Purisima Hills

Allegation investigated: Facility is not meeting resident's diabetic needs. Facility did not follow physician's orders.

At 5:10am on 05/21/2026, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to continue the investigation to the allegations to this complaint. LPA met with Care Staff 2 (S2) announce who he is and the reason for the visit. LPA texted the Administrator Susan Marsh and informed her of LPA arrival to the facility. LPA conducted observations of Residents morning routines, including, waking, clothes preparation, breakfast, and medication administration.LPA also conducted interview with Resident (R1) and Staff (S2). LPA collected enough evidence to determine and delever final findings as flollows: As to the allegation of, “Facility is not meeting resident’s diabetic needs.” It was alleged that, facility is not following diabetic diet and diabetic care. It was discovered on 05/21/2026 LPA Jeffries conducted a facility continuing investigation visit at 5:10am and observed R1 morning preparation. LPA observed Staff 1 (S1) assisting residents with basic morning routinethe state’s words, verbatim · CDSS document, May 21, 2026 · control 29-AS-20260506124722

Allegation investigated: Staff engaged in an inappropriate conversation with resident in care. Staff does not ensure facility is maintained in good repair. Staff does not follow dietary plan for resident in care. Staff does not ensure food portions are of adequate serving sizes. Staff does not ensure residents transportation needs are being met. Staff does not ensure medications are dispensed as prescribed. Staff does not ensure residents health care needs are being met.

At 8:30am on 01/08/2026. Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to issue final findings to the allegations to this complaint. LPA also conducted facility annual inspection on a separate report on this visit. LPA met with Administrator Susan Marsh who provided verbal permission for Care Staff Elena Perez to sign for both complaint and annual inspection as Administrator had appointments. As to the allegation of, “Staff engaged in an inappropriate conversation with resident in care.” It was alleged that, administrator asked Resident 1(R1) to marry her a year and a half ago, from the date of this report. It was discovered in interviews on 10/30/2025 LPA conducted an in-person interview with R1 who stated, to the question: Was any marriage or marital arrangement ever discussed with you and the Administrator? “That is the most ridiculous thing I have ever heard.” R1 denied recalling any conversations pertaining to marriage. On 10/30/2025 LPA Jeffries conthe state’s words, verbatim · CDSS document, Jan 8, 2026 · control 29-AS-20251022120849

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff mismanaged resident's medication.

At 11:35am on 11/19/2025, Licednsing Program Analyst (LPA) Jeffries arrived to the facility unannounced to address the allegation to this complaint. LPA met with facility Administrator, Susan Marsh, announced who he is and the reason for the visit. LPA conducted a cursory medication audit of medications pertaining to the allegation to this complaint. LPA noted that the Medication Administration Record (MAR) indicated that Resident 1 (R1) MAR November of 2025 entries were noted for the medication in question to the allegation. LPA observed the facility Centrally Stored Medication Record (CSMR) for R1 that noted entry of "18 Pills" and "Plus 50". LPA noted that there were a total of 50 pills counted during medication audit, in addition to the 18 MAR entries equalling the total on the CSMR. At to the allegation of, "Staff mismanaged resident medication." It was alleged that on Novermber 11, 2025 facility only had 9 of 50 pills of medication noted in allegation. On 11/18/2025,Family Memberthe state’s words, verbatim · CDSS document, Nov 19, 2025 · control 29-AS-20251114154010

Allegation investigated: Licensee did not issue a refund of advance fees as required.

At 2:40pm on 05/19/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to issue final findings to the allegations to this complaint. LPA also conducted a continuation annual review of facility owned and operated by same Administrator next door under a different license number. LPA met with Administrator, Susan Marsh, announce who he is and the reason for the visit. As to the allegation, “Licensee did not issue a refund of advance fees as required.” It was alleged that facility did not refund deposit of $1250.00 after potential resident was denied admission to the facility. It was discovered that on 05/05/2025, LPA Jeffries conducted an interview with Administrator, Susan Marsh, who stated that they believed that the perspective resident (R1) was being “dumped” by family member (W1) due to W1 flying out of the country the day R1 was negotiated to become a resident at the facility. Administrator stated that W1 did not complete the Admissions Agreement on 04the state’s words, verbatim · CDSS document, May 19, 2025 · control 29-AS-20250429162031

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff failed to provide proper care and supervision for resident Staff did not seek medical attention for resident Staff violated residents visitation rights Facility failed to update responsible party on resident's status

On 9/23/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint investigation visit to the facility above to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Administrator Sue Marsh and explained the reason for the visit. On the allegation: Staff failed to provide proper care and supervision for resident. It is alleged that on 10/07/2022, Resident #1 (R1) had eloped from the facility without staff supervision and without the use of a wheelchair. The responsible party for R1 indicated that R1 always needs the use of a wheelchair when outside of the facility. Additionally, it is alleged that on 09/09/2023, R1 eloped from the facility without staff knowledge and without the use of a wheelchair. R1 fell during this elopement causing head, arm, and hand trauma which bled profusely. A neighbor of the facility found R1, contacted 911, and returned R1 to the facility as staff allegedly would not leave the fthe state’s words, verbatim · CDSS document, Sep 23, 2024 · control 29-AS-20231127090429

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.