Pacific Gardens on Hawkesbury

Allegation investigated: Resident care needs are not being met

On 09/14/2026, at approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct further investigation and deliver complaint investigation findings regarding LIC802 - Complaint Report #21-AS-20260616141002, which was received by Community Care Licensing (CCL) on 06/16/2026. Reporting Party (RP) claims resident care needs are not being met. LPA met with Mary Grace Defeo, Administrator. On 06/24/2026, LPA conducted a 10-day complaint investigation. During the visit, LPA obtained documents, made observations, and conducted interviews. The complaint identified concerns regarding the quality and quantity of food provided to Resident 1 (R1) and does not identify any other specific manner in which R1's care needs were allegedly not met. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... During an interview, Administrator stated that R1 moved into the facility on 06/03/2026 at approximately 3:00 PM and remained at the facility for less than 24 hours before calling 911 at approximately 8:30 AM on 06/04/2026 and requesting transport to the emergency room (ER) for hemorrhoid pain. Administrator stated that although R1 was receiving hospice services, R1 did not want to wait to be seen by their hospice nurse. Administrator stated that R1 requested a peanut butter and jelly sandwich and a glass of juice which Administrator states was provided. Administrator further stated that R1 received a dose of prescribed pain medication around 4:00 PM. At approximately 6:00 PM, a caregiver offered R1 dinner consisting of a cheeseburger, salad, soup, and a glass of juice. According to Administrator, R1 consumed approximately 50% of the meal, and care staff reported that R1 stated they did not have an appetite. The following morning, at approximately 7:00 AM, R1 was provided breakfast consisting of oatmeal, eggs, sausage, and orange juice. Care staff again reported that R1 ate only a small amount of the meal. On 06/24/2026, Interviews conducted with Resident 2 (R2) and Resident 3 (R3) revealed that the food provided in the facility is of sufficient quality and quantity. During today's inspection, LPA conducted a walk-through of the facility, completed interviews, and made observations. LPA observed that the facility maintained the required two-day supply of perishable and seven-day supply of nonperishable food. LPA observed fresh fruit, vegetables, protein, dairy products, and snacks available at the facility. LPA also observed staff preparing a hot meal for lunch consisting of ground beef, vegetables, and rice. LPA interviewed a representative from the hospice agency, who confirmed that the only complaint reported to the agency by R1 involved the food provided at the facility. The hospice representative stated that the agency investigated R1’s concern and determined that the food provided at the facility was sufficient. Information obtained during the investigation regarding whether R1’s care needs were adequately met was conflicting. Based on interviews conducted, observations made, and records obtained, the listed allegation is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Sep 14, 2026 · control 21-AS-20260616141002

Type of visit: Case Management - Other

On 09/14/2026, at approximately 1:00 PM, during a complaint investigation visit, Licensing Program Analyst (LPA) Julie Florio, observed areas of noncompliance. LPA is conducting a case management - other visit and met with Mary Grace Defeo, Administrator. LPA conducted a case management visit to address staff sleeping areas observed in portions of the facility not approved for that purpose. LPA observed a blue metal bunk bed in the facility garage with a single mattress on the bottom bunk covered with a fitted sheet and two pillows on the bed (see pictures). LPA also observed a privacy screen folded up and a black suitcase bearing the name of Staff 1 (S1) at the foot of the bed (see pictures). Administrator stated the suitcase belonged to S1 who works 48-hour shifts on weekends. Additionally, LPA observed another suitcase, two plastic bags containing personal belongings, and a shelf arranged as a night stand containing personal items. LPA was informed that these items belong to Staff 2 (S2) and Staff 3 (S3) (see pictures). S2 stated that they are currently working a 24-hour shift and slept on the facility couch the previous night beginning at approximately 10:00 PM. Deficiencies are cited from Title 22 Regulations, Division 6, (see LIC809D). Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Mary Grace Defeo, Administrator, whose signature on form confirms receipt of documents. Appeal rights provided.the state’s words, verbatim · CDSS document, Sep 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a) · Plan of correction due date: Sep 15, 2026

87307 Personal Accommodations and Services: (a) ....The facility shall...provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by: Based on observation and interviews the Licensee did not ensure that staff who may reside or sleep in the facility are provided private accommodations within the scope of their fire clearance which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 14, 2026

Plan of correction: Licensee to submit self-certification stating they will ensure no staff are living or sleeping in the garage or in communal areas of the faciity to CCL by POC due date of 09/15/2026.

