Delia's Residential Community 2

Allegation investigated: Facility staff did not address resident diabetic care being provided at the facility.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced complaint investigation visit. LPA Rai met with Administrator (ADM) Dina Domingo and stated the purpose of today's visit. During visit, LPA Rai interviewed 1 staff (S1) and Administrator (ADM). Both staff stated resident (R1) does not reside at this location but is a resident at another location owned by the Licensee. LPA Rai confirmed R1 does not reside at this facility, but at another licensed facility. The Department has completed the investigation of the above allegation. Based on interviews conducted and record reviews, the department has found that the above allegation were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Nothe state’s words, verbatim · CDSS document, Jun 25, 2026 · control 26-AS-20260616161940

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator, Carmen Buno and stated the purpose of today's visit. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 1 shed in the backyard which was locked and used for storage and not habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the facility to include 6 resident rooms, 1 staff room, living room, dining room, kitchen and garage. 6 Out of 6 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom and kitchen sink ranged from 109.2 - 109.4 degrees F. Fire extinguisher was observed and inspected on 01/07/2026. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drills were conducted on 12/20/2025 and 03/11/2026. LPA Rai observed a complete first aid kit at the facility. LPA Rai reviewed facility records for 2 staff and 2 residents. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. LPA Rai reviewed at random 2 residents' medications and central stored medication records. LPA Rai reviewed resident R2's 10 medications and observed 1 out of 10 medications (MED1) was not logged on the Centrally Stored Medication Record. LPA Rai and facility staff S1 Patricia counted the medication tablets in MED1 bottle and 194 tablets were counted. The medication bottle was opened and the medication was administered from the bottle on 04/03/2026. LPA Rai and facility staff S1 reviewed R2's Medication Administration Record for MED1 and observed staff initials for medication administered from 04/03-04/06/2026. LPA Rai observed on 04/5/2026 the staff's initials and the circle around the initials. S1 stated those are her initials and the circle around the the letter "R" means the resident refused. LPA Rai observed R2's MARs and there were staff initials and then a letter R and a circle was created on top. Administrator Carmen Buno stated the staff should not sign off on the MARs before administering the medication as the resident may refuse the medication, which happened in this case where in R2 refused the medication after S1 signed on the MARs stating the medication was administered to the R2. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. Technical Violations was provided. This report was reviewed with Administrator, Carmen Buno and a copy of the report was provided. LIC 858 and LIC 859 were provided. Appeal Rights was provided.the state’s words, verbatim · CDSS document, Apr 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Apr 14, 2026

87465 Incidental Medical and Dental Care (h) (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement is not met as evidenced by: Based on interview and record review, resident R2's 1 out of 10 medications was not logged on the Centrally Stored Medication Log which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure R2's centrally stored prescription medication are recorded on the Centrally Stored Medication log by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Apr 8, 2026

87207 No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on interview and record review, staff S1 wrote initials on resident R2's Medication Administrator Record (MAR) for Medication 1 was administered on 4/5/2026 but later wrote resident refused after initialing the records stating the medication was given to the resident which poses/posed a potentialthe state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure staff are trained to record true statements regarding the services provided by the facility by POC due date. Administrator agreed and understood. (con't) health, safety or personal rights risk to persons in care.

Allegation investigated: Facility staff physically abused resident when resident requested for assistance. Facility staff left resident's undergarments soaked in urine.

Licensing Program Analyst (LPA) Simi Ran conducted an uannounced visit to conclude the complaint investigation of the allegations above. LPA met with Administrator, Dina Domingo and stated the purpose of today's visit. On 11/21/2024, the Department received a complaint with the above allegations. On 11/27/2024, the Department coducted the initial 10-day compliant investigation visit. Continuation on LIC 9099-C, Page 1 of 3. Unsubstantiated Page 2 of 3. Facility staff physically abused resident when resident requested for assistance. It was alleged that the facility staff physically abused the resident (R1) when R1 was requesting assistance. On 11/20/2024, the Department interviewed 3 staff including ADM. Four out of the four staff stated resident R1 required assistance with ADLs, such as grooming and incontinence. Four out of four staff stated they have assisted R1 with ADLs and provided additional assistance when R1 requested. Four out of four staff stated they have not physically abused residents and they have not seen or heard staff physically abuse residents at the facility. On 11/20/2024, the Department interviewed 4 residents. Four out of the four residents refused to speak with LPA and provide information during the investigation. Based on review of R1’s Appraisal Needs and Services Plan dated and signed on 10/30/2024 by the Licensee and R1’s authorized representative, R1 is diagnosed Delirium and needs constant reminders and reality orientation. Facility staff’s plan is to provide constant reality orientation and reassurance and provide tools for reality orientation. R1 has agitation and anxiety with episodes of calling out constantly for no reason. Facility would reduce anxious mood and agitation and provide assurance by attending to needs timely. 1:1 social visit to promote a trusting relationship with staff. Facility staff left resident's undergarments soaked in urine. It was alleged the facility staff left resident's undergarments soaked in urine. On 11/20/2024, the Department interviewed 3 staff including ADM. Three out of three staff stated they have not left resident’s undergarments soaked in urine. S1 stated she helped with assisting R1 in continence care and routinely checks on R1 and ensures R1's incontinent products are not soaked in urine. Page 3 of 3. On 11/20/2024, the Department interviewed 4 residents. Four out of the four residents refused to speak with LPA and provide information during the investigation. Based on review of R1’s Appraisal Needs and Services Plan dated and signed on 10/30/2024 by the Licensee and R1’s authorized representative, R1 is incontinent of bladder and bowel and needs assistance with transfers. R1 is able to turn in bed. The facility staff will assist and provide care in all areas needed. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 26-AS-20241121142405

