Santa Maria Terrace

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Wellness Director and Administrator and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 7/21/2025 from 11:44 am to 2:30pm, where LPA conducted interviews with administrator, staff, wellness director, and obtained relevant documents. Interviews with reporting party were conducted on 7/21/25, pictures of Resident 1 [R1] following incidents were provided. Additional documentation was requested from the facility on 7/25/25 and provided to the LPA by the facility on 7/25/25 and 7/28/25. Interviews with the Nurse Practitioner (NP) were done on 7/25/25 at 3:20 pm. Tour of R1’s room was done on initial visit on 7/21/25. Continue on 9099-C UnsubstantiatedRead the full finding— CDSS inspection report, August 5, 2025 · control 29-AS-20250717121638

On 3/25/25 at 12:52 p.m. Licensing Program Analyst (LPA) Melisa Rankin arrived at the above to conduct a Complaint Investigation Site Visit. LPA met with Administrator Joanna Casillas and Wellness Director Vanessa Vazquez and explained the purpose of the visit. During visit LPA conducted interviews with staff and resident and reviewed and gathered relevant documents. ------------------------------------------------------------------------------------------------------- On allegation staff are violating residents’ personal rights Complaint states the resident is unable to leave the facility unassisted when resident has requested to go to their vehicle, attend events in the community, and go to shopping centers. UnsubstantiatedRead the full finding— CDSS inspection report, March 25, 2025 · control 29-AS-20250320162158

Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit on 10/1/24 to issue final findings on the allegations above. During the investigation, LPA, Miller, toured the facility and interviewed staff on August 16, 2024, from 10:49 a.m. to 1:00 p.m. LPA also obtained and reviewed relevant documents. LPA met with Joanna Enriquez, Administrator and Amy Bowman (Bowman), Wellness Director, to explain the purpose of the visit. On the allegation: Facility staff did not provide medication to resident for pain management. It was alleged by Reporting Party (RP) that on August 8, 2024, they observed that Resident 1(R1) was complaining of pain in her neck, spine, and leg. RP states they advised a Staff and expressed concern for the R1’s pain. It was alleged that the staff did nothing to help R1 with pain management. Bowman stated that the facility does not deny pain medication to residents in pain. Bowman further stated that staff may not provide pain medicatioRead the full finding— CDSS inspection report, October 1, 2024 · control 29-AS-20240809092613

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Sanjuana Enriquez, Administrator and Amy Bowman, Designee and explained the purpose of the visit. On the allegation: Staff did not dispense resident’s medication according to doctor’s orders. It was alleged that for two weeks the facility did not administer Resident 1 (R1) pain medication as prescribed which was stated by Family 1 (F1) to be taken every six hours or as needed (PRN). It was also alleged staff have refused to give R1 pain medication when asked. Continued on 9099-C UnsubstantiatedRead the full finding— CDSS inspection report, June 10, 2024 · control 29-AS-20240524153030

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Sanjuana Enriquez and explained the purpose of the visit. On the allegation: Staff did not provide proper notification of rate increases. It was alleged the facility did not notify the Family 1 (F1) for Resident 1 (R1) that there would be rate increases. Unsubstantiated— CDSS inspection report, June 10, 2024 · control 29-AS-20240520154222

Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA Olson and Miller interviewed Staff and Administrator on 12/15/23 and requested relevant documents. LPA met with Administrator and explained the purpose of the visit. On the allegation: Staff made inappropriate comment towards resident. It was alleged that Staff stated a resident with dementia was “ pathetic “ because they needed help being assisted back to their room. LPA interviewed the staff who stated they had just called for a care staff to come assist the resident back to their room. They thought they were just talking to a co-worker and said, it’s pathetic that you can’t get back to your room when you have dementia. Staff stated there was no one else in the room at the time and there was no way anyone overheard. Staff also stated they would never say anything like that to a resident or around residents. Staff said they have a family memberRead the full finding— CDSS inspection report, February 2, 2024 · control 29-AS-20231211123120

