Eastlake Villa Home Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Tyrone Vega. During visit, LPA toured the facility inside and out. During visit, LPA toured the kitchen area and observed there to be locked cabinets for sharp objects and medications. LPA observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured two out of two resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks were 116 F. LPA toured six out of six bedrooms. Each bedroom had working lights and available bedding and clothing storage. LPA tested the smoke detectors in the hallways and resident bedrooms. Each smoke detector functioned properly when tested. LPA tested the carbon monoxide detector in the hallway and it functioned properly when tested. LPA toured the outside area and found the exits to be clear of obstructions. LPA reviewed the Centrally Stored Medication and Destruction Records (CSMDR) for residents R1-R5. Resident R1 had one medication missing from the CSMDR and R2 had two medications missing from the CSMDR. LPA reviewed the resident records of R1-R5 and found them to be complete. LPA reviewed five staff records and found them to be complete. See LIC809-C page for more information. Page 1 of 2. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. A civil penalty was issued today for $250 for a repeated violation. See LIC421FC for more information. LPA Marrufo requests that the following records be updated and copies sent to the department by 01/13/2026: LIC500 Personnel Report LIC308 Designation of Administrative Responsibility Liability Insurance LIC610 Emergency Disaster Plan This report was reviewed with Tyrone Vega and a copy of this report was provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Jan 6, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management Visit and met with Tyrone Vega. The purpose of the visit was to follow up on a citation issued to the facility on 04/02/2025 for an incident involving resident R1 eloping from the facility without supervision. R1's Physician's Report stated that R1 cannot leave the facility unassisted. During today's visit, LPA Marrufo interviewed staff S1-S3. LPA Marrufo conducted a wellness check with resident R1. No deficiencies were cited were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Tyrone Vega and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 9, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management Visit and met with Yuly Arita, Office Manager (OM). The purpose of the visit was to follow up on an incident reported by the facility via Unusual Injury/Incident Report (IR) on 03/21/2025. The IR states that on 03/21/2025 at approximately 3:00 PM, resident R1 left the facility via taxi to go to the post office. The IR states that staff attempted to bring R1 back into the facility, but R1 entered the taxi and left. Staff found R1 at a local post office and returned R1 to the facility at approximately 3:20 PM. During visit, LPA Marrufo interviewed OM, who stated that R1 left the facility through the front patio door. OM stated that OM normally takes R1 to the post office, but on the day of the incident, OM was busy and was not able to take R1 to the post office. OM stated R1 called the taxi service. OM stated when the taxi service arrived, staff let the taxi driver know that R1 is unable to leave the facility, but the taxi driver took R1 anyway. OM stated the facility has previously contacted the taxi company and informed them that R1 is not able to leave the facility unassisted. OM stated to have assessed R1 upon his/her return to the facility and determined R1 was fine. During visit, LPA discussed with OM about reminding R1 to not leave to the post office alone and to wait for a staff to take him/her to the post office. R1's Physician's Report states R1 has dementia and is unable to leave the facility unassisted. R1's Physician's Report states R1 has wandering and sundowning behavior. R1's Appraisal/Needs and Services Plan states R1 has been trying to leave the facility. See LIC809-C page for more information. Page 1 of 2. During visit, LPA Marrufo conducted a health and wellness check with R1. LPA observed that the front patio door alarm was triggered when the door was opened. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with OM Yuly Arita and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 2, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 3, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Licensee did not ensure that resident R1 left the facility unassisted, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 2, 2025

Plan of correction: Licensee agrees to submit a Plan of Correction by POC date detailing how the facility will ensure that residents, particularly resident R1, does not leave the facility unassisted. The plan should include how the facility will communicate with the taxi company that R1 is unable to leave the facility unassisted, reminding R1 that he/she is unable to leave the facility unassisted, coordinating with R1 to have a staff take R1 to the post office, and instructing staff on what to do if a taxi comes to pick up a resident with dementia.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Yuly Arita, Office Manager. During visit, LPA toured the facility inside and out. LPA toured the kitchen area. LPA observed there to be locked drawers for sharp objects and cleaning supplies. LPA observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA reviewed the first aid kit and found it to be complete. LPA toured the hallways and 6 out of 6 resident rooms. The smoke detectors in the hallways and in the resident rooms all functioned properly when tested. Two out of two carbon monoxide detectors functioned properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels as well as functioning lights. The showers had anti-slip mats and shower chairs. The water temperatures in both bathroom sinks measured at 117 F. LPA toured the garage area and observed the garage door had a doorknob that could be locked and unlocked from inside the house. LPA observed that there were laundry detergents on top of the washing machine. LPA advised staff to either change the lock on the garage door so that it cannot be unlocked by residents or to install locks on one of the garage cabinets and store the laundry detergent in the locked cabinet. During visit, staff installed a lock on one of the cabinet inside the garage and placed the laundry detergent inside the locked cabinet. LPA toured the outside of the facility and found both exits to be clear of obstructions. See LIC809-D page for more information. Page 1 of 2. LPA Marrufo reviewed the Centrally Stored Medication and Destruction Record (CSMDR) during visit for residents R1-R5. The following errors were found in the CSMDR: R3 had two medications that were not recorded and R4 had one medication that was not recorded. LPA Marrufo reviewed the resident records for residents R1-R5 and found them to be complete. LPA reviewed the staff records of five staff and found them to be complete. An advisory note was issued. See LIC9102 for more information. A deficiencies was cited as per California Code of Regulations Title 22. See LIC809-D for more information. This report was reviewed with Yuly Arita and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 24, 2025

