms. On 10/12/2023, LPA observed that the back door of a resident bedroom in the facility is an exit out of the facility that connects to the back/side of the facility or “back lot.” On 10/12/2023, interviews with residents indicated that that individuals would use a resident bedroom to enter and exit the facility from the “back lot” area of the facility. At least 1 Staff member interviewed by LPA indicated that the back entrance in R1’s room was the easiest way to enter and exit the facility from the outside area of the facility. The other resident bedroom backdoor that exits to the outside of the facility is located on the opposite side of the facility away from the “back lot” area and was not mentioned through interviews as having been used by individuals to enter and exit the facility. According to California Code of Regulations Section 87307(a)(2)(C) Personal Accommodations and Services, living accommodations and grounds shall be related to the facility's function. The following provisions shall apply: Resident bedrooms shall be provided which meet, at a minimum, the following requirements: No bedroom of a resident shall be used as a passageway to another room, bath, or toilet. In this instance, a resident bedroom has a door remain unlocked because it is the only access into the facility from the “back lot” area of the facility, and multiple individuals use the resident bedroom as a passageway into and out of the facility. Based on the information obtained, there was sufficient evidence to prove the allegation. Therefore, the allegation is deemed Substantiated at this time. Exit interview conducted. A copy of the report was issued to the facility. All the restrooms in the facility have similar measurement dimensions averaging 5 feet in width and 8 to 10 feet in length. Both shower/bathtubs in the facility do not have the size/dimensions for a wheelchair to access the bathing/washing areas by rolling straight in from the facility hallway or interior restroom toilet area. On 12/05/2023, LPA conducted additional observation of each restroom in the facility and took photographic evidence of each shower/tub and/or washing/bathing area. Each washing/bathing area in each facility restroom has a raised edge higher than the floor of the facility, meaning a wheelchair is unable to freely roll into the bathtub/shower area of each facility restroom. However, all restrooms inspected had assistive equipment for residents including grab bars and/or non-skid surfaces. Each resident restroom also contains a folded wheelchair located at the edge of the bathtub/shower to transfer residents into the bathing/washing area. Licensing does not require facilities to make structural modifications to the physical plant of the building to accommodate the accessibility of resident assistant devices such as wheelchairs. Licensing regulations dictate that resident bedrooms, but not resident bathrooms, meet the requirement to be large enough to allow for easy passage between and comfortable usage of beds and other required items of furniture, and any resident assistant devices such as wheelchairs or walkers. The licensing agency may require the facility to acquire a local building inspection where Licensing determines that a suspected hazard to health and safety exists. However, there is no suspected hazard to health or safety as R1 is still being cleaned hygienically by the facility through the washing of private areas and the changing of diapers on a regularly scheduled basis. It is the duty/responsibility of the Responsible Party and/or Conservator for each resident to make sure that the prospective facility restrooms have the necessary space for the individual resident’s wheelchair prior to moving the resident into the facility. The California Building Code states in existing buildings or facilities, when the enforcing agency determines that compliance with any building standard under toilet accessibility would create an unreasonable hardship, an exception to such standard may be granted when equivalent facilitation is provided. Here, Licensing has determined that there is no unreasonable hardship, and additionally there is equivalent facilitation as R1 is still being cleaned hygienically through the washing of private areas and the changing of diapers on a regularly scheduled basis. The facility also provides a transfer wheelchair to assist residents into the shower/tub for bathing/washing, and each restroom is equipped with assistive grab bars and non-skid surfaces. Based on the information obtained, there was Insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit Interview conducted. Copy of Report given to facility.the state’s words, verbatim · CDSS document, Jan 4, 2024 · control 29-AS-20231011194611

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(2)(C) · Plan of correction due date: Feb 1, 2024

87307(a)(2)(C) Personal Accommodations and Services. (a)Living accommodations...the following provisions shall apply: (2) Resident bedrooms provided which meet…following requirements: (C) No bedroom of resident shall be used as passageway to another room, bath, or toilet. This requirement was not met by: Based on interview, observation, and record review the facility used the bedroom of a resident as a passageway for individuals to enter and exit the facility.the state’s words, verbatim · CDSS document, Jan 4, 2024

Plan of correction: The Administrator of the facility will provide the LPA with evidence that Staff and other individuals entering and exiting the facility will be trained on Resident Personal RIghts regarding personal accommodations. All individuals will cease using resident bedrooms as passageways immediately.