Type of visit: Case Management - Incident

On 08/04/2026, at approximately 10:30 a.m., Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management - incident visit and met with Mary Grace Defeo, Administrator. LPA is conducting a case management visit to obtain more information regarding a facility self reported SOC341 Report of Suspected Dependant Adult/Elder Abuse received by the Department on 08/03/2026 for concerns reported by Resident 1 (R1) regarding Staff 1 (S1) placing a fist in R1's face. LPA made observations, obtained documents, and conducted interviews. No deficiencies were cited during todays visit. Exit interview was conducted with Mary Grace Defeo, Administrator, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 4, 2026

Allegation investigated: Staff do not ensure residents are given privacy Unqualified staff attempted to administer morphine to a resident in care

***AMENDED COMPLAINT INVESTIGATION FINDINGS*** On 02/27/2026, at approximately 10:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct further investigation and deliver amended complaint investigation findings regarding LIC802 - Complaint Report #21-AS-20251022103435, which was received by Community Care Licensing (CCL) on 10/22/2025. Reporting Party (RP) claims the above allegations. LPA met with Mary Grace Defeo, Designated Responsible Party (DRP). On 10/27/2025, LPA conducted a 10-day complaint investigation. During that visit, LPA toured the facility, made observations and conducted interviews. LPA did not observe a privacy screens being utilized in the facility for residents in shared rooms, nor was facility able to provide proof of any such items. Continued on LIC9099C... Substantiated ***AMENDED COMPLAINT INVESTIGATION FINDINGS*** Continued from LIC9099... Per an interview conducted with DRP during that visit, a subsequent interview conducted on 02/12/2026, and an interview conducted with RP on 02/12/2026, LPA received consistent information from both parties that no privacy shield was put in place to ensure privacy for Resident 1 (R1) while having their briefs changed or receiving any sort of bedside care in their shared room. Facility has since purchased portable privacy screens and agrees to utilize them in shared rooms when providing any sort of care moving forward. During the above mentioned interviews with DRP and RP, LPA received consistent information from both parties that that Staff 1 (S1) drew up R1's PRN narcotic and attempted to hand it to RP to administer to R1. Additionally, on 02/27/2026, LPA conducted a phone interview conducted with a representative from the third party Hospice agency which revealed that the narcotics prescribed for R1 were not delivered to the facility in pre-filled syringes for facility staff to assist R1 with administering the narcotic to themselves as required per regulation. Based on interviews conducted and records obtained, S1 should have contacted the Hospice agency nurse to come to the facility to assist R1 with drawing up and and administering their narcotics. Based on observations made and interviews conducted, the allegations that staff do not ensure residents are given privacy and unqualified staff attempted to administer morphine to a resident in care are SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from Title 22 Regulations, Division 6, (see LIC9099D). Exit interview conducted with DRP, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to DRP.the state’s words, verbatim · CDSS document, Feb 17, 2026 · control 21-AS-20251022103435

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(j)(1) · Plan of correction due date: Mar 2, 2026

Hospice Care of Terminally Ill Residents 87633(j)(1) ...[F]acility staff, other than appropriately skilled health professionals, shall not perform any health care procedure that under law may only be performed by an appropriately skilled professional. This requirement is not met as evidenced by: Based on interviews conducted, Licensee did not ensure that R1's morphine was administrered by an appropriately skilled professional. This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 17, 2026

Plan of correction: Licensee to self-certify that all staff have reviewed the regulation and have been retrainied on the proper administratrion of narcotics to CCLD by POC due date of 03/02/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Mar 17, 2026

Additional Personal Rights of Residents in Privately Operated Facilities 87468.2(a)(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance.... This requirement is not met as evidenced by: Based on observations made and interviews conducted, Licensee did not ensure that R1 received a reasonable level of personal privacy while having their briefs changed. This poses a potential Health, Safety and/or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 17, 2026

Plan of correction: Licensee to submit proof to CCLD that a privacy barrier has been implemented in the facility to use in shared rooms while performing care to residents in order to ensure their privacy by POC due date of 03/17/2026.