Licensing Program Analysts (LPA's) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA interviewed reporting party on 11/22/23 and 2/2/24, interviewed Staff and residents on 11/27/23 and requested relevant documents, interviewed Administrator on 12/15/23 and 2/2/24, and staff and residents on 12/15/23 and 2/2/24. LPA met with Administrator and Wellness Director over the phone and explained the purpose of the visit. On the allegations: Staff did not meet resident’s hygiene needs and Resident was charged for services not rendered. It was alleged Resident 1 (R1) is paying for 2 showers a week but sometimes doesn’t get their shower and the facility refuses to refund R1. Interviews revealed R1 has a shower log to track the showers R1 receives. It was alleged that on 10/31/23 a staff member called off so R1 was unable to get their shower. Interviews with staff confirmed if there are any call offs Residents don’t receive their showerRead the full finding— CDSS inspection report, February 2, 2024 · control 29-AS-20231117112744

Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA interviewed reporting party on10/23/23, interviewed Wellness Director and Care Staff on 10/25/23, 11/27/23, 12/15/23 and 2/2/24 and requested relevant documents. LPA met with Administrator and Wellness Coordinator over the phone and explained the purpose of the visit. On the allegation: Staff mismanaged resident medication. It was alleged that Resident 1 (R1) received three times the amount of medication Warfarin that the doctor ordered. It was alleged that R1’s blood clotting International Normalized Ratio (INR) reading was 8 when the normal is between 2 and 3. LPA received a call from the Wellness Director who informed LPA of the medication error. On 10/25/23 LPA interviewed staff that stated they did not read the label for the medication. They provided R1 the medication the day before and it was a 1mg tablet, and assumed the medication was tRead the full finding— CDSS inspection report, February 2, 2024 · control 29-AS-20231020141823

Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA interviewed reporting party on 3/1/23, interviewed Administrator and Care Staff on 3/2/23 and 6/12/23 and and requested relevant documents, and Wellness Director on 5/30/23. LPA met with Administrator and explained the purpose of the visit. On the allegation: Staff did not provide complete records to authorize representative. It was alleged that R1’s responsible parties requested records multiple times with no response. Interviews revealed the responsible party wanted records of the time medication was given and a staff agreed to check with IT to see how to print that information and would get back to them. At the time of the visit the staff said it still wasn’t provided. Interviews also revealed that the MAR and other documents wouldn’t print when the responsible party requested it. Staff wasn’t sure if it had been given but agreed to check. BaRead the full finding— CDSS inspection report, June 15, 2023 · control 29-AS-20230224144738

Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA requested relevant documents, interviewed reporting party on 3/1/23, interviewed Administrator and Care Staff on 3/2/23, and interviewed Wellness Director on 3/28/23. LPA met with Wellness Director and explained the purpose of the visit. On the allegation: Facility did not issue a correct refund. It was alleged that there were double charges for tray service and R1 was not issued a correct refund. LPA reviewed R1’s invoices from June 2022 through March 2023 and observed multiple charges, credits, and adjustments. LPA made a spreadsheet with all charges and credits and observed the following: On 7/1/22, $300 was charged for “Tray Charges.” On 7/1/22, there was a second charge of $438 for “Tray Charges” for the same month. No refund was issued for the duplicate charge. On 9/1/22 the facility billed $300 for tray charges as well as another chargeRead the full finding— CDSS inspection report, May 30, 2023 · control 29-AS-20230224163929

Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA interviewed reporting party on 3/1/23, interviewed Administrator and Care Staff on 3/2/23 and requested relevant documents. LPA met with Administrator and explained the purpose of the visit. On the allegation: Facility did not inform authorized representative of change in living arrangement. It was alleged that Resident 1 (R1) has dementia yet the facility allowed Resident 2 (R2) to move into R1’s apartment and didn’t inform the authorized representative. All staff interviewed stated that R2 frequently sleeps over and stays in R1’s room all day and night. Some staff state they’ve seen R1 in R2’s room on occasion, usually for coffee in the morning. Administrator stated they did not allow the move, they had no idea until the responsible party called on 2/27/23 and told them R2 moved into R1’s apartment. Staff went to check and saw R2’s closet emptRead the full finding— CDSS inspection report, April 26, 2023 · control 29-AS-20230228161535