Applegate @ Dorado

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:03AM. Upon arrival, LPA met with staff and Administrator Emma Carmona, and Licensee Irma Carmona who arrived at 12:05PM. Entrance interview conducted. At 11:05AM, the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. BEDROOMS: There are six (6) resident bedrooms. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms were equipped with functional auditory exit alarms. There is a staff room on the ground floor that is accessed from outside. RESTROOMS: There are six (6) resident restrooms and one (1) staff/visitor bathroom in the hallway. Each bedroom has an attached restroom. LPA observed bathrooms to be clean, sanitary, and in operating condition with slip-resistant surfaces and grab bars. Hot water temperatures were measured in bathrooms and were between 109.4-113.0 degrees F, which is within the required range. KITCHEN: The LPA inspected the kitchen/food service area at 11:12AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility had a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for expiration dates and dates were clearly marked. Knives and sharps were observed locked and inaccessible in a drawer. (Report Continued on LIC 809C...) COMMON AREAS: At the time of the visit, living room and dining room furniture were observed to be in good condition. The facility maintained a comfortable temperature. At 11:27AM, smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The fire extinguisher was observed fully charged and last serviced on 04/03/2025. Auditory exit alarms were functioning at the time of the visit. The washer and dryer are located in a closet next to Bedroom #1. LPA observed detergents and toxins in a locked cabinet above the washer and dryer. The LPA observed a closet with additional cleaning supplies and personal hygiene products locked and inaccessible to residents in care. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. LPA observed side gate to self-latch. No bodies of water noted at the time of the visit. RECORD REVIEW: Beginning at 11:30AM, LPA reviewed five (5) out of five (5) resident files and three (3) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident and personnel files were in order. MEDICATION REVIEW: At 12:45PM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in a cabinet by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs were properly documented and logged. Medications were observed to be properly documented on the centrally stored medications and destruction record and were in compliance with regulation, state, and federal law. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency drills are conducted quarterly as required, with the last drill conducted on 10/23/2025. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 18, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Questionable death.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to deliver the findings for the allegation listed above. LPA Urena met with the Licensee Irma Carmona and explained the reason for the visit. On 03/22/2024, Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit to the facility. LPA met with administrators Irma Carmona, Emma Carmona and Cynthia Alvarez and explained the reason for the visit. 04/16/2025, Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to investigate the allegations listed above. LPA Urena met with the Administrator Emma Carmona and Cynthia Alvarez explained the reason for the visit. LPA Urena interviewed the Administrators, and staff from approximately 11:10 to 2:44 p.m. requested records pertinent to the investigation. Continues on LIC 9099C...pg. 2 Unsubstantiated Questionable Death On the allegation of the questionable death of R1, it is the concern of the reporting party that the death of R1 is the result of the staff administering medication and not providing proper suctioning. To investigate the allegation, LPA Urena interviewed staff, administrators and the RP, and conducted record review. The record review revealed that R1 was receiving hospice services at the time of death. The Certificate of Death from the State of California indicates that R1’s immediate cause of death was Cardiopulmonary Arrest and terminal disease and condition (chronic kidney disease and congestive heart failure) resulting in death. No autopsy was conducted after death. Hospice records dated 11/14/2023, revealed that R1 had discontinued all curative treatments and had a terminal prognosis of six (6) months at the time of the report. Records review of the Medication Administration Record (MARS) used by the facility, indicated by the initials on the date of 03/17/2024, that S2 was the facility staff that prepared /administered the liquid Ativan (0.25ml) to R1, and that R1’s Representative administered liquid pain medication (Morphin 0.25ml). The interview with the RP revealed that on 03/17/2024 at approximately 3:00 p.m., R1’s representative found R1 in their bed in distress. R1’s representative was told by facility staff that R1 was unable to swallow the pain medication, which was due at 2:00 p.m. Facility staff stated to the representative that they were not skilled professionals and consequently could not administer the pain medication. The facility staff provided the pain medication to R1’s representative to administer to R1 at approximately 3:50 p.m. and after the pain medication was administered, R1 appeared to be relaxed. Furthermore, the R1’s representative stated that they were