Allegation investigated: Staff did not refill medications timely causing resident to miss medications

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Myla Ilagan. On 08/08/2024, the Department received a complaint with the above allegation. LPA Marrufo conducted an initial complaint investigation visit on 08/15/2024. During visit on 08/15/2024, LPA observed that resident R1 did not have any medications. Administrator (ADM) Tyrone Vega stated that R1 did not have any medications at the facility because R1’s Medical have been deactivated and thus there were no funds to purchase prescription medication or to pay for a doctor’s visit to prescribe new medications for R1. ADM stated that R1 was admitted to the facility on April 18th, 2024 and R1 had a medication supply that lasted until April 30th, 2024. ADM stated that on May 7th, 2024, ADM received a telephone call from R1’s placement agency and was told that R1’s Medical was de-activated. ADM stated R1’s placement agency did not provide any alternative funding to pay for See LIC9099-C for more information. Page 1 of 3. Unsubstantiated R1’s admission at the facility or for R1’s medications. ADM stated to have made numerous attempted telephone calls to R1’s Family Member (FM) FM1 to seek assistance in re-activating R1’s Medical funding. LPA reviewed R1’s resident record and obtained copies of resident records. LPA did not observe any documents in R1’s record that R1 is conserved or has a Power-of-Attorney. LPA interviewed R1 during visit and R1 stated that R1 does not need medications. On 08/16/2024, LPA Marrufo conducted a telephone interview with FM1. FM1 stated to not have any conservatorship or legal authority on behalf of R1. FM1 stated to have visited R1 at the facility and observed changes in R1’s verbal communication that led FM1 to believe R1 was not receiving any medications. On 08/16/2024, LPA Marrufo conducted a telephone interview with Witness W1, who is a staff at R1’s placement agency. W1 stated that R1 has been R1’s own decision maker throughout the entire process of R1’s Medical becoming de-activated. W1 stated that after R1 was discharged from the hospital before R1 was admitted to the facility, there were discussions within R1’s placement agency that R1 lacked capacity to make decisions and the only person available to help R1 was FM1, who was not R1’s conservator or power of attorney. On 08/16/2024, LPA Marrufo conducted a telephone interview with Witness W2, who is a staff at R1’s placement agency. W2 stated to have left a voicemail with ADM on 08/02/2024 and then later received a telephone call back from ADM on 08/07/2024 and reported to ADM that R1’s Medical had been re-activated. See LIC9099-C for more information. Page 2 of 3. During interview with ADM on 08/22/2024 at another facility where ADM is a staff and where LPA was conducting an annual inspection visit, ADM stated that R1’s placement agency contacted ADM stating that R1’s Medical had been re-activated. However, ADM stated that when ADM contacted R1’s placement agency’s billing department to receive funds for R1, the billing department staff at R1’s placement agency told ADM that R1’s Medical had not been reactivated and the billing agency would be rejecting ADM’s request for back pay for R1’s care. ADM stated that during a meeting between ADM, R1, and R1’s placement agency that occurred on 08/20/2024, R1 was asked if R1 would like to have R1’s Medical re-activated and R1 declined. Based on information from interviews conducted with staff, resident, and witnesses, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. No Deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Myla Ilagan and a copy of this report was provided. Page 3 of 3. END REPORTthe state’s words, verbatim · CDSS document, Aug 23, 2024 · control 26-AS-20240808094002

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Tyrone Vega. During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen area and observed there to be a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPA observed locked drawers for sharp objects and cleaning supplies. LPA Marrufo toured 6 out of 6 resident bedrooms and observed each bedroom to have functioning lights, bedding, and furniture. LPA tested the smoke detectors in each room and in the hallways, and the smoke detectors functioned properly when tested. Two out of two carbon monoxide detectors functioned properly when tested. LPA Marrufo observed the alarm system on the exit doors functioned properly when tested. LPA Marrufo toured two out of two resident bathrooms, and each bathroom had working lights and available soap and paper towels. The showers had non-skid mats and shower chairs. The bathroom water temperature was 114 F. The outside area exits were clear of obstructions. LPA Marrufo reviewed resident and staff records. The resident records, including the Centrally Stored Medication Logs, were complete. The staff records were missing the LIC503 Health Screening form for staff S1-S3. The facility was also missing an Emergency Disaster Drill Log. Advisory Notes were Issued. See LIC9102 for more information. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Tyrone Vega and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 23, 2024