Allegation investigated: Facility staff did not administer resident's medication as prescribed by physician. Facility staff installed a security camera in resident's room without resident's consent.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator Dina Domingo and stated the purpose of today’s visit. On 3/11/2025, the Department received a complaint with the above allegations. On 3/19/2025, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 2. Unfounded Page 2 of 2. Facility staff did not administer resident's medication as prescribed by physician. It was alleged that resident R1 was not being administered Medication #1 as prescribed by physician. On 3/19/2025, the Department interviewed 2 staff (S1-S2). S2 stated R1 did not have physician’s order for facility to administer Medication #1, which was not a routine medication but as need (PRN) medication. S2 stated the Hospice RN was able to administer the medication but they only had orders signed by a nurse and not a physician. S2 stated Hospice agency was aware of this and they would administer the medication #1 as it was a PRN medication. On 3/19/2025, the Department interviewed 2 residents (R1-R2). Two out of two residents were not able to answer the questions requested at the time of the visit. On 3/19/2025, the Department interviewed 1 witness (W1). W1 stated that they did not see or hear any issues with facility staff not administering medications to the residents. Based on review of resident R1’s file, R1’s Hospice medication orders for Medication #1 was signed by a nurse and not a physician. Based on review of R1’s hospice visit log, R1’s nurse stated medication #1 order, but order was signed by nurse and not physician. Facility staff installed a security camera in resident's room without resident's consent. On 3/19/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated resident’s responsible party was aware of security camera and signed consent forms to have camera in resident’s room. On 3/19/2025, the Department interviewed 2 residents (R1-R2). Two out of two residents were not able to answer the questions requested at the time of the visit. Based on review of resident R1’s Admission Agreement, page 35 out of 36, R1’s responsible party signed to have non-recording video monitors in the resident’s living space. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided. Page 2 of 3. Facility staff is not meeting resident's needs due to lack of staffing. On 3/19/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated there was enough staffing to meet the resident’s needs. S1 stated there were two residents and 1 staff assisting both resident. S1 stated there were available staff from the next facility, which also belongs to the Licensee, and they can always come to assist residents in an emergency. S2 stated there are enough staff to meet the resident’s needs. S2 stated they will help assist S1 when there were only 2 residents at the facility to cover breaks and assist with other duties at the facility. On 3/19/2025, the Department interviewed 2 residents (R1-R2). Two out of two residents were not able to answer the questions requested at the time of the visit. On 3/19/2025, the Department interviewed 1 witness (W1). W1 stated they did not hear or see any issues with the facility staff not meeting the resident’s needs at the facility. W1 stated the staff are always available when requested. Based on review of staff schedule from January 2025 to March 2025, there are 1 to 2 staff assigned throughout the day, along with 1 administrator on shift throughout the day. Facility staff did not follow resident's care plan. It was alleged that the resident wasn’t having a consistent sleep pattern, where the staff did not ensure the resident was sleeping in the night and awake in the day. On 3/19/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated the R1 had a hard time adjusting to the new facility and was restless at night. S2 stated the night shift staff would do safety checks at night with the other residents and stay in R1’s room to ensure R1 was comfortable to sleep. S2 stated R1’s hospice team had initiated medication which they was administer when facility staff would report R1 being restless at night. On 3/19/2025, the Department interviewed 2 residents (R1-R2). Two out of two residents were not able to answer the questions requested at the time of the visit. Page 3 of 3. On 3/19/2025, the Department interviewed 1 witness (W1). W1 stated they have not seen or heard facility staff not following resident’s care plan. W1 stated they are present in the facility in the day time and have not observed facility staff’s night time activities. W1 stated when they are present in the facility, the residents are awake and doing activities Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 26-AS-20250311101753

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator, Dina Domingo and stated the purpose of today's visit. LPA Rai observed 3 staff who have obtained a Criminal Record Clearance. LPA Rai observed 4 residents at the facility. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 1 shed in the backyard which was locked and used for storage and not habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the facility to include 6 resident rooms, 1 staff room, living room, dining room, kitchen and garage. 6 Out of 6 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom and kitchen sink ranged from 105.1 - 106.0 degrees F. Fire extinguisher was observed and inspected on 01/21/2025. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 03/03/2025. LPA Rai observed a complete first aid kit at the facility. LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai reviewed resident medications and central stored medication records. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Dina Domingo and a copy of the report was provided. LIC 858 and LIC 859 were provided.the state’s words, verbatim · CDSS document, Apr 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Licensee (LIC) Dina Domingo. LPA Rai observed 2 staff and 5 residents at the facility. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed a shed in the backyard used as storage and not habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the resident bedrooms. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 118.9 degrees Fahrenheit - 119.7 degrees Fahrenheit. The water temperature in the kitchen sink was 118.4 degrees Fahrenheit. Facility temperature was observed at 71 degrees Fahrenheit. Fire extinguisher was observed and inspected on 2/4/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 4/24/2024. LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai reviewed resident medications and central stored medication records. No deficiencies were cited per California Code of Regulations, Title 22. Technical Violation was provided. This report was reviewed with Licensee (LIC) Dina Domingo and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 12, 2024