informed that R1 could not swallow and started communication with the hospice nurse in charge to ensure that R1 would continue to receive the pain medication as needed to keep them comfortable. At approximately 5:49 p.m. R1’s representative texted the hospice nurse of R1’s condition, letting them know that R1 is experiencing distress again due to gurgling their own saliva because they cannot swallow. Per R1’s representative, the hospice nurse in charge was out and did not have a reliable cell phone, consequently the hospice nurse in charge referred the representative to the hospice on-call nurse at approximately 6:00p.m. Continues on LIC 9099C pg.3 Pg. 3 Between 6:00 p.m. and 6:39 p.m. R1 started experiencing distress again (gurgling on their own saliva secretion). At some point during this time frame, the on-call nurse directed the facility staff (S1) to clear R1’s throat with sponges and to give R1 liquid Ativan (0.25 ml). Per R1’s representative, they watched “S1 clear out all this goo out of R1’s mouth with three different wet mouth sponges while R1 struggled in discomfort”. S1 cleared R1’s throat with at least three swab sponges and administered the liquid Ativan and left the room. S1 then tells R1’s representative, “to call hospice to tell them to send a nurse to clear out the ‘liquid’ from R1’s throat with a suction machine, the facility has the machine at the facility, but staff are not allowed to use it”. Per R1’s representative, a couple of minutes later, R1 started to throw up liquid, and was pronounced deceased. LPA Urena interviewed the staff (S1) about administering the liquid Ativan to R1 and S1 stated that they gave the medication to R1’s representative in an oral syringe to give to R1. Furthermore, S1 stated that they did not remember much about the incident, since it happened a year ago. LPA Urena interviewed staff 2 (S2) about the liquid Ativan, S2 stated that they prepared the oral syringe with the liquid Ativan, and they gave it to S1, but because they were not in the room, they are not sure who actually administered the medication to R1. On 04/25/2025, LPA Urena reached out to the Hospice agency’s nurse in charge and asked about the facility’s staff diligence in obtaining assistance for R1, and the Hospice nurse stated that the staff at the facility followed all instructions given to them by the hospice staff, and provided oral suction as instructed by hospice staff. Furthermore, R1 has a DNR/Polst and at no time did family requested for 911 to be called. Based on the information obtained through interviews and record review, R1 was experiencing distress due to pain and choking on their own saliva. Although S1, cleared R1’s throat with wet sponges and administered the liquid Ativan (0.25 ml) minutes before R1 was pronounced deceased, there is not sufficient evidence to prove that the medication or the clearing of the throat with wet sponges was the cause of R1’s death. R1 was receiving hospice care due to terminal disease. Furthermore, no autopsy was performed, and the Death Certificate lists the immediate cause of death as Cardiopulmonary Arrest, and to Chronic Kidney Decease. Although the allegation may have happened or is valid, based on the interviews, and record review; there is not sufficient evidence to prove the alleged violation did or did not occur Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted. A copy of the report was issued. Staff did not notify resident's responsible party of a change in condition. On the allegation that the staff did not notify the resident’s representative of a change in condition; it is the concern of the reporting party (RP) that the facility staff did not report directly to the resident’s representative about R1’s change in condition. The interview with the Administrators revealed that it is the facility’s policy that if a resident is receiving hospice services, the facility’s staff informs the hospice agency about the residents’ change in condition, and that the hospice agency in turn informs the resident’s representative. Per the Administrator, it is done in this manner because they feel that the hospice agency is better equipped to explain the changes and medical condition of the resident, to the residents’ representatives. The facility’s policy is an implied policy, and not part of the Admission’s Agreement policy. Record review revealed that the facility staff communicated with the hospice agency’s nurse about the change in condition (appetite/swallowing) of R1. The hospice staff communicated via text message with R1’s representative and vice versa about the changes in appetite and/or swallowing. The record review reveals that R1’s representative then communicates with the facility’s staff about the information received by the hospice nurse. However, the record review does not show direct communication between the facility Administrators and R1’s representative as a starting point about the observation of the resident and the changes in condition. Although the facility’s implied policy is that the hospice agency staff will communicate with the resident’s representatives, the policy was not found as part of Admission’s agreement or any other policy; furthermore, it does not supersede CCR regulations. Record review revealed that the care givers staff and the administrative staff initially communicated with the hospice nurse, but not with R1’s representatives. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Apr 29, 2025 · control 29-AS-20240320120018

