Foothill Cottage

Type of visit: Case Management - Incident

On September 9, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of following up on an incident report received from a separate licensed day program concerning Resident #1 (R1). In the incident report, day program staff reported R1 showed up to the program on July 20, 2026, with a deep, wet, cough. As the day progressed, R1 began to experience shortness of breath and wheezing. Day Program Nurse arrived and determined R1 was struggling to breathe and their oxygen saturation level was at 69%. Emergency Medical Services (EMS) were contacted. When EMS arrived, R1 was placed on oxygen and transported to the hospital for further evaluation. As of September 9, 2026, LPA has not received any notification of R1's hospitalization from R1's home facility (Foothill Cottage). During the visit, LPA interviewed Licensee, Kristine Abejo, via telephone regarding the circumstances of the incident. LPA requested Licensee forward all of R1's hospital discharge paperwork and all Butte Home Health documentation for the two (2) weeks that R1 was seen by the agency. Deficiencies are being cited from the California Code of Regulations, Title 22, and are recorded on the attached LIC 809-D. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and Appeal Rights were provided, via email, to Licensee, Kristine Abejo.the state’s words, verbatim · CDSS document, Sep 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(d) · Plan of correction due date: Sep 18, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. Based on record review, it was determined staff failed to furnish a report to the Department within seven (7) days regarding an incident which threatened the welfare, safety, or health of R1. This poses a potential health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 9, 2026

Plan of correction: Licensee shall review the regulation and create a written plan to ensure all incidents that require reporting to Community Care Licensing are properly documented and reported within seven (7) days. Licensee shall provide the written plan to LPA Kayla Adkison via email, or in person by end of business on September 18, 2026.

Type of visit: Required - 1 Year

On July 15, 2026, Licensing Program Analyst (LPA) Kayla Adkison, arrived at the facility unannounced to conduct a Required Annual Inspection. LPA met with Kristine Abejo, Licensee, and Ed Murrillo, Care Staff, and explained the purpose of the visit. During the inspection, there were two (2) clients present and two (2) staff providing care. The remaining client was participating in an off-site day program. During the inspection, LPA observed clients watching television, socializing, and getting a manicure. LPA and Care Staff toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) resident bedrooms, two (2) bathrooms, kitchen, storage areas, garage, and backyard. All areas observed were found to be clean and in good repair. All walkways were clear of obstructions. LPA observed each bedroom to have the required furnishings and working lights. LPA observed the facility to be at a comfortable temperature. LPA measured the water temperature at 102.7 degrees Farenheight, below the required Title 22 requirements. Staff adjusted the hot water heater during the inspection and brought the temperature within Title 22 regulations. Facility has a 2-day perishable and a 7-day non-perishable amount of food. LPA observed all medications, sharps, and cleaning supplies to be locked away and inaccessible to clients in care. LPA observed (1) one fire extinguisher which was last inspected in May 2026. Smoke detectors and carbon monoxide detectors were observed and found to be in working condition. The facility is conducting emergency disaster drills every three months with the last drill being documented in June 2026. LPA observed a complete first aid kit ready for use. LPA reviewed a total of three (3) resident files and three (3) staff files which contained all the required documentation. All staff are fingerprint cleared and associated to the facility. Administrator certificate is current and posted in the facility for public view. No deficiencies are being cited as a result of this inspection. Exit interview conducted. A copy of this report was provided to LIcensee, Kristine Abejo, via email.the state’s words, verbatim · CDSS document, Jul 15, 2026

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 - Legal/Non-compliance

Licensing Program Analysts, Kayla Adkison and Marisa Chiarelli arrived on June 9th, 2026 for an unannounced visit to follow up on substantiated findings of neglect/lack of care, resulting from an investigation of an incident report. On June 16, 2025, the Department concluded an incident report investigation regarding the following allegations: Neglect/Lack of Care and Supervision: staff failed to seek timely medical attention for resident. The licensee was cited for California Code of Regulations (CCR) Title 22, § 87465(g) Incidental Medical and Dental Care. Following the virtual Non-Compliance Conference, on June 16, 2025, an immediate civil penalty of $500 was issued via email, the licensee was informed that an additional civil penalty may be assessed based on Health and Safety Code (HSC) § 1569.49. Continued on 809-C The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing care and supervision of a resident (R1), staff not seeking timely medical attention for R1, which resulted in R1 experiencing pain related to a fracture of the lower leg and subsequent hospitalization, surgery, and post-acute rehabilitation. Today, June 9th 2026, the Department will be issuing a civil penalty per HSC § 1569.49(f) for a violation that the Department determines constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on June 16, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Facility Representative signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jun 9, 2026