Allegation investigated: Staff did not assist residents with incontinence needs. Staff are not following resident's dietary needs. Staff did not ensure resident was fed an adequate amount of food. Staff did not empty resident's urinal. Staff left resident's in a soiled diaper for a long period of time.

***AMENDED COMPLAINT INVESTIGATION FINDINGS*** On 02/27/2026, at approximately 10:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct further investigation and deliver amended complaint investigation findings regarding LIC802 - Complaint Report #21-AS-20251022103435, which was received by Community Care Licensing (CCL) on 10/22/2025. Reporting Party (RP) claims the above allegations. LPA met with Mary Grace Defeo, Designated Responsible Party (DRP). On 10/27/2025, LPA conducted a 10-day complaint investigation. During the visit, LPA obtained documents, made observations, and conducted interviews. Per an interview conducted with DRP during... Continued on LIC9099C... Unsubstantiated ***AMENDED COMPLAINT INVESTIGATION FINDINGS*** Continued from LIC9099... the visit, a subsequent interview conducted with DRP on 02/12/2026, and an interview conducted with RP on 02/12/2026, both stated that Resident 1 (R1) moved in around 7pm at night on 10/20/25 and moved out between 1:00-2:00pm on 10/21/2025. RP stated R1 was not offered breakfast foods but rather was offered dinner foods the morning of 10/21/2025. RP also stated they changed R1 on their own but admitted not notifying facility staff that R1 needed to be changed or requesting assistance. RP stated that R1 did not incur any change of condition including compromised or decreased skin integrity as the result of their stay at the facility. RP further stated that they observed commodes and urinals full and smelled urine in the facility. Per interviews with DRP, facility staff check on each resident every couple of hours and this includes checking their briefs, commode, and urinals which are then changed and/or emptied as needed. During today's inspection, LPA completed a walk through of the facility, conducted interviews, and made observations. LPA found the facility to be clean, sanitary, and free from odors. LPA observed an empty bedside commode and urinal in two separate resident rooms. Based on interviews conducted with DRP and with residents R1, R2, and R3, residents are offered eggs, toast, pancakes, sausage, fruit, oatmeal, and similar foods for breakfast each day. Each stated they are checked on every couple hours where they are assisted with changing their briefs and urinals are emptied if indicated. LPA received conflicting information regarding food, incontinent care, and bedside care provided to R1 and other residents in care.. Based on interviews conducted, observations made, and records obtained, the listed allegations ARE UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with DRP, whose signature on form confirms receipt of document(s).the state’s words, verbatim · CDSS document, Feb 17, 2026 · control 21-AS-20251022103435

Type of visit: Case Management - Annual Continuation

At approximately 12:15 PM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to CONTINUE a Required - 1 Year inspection and met with caregiver Jyd Leong, who called Administrator Kristine Bernadino. At approximately 12:45 PM House Manager Mary Grace Defeo arrived to help with today's continued inspection. At approximately 12:45 PM LPA reviewed five (5) staff files and 5 of 5 had all required documentation including health screening/evidence of neg TB test, current 1st aid/CPR, background clearance and Guardian association to facility. At approximately 1:15 PM LPA reviewed five (5) of 5 resident files and observed all 5 to have the required documentation. At approximately 1:35 PM LPA observed medicines to be centrally stored and locked. Licensee is reminded to ensure that caregivers trained to pass medicines document the date and time of when medicines are given at the time of administration. LPA reviewed records and determined the last fire/disaster/evacuation drill was performed on 10/03/2025. LPA obtained the following documents for the facility file today including: LIC 308 Designation of Facility Responsibility (3) LIC 500 Personnel Report LIC 9020 Register of Facility Residents Continued on LIC809C Continued for LIC809 LPA requested the following UPDATED documents for the facility file to be submitted to CCL by 11/14/2025 1)Copy of current Liability insurance for 2026 2)Copy of current rental agreement for 2025 and beyond This report was reviewed with House Manager Mary Grace Defeo. No deficiencies cited during this inspectionthe state’s words, verbatim · CDSS document, Oct 14, 2025