Type of visit: Required - 1 Year

On July 29, 2025, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with the staff (S1), Edmundo Murillo, and explained the purpose of the visit. S1 contacted Administrator, Kristine Abejo, via telephone who gave S1 verbal permission to act in her absence during the inspection. Three (3) residents were present at the time of the inspection. LPA and S1 toured facility together to ensure health and safety of residents in care. LPA observed the facility to be clean, in good repair and odor-free. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, shed, and common restrooms. LPA observed each bedroom to have the required lights, linens, and furnishings. The facility maintains extra clean linens for each resident. LPA observed all sharps and toxins to be locked in cabinets and inaccessible to residents in care. Facility has a 2-day perishable and a 7-day non-perishable amount of food. Hot water temperature was measured at 105 F. The facility is checking hot water temperatures regularly on their own and provided documentation. LPA observed smoke detectors, one carbon monoxide detector and one fire extinguisher which was last inspected in May 2025. LPA observed a complete first aid kit ready for emergency use. The facility is conducting emergency drills quarterly with the last drill being completed in June 2025. LPA reviewed medications which were locked in a cabinet and inaccessible to residents. LPA reviewed a total of three (3) residents' files which contained all required documentation. LPA reviewed two (2) staff files. One (1) of two (2) staff files was missing a health assessment, however, there was documentation of a completed tuberculosis exam for that staff member. All staff have been fingerprint cleared. Deficiencies are being cited from Title 22 Regulations and or the California Health and Safety Code as a result of this inspection (See LIC 809-D). Exit interview conducted and deficiencies were discussed with S1. Due to printer issues, a copy of this report and Appeal Rights were provided to administrator via email.the state’s words, verbatim · CDSS document, Jul 29, 2025

Type of visit: Office

On June 16, 2025, an office meeting was held to discuss an incident that occurred on April 24, 2024, and the results of the subsequent Investigations Bureau (IB) investigation. In attendance were Regional Manager Alycia Rayner, Licensing Program Manager Troy Ordonez, Licensing Program Analyst Kayla Adkison, Licensee/Administrator Kristine Abejo, and Michael Goryan, Licensee's Consultant. On April 24, 2024, at approximately 0400 hours, a resident (R1) experienced a "slide" while in the presence of staff. Based on the Unusual Incident Report (UIR) , and the Department's interviews with staff and day program personnel, the resident reported pain and was observed with swelling, but emergency medical assistance was not sought immediately. On April 25, 2025, at approximately 0940 hours, the resident was sent to the medical clinic were x-rays were taken. As a result, at approximately 1146 hours the resident was transferred from the medical clinic, via ambulance, to the emergency room. Medical attention was delayed for nearly 29 hours, and the resident was ultimately diagnosed with fractures that required emergency surgery, physical therapy, and the resident suffered prolonged pain. This delay in care constitutes a failure to meet the requirements under Title 22, Section 87465(g), which mandates that 9-1-1 be called immediately when there is an imminent threat to a resident’s health. As a result of the resident’s injury and the facility’s failure to seek medical attention in a timely manner, the violation warrants an immediate civil penalty in the amount of $500, which is being issued today. At this time, the issuance of an additional civil penalty is still being determined and the Administrator has been informed that an additional civil penalty may be assessed, at a later date, based on Health and Safety Code §1569.49. CONTINUED ON LIC-809C. The licensee was encouraged to: -Review regulations on Restricted Healthcare Plans -Review regulations on Prohibited Healthcare Plans -Review when to call 9-1-1 -Update the facility’s policies and procedures for seeking timely medical attention. Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Signature on this report acknowledges receipt of these reportsthe state’s words, verbatim · CDSS document, Jun 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jun 17, 2025

Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis … This requirement has not been met as evidenced per the department's investigation which substantiated that R1 did not receive timely medical care.the state’s words, verbatim · CDSS document, Jun 16, 2025

Plan of correction: Licensee shall update and submit the facilities emergency response policy and training plan for all direct-care staff. Updated Policy shall be submitted by end of business on 06/17/24.

Type of visit: Required - 1 Year

On 06/25/2024, Licensing Program Analyst (LPA) Jaynae Boyles arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with the administrator, Kristine Abejo, and explained the purpose of the visit. LPA Boyles and House Manager toured facility together to ensure health and safety of residents in care. LPA's observed the facility to be clean, in good repair and odor-free. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, shed, and common restrooms. LPA observed each bedroom to have the required furnishings, working lights and windows with screens. LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. LPA observed cleaning supplies under the bathroom sink which are accessible to residents in care. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 105 F. LPA observed one fire extinguisher, fire detectors, and carbon monoxide detectors. LPA observed a complete first aid kit ready for emergency use. LPA observed a complete emergency disaster plan and emergency drills conducted as required. LPA observed medications to be locked and inaccessible to residents. LPA reviewed a total of three (3) residents' files and two (2) staff files which contained all of the required documentation. Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Several topics were discussed. An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.the state’s words, verbatim · CDSS document, Jun 25, 2024

Type of visit: Case Management - Other

On 6/10/2024 LPA Jaynae Boyles and LPM Lauren Crocker held an office meeting with Licensee/Administrator Kristine Abejo to review the outcome of her 2nd level appeal regarding a complaint that was received by the Department on 9/20/22 along with reviewing the 1st level appeal for a citation from the facilitys annual inspection on July 24, 2023 and issue her Cleared Plan of Correction letter. During a complaint investigation in September of 2022 it was established that a Technical Violation occurred and is attached to this office visit. The TV (advisory note)the state’s words, verbatim · CDSS document, Jun 10, 2024

Type of visit: Case Management - Incident

On 06/10/2024 LPA Jaynae Boyles and LPM Lauren Crocker held an office visit to meet with Licensee/Administrator, Kathrine Abejo to discuss concerns regarding an incident report received from the licensee. The report received on April 26, 2024 outlines an incident where a resident (R1) sustained a fall in the early morning hours on 4/24/24, followed by a detailed timeline showing the facility failed to seek medical attention in a timely manner. Details in the report include the following information: the fall happened at 4am on 4/24/24, followed by the resident being sent to day program by facility staff at 8:30 am. At 9:50 am that same morning, the day program sent the resident home stating R1 “is not feeling well” and “cant get up from her wheelchair to use the bathroom.” R1 was returned to the facility at 10:30 am. R1 had soiled their pants twice while at day program due to inability to transfer to the toilet. At 6:00 pm the same day facility staff contacted the facility Administrator, Kristine Abejo, to inform her R1’s left leg was swollen. According to the incident report, Abejo advised staff to put a leg brace on, which R1 used last year in March when R1 had a broken ankle, “until tomorrow morning because it hurts every time she moves.” The following day, 4/25/24 at 9:40 am, almost 29 hours after the incident occurred, R1 was taken to the medical clinic where they took x-rays. The doctor’s orders were for the resident to go to the emergency room due to x-rays showing that the tibia and fibula were fractured. At 1:00 pm at the emergency room and the administrator was informed that the resident “will need a surgery tomorrow by placing a titanium rod to straight the bone. She will stay at the hospital for 3-4 days.” As a result of the resident’s injury and the facility’s failure to seek medical attention in a timely manner, the violation warrants an immediate civil penalty in the amount of $500, which is being issued today. At this time, the issuance of an additional civil penalty is still being determined and the Administrator has been informed that an additional civil penalty may be assessed, at a later date, based on Health and Safety Code §1569.49. Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Signature on this report acknowledges receipt of these reports.the state’s words, verbatim · CDSS document, Jun 10, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jun 10, 2024

Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis … This requirement has not been met as evidenced by the incident report submitted to the Department which describes the events of the incident and articulates that R1 did not receive medical treatment for over 24 hours for an fall resulting in injury that they had at the facility.the state’s words, verbatim · CDSS document, Jun 10, 2024

Plan of correction: Licensee will submit a copy of the emergency response policy as well as a plan to provide training with all employees prior to their work in the home. The POC is due by 06/17/24. Policy, training plan and 7 day schedule to be submitted.