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 1:00 PM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to BEGIN a Required - 1 Year inspection and met with caregiver Jyd Leong, who called Administrator Kristine Bernadino. Facility had three (3) hands-on care staff upon my visit. Facility is a Residential Care Facility for the Elderly (RCFE) with a dementia care plan on file, and is approved for six (6) residents that can be non-ambulatory and the RCFE has clearance to care for one (1) bedridden resident in rooms #5 or #6; they have a hospice waiver for three (3) residents. There are currently five (5) residents living in this facility, one of which is on hospice. At approximately 1:30 PM House Manager Mary Grace Defeo, arrived and LPA conducted an inspection of the facility and grounds and observed facility was found to be clean, at a comfortable temperature with all exits free from obstruction. Resident rights and Ombudsman posters are posted. Resident rooms were observed to have the required furnishings and linens. Fire Extinguisher was observed to be charged and serviced in September of 2025. Carbon monoxide detector was found to be operational, smoke detectors were tested and operational. LPA observed a broken down flower (planter) box in the front of the facility and a badly ripped cloth shade structure and the licensee was advised as a commercial property to replace or repair the items to both maintain appearance and meet regulation. Water available to residents in care was within 105-120F per title 22 regulation. Extra hygiene products and linens were available and are kept in the laundry area in the garage. There was a sufficient and variety of both perishable and nonperishable foods as required by Title 22 Regulations. Facility was advised to ensure all food is labeled with the date it is removed from a commercial bag and stored in a separate storage bag, regardless if the food is for staff or residents. Continue on LIC809-C Continued from LIC809 Licensee was advised that LPA will return at a later unannounced date to conduct staff and resident file review, as well as, medicine administration review. LPA will request documents including LIC500, LIC9020, updated Liability Insurance and copy of deed or current lease agreement upon completion of this inspection at next visit. Technical Violation and/or advisories are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), may result in a civil penalty assessment. This report was reviewed with House Manager Mary Grace Defeo, and Appeal rights were given. No deficiencies cited during this inspectionthe state’s words, verbatim · CDSS document, Oct 7, 2025

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, care staff, Eller Obias. Administrator, Grace Caramat was called but was unable to meet with LPA. LPA requested facility to submit a current LIC500 identifying the days and hours the administrator works in the facility. LPA also requested facility to submit the required paperwork to Community Care Licensing (CCL) to change the. There are currently 6 residents living in this facility. This facility is licensed for 6 non-ambulatory residents, with no approval for bedridden and there is a Hospice waiver for 3 of the residents. LPA toured facility and grounds and observed facility was found to be clean at a comfortable temperature with all exits free from obstruction. Resident rooms have the required furnishings and linens. Medications are stored locked in a locked cabinet in the hallway closet. Extra hygiene products and linens were available and will be kept in the laundry area and extra in the garage. Facility understands they need to remove all the linens that are being kept in the dresser in a residents room. Facility understands they may not use the residents room and space to store all the facility linens. Fire Extinguisher was found to be charged and serviced on 9/18/2024. Carbon monoxide detector was found to be operational, smoke detectors were tested and operational. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Toxins sharps and medications are locked and not accessible to residents. During the inspection an additional staff showed up to do activities with the residents and explained they do this several days a week with this and 2 other sister facilities. LPA reviewed 6 of 6 resident files and facility will need to update 3 of 6 resident admission agreements. Facility complete staff files were not available. Continue report see LIC809-C LPA requested the following updated records to be submitted to Community Care Licensing by 12/22/2024. LPA will need to return to review staff files and requested clarification and an updated LIC602 for resident R1. · LIC 308 Designation of Facility Responsibility · LIC 500 Personnel Report · LIC 610D Emergency Disaster Plan · LIC 9020 Register of Facility Residents · Copy of Liability insurance Copy Admin Certficate Exit interview conducted with Eller Obias No deficiencies cited during this inspectionthe state’s words, verbatim · CDSS document, Nov 26, 2024