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 12, 2025

87466- Observation of the Resident-The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided.. When changes such... or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of... the resident's responsible person, if any. This requirement is not met as evidenced by: Based on the information gathered via interviews and record review, although the facility’s staff informed the resident’s medical hospice team of the changes in condition, the staff did not communicate directly with the resident’s responsible party, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 29, 2025

Plan of correction: Licensee will review the regulation for understanding and will email the LPA a plan of correction.

Allegation investigated: Staff are not properly trained Staff are mismanaging residents' medication

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint visit at 10:15AM. LPA initially met with facility staff. Licensee Ruben Carmona arrived shortly after the visit began. Entrance interview conducted. During today's visit, LPA interviewed three (3) staff members beginning at 10:20AM, interviewed Licensee, conducted a medication review for two (2) residents at 10:25AM, reviewed records and obtained copies of pertinent documents, and interviewed residents beginning at 10:55AM. The following was then determined: It was alleged that the Licensee did not provide proper medication training to facility staff. Interviews revealed that staff are trained on medication administration, including education, quizzes, and shadowing training prior to administering medications. LPA reviewed five (5) staff files and verified that all staff handling medications are trained both initially and annually on medication administration per regulation. Report Continued on LIC 9099-C. Unsubstantiated The information obtained during the investigation did not include evidence sufficient to corroborate the allegation related to proper medication training. Records confirmed that all staff handling medications receive proper medication training annually. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation that Licensee did not provide proper medication training is deemed Unsubstantiated at this time. The complaint also alleges that the facility is mismanaging residents' medications, including improper preparation and documentation of medications administered. LPA reviewed medications for two (2) residents, which were observed to be administered as ordered and documented on both the Centrally Stored Medication and Destruction Record (CSMDR) and the Medication Administration Record (MAR) in accordance with regulation. LPA observed no discrepancies during the medication review. The MAR form was not pre-filled out or signed and is updated daily as medications are administered. Residents interviewed confirmed their medications are administered by the staff and are given as prescribed. Staff indicated that morning medications are prepared the night before and that during the day they prepare the rest of the day's medications, as time permits. Staff indicated that at no time are medications prepared more than one (1) day in advance. During medication review, LPA observed medications for today's 05:00PM, tomorrow’s 08:00AM, and tomorrow’s 05:00PM medication passes were pre-prepared. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Jan 17, 2025 · control 29-AS-20250113113028

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 10:35AM. LPA was greeted at the door by staff and the reason for the visit was explained. The Administrator, Emma Carmona arrived at 10:43AM and Licensee Irma Carmona at 11:11AM. Entrance interview conducted. At 10:39AM, the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPA inspected the kitchen/food service area at 10:39AM with staff. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The knives and sharps were observed in a locked drawer next to the refrigerator. Cleaning supplies and disinfectants are stored in a cabinet next to the dishwasher inaccessible to residents. COMMON AREAS: At the time of the visit, living room and dining room furniture were observed to be in good condition. The facility maintained a comfortable temperature. At 11:04AM, smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed fully charged and last serviced on 03/19/2024. Auditory exit alarms were functioning at the time of the visit. The washer and dryer are located in a closet next to bedroom #1. The LPA observed detergents and toxins in a locked cabinet above the washer and dryer. The facility has emergency food and water which was observed to be in good condition. The LPA observed a closet with additional cleaning supplies and personal hygiene products locked and inaccessible to residents in care. (Report Continued on LIC 809C...) BEDROOMS: There are six (6) resident bedrooms. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is a staff room on premises. The LPA observed a closet with extra towels and linens. RESTROOMS: There are six (6) resident restrooms and one (1) communal bathroom. Each bedroom has their own bathroom. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. Between 10:48AM – 10:55AM, hot water temperature was measured in resident bathrooms and were between 105.2 degrees F – 106.5 degrees F, which is within the required range. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. LPA observed side gate to self-latch and self-close. No bodies of water noted at the time of the visit. MEDICATION REVIEW: At 11:05AM, LPA reviewed medications. Medications are centrally stored and locked in a closet adjacent to the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. RECORD REVIEW: Beginning at 11:20AM, LPA reviewed four (4) out of four (4) resident files and three (3) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident and personnel files were in order. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency drills are conducted quarterly as is required, with the last drill conducted on 09/09/2024. INTERVIEWS: During today’s visit, LPA interviewed two (2) residents and four (4) staff. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 21, 2024

Type of visit: Case Management - Deficiencies

On 3/4/2024, Licensing Program Analyst (LPA) Teresa Camara met with facility administrator Emma Carmona for a Case Management visit to issue a civil penalty per Health & Safety (H&S) Code §1569.49(f). On June 21, 2019, the Department received an Unusual Incident Report regarding resident (R1). The report indicated R1 was left unattended in the bathroom and while unattended, R1 fell. The fall resulted in injuries and subsequent hospitalization. To investigate, the Department conducted visits to this facility on June 24, 2019, September 18, 2019, and February 25, 2020. On February 25, 2020, the Department concluded their investigation, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, Section 87464(f)(4) Basic Services, due to the staff failing to provide adequate supervision, as R1 was left unattended, suffered a fall, a right femur fracture and two (2) right rib fractures. The investigation revealed that on June 21, 2019, at approximately 6:30 a.m., R1 was assisted to the bathroom by staff (S1). R1 was left unattended while S1 walked out of the bathroom, into R1’s closet to obtain a change of clothes and a new pull-up adult brief. S1 overheard a noise and upon re-entering R1’s bathroom, observed R1 lying on the bathroom floor on their right side. S1 informed facility management, R1’s responsible party, and R1’s hospice agency of the fall. It was decided R1 required emergency services and 9-1-1 was called. Per hospital records, R1 suffered a right femur fracture and two (2) right rib fractures. R1 elected to not have surgery and was discharged back to the facility on hospice care on June 21, 2019, at 11:42 a.m. (continued on 809-C) (continued from 809) On February 25, 2020, an immediate civil penalty of $500 was assessed as a result of this violation. The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that resulted in R1 sustaining serious bodily injuries while under the care of this facility. Per 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’s failure to provide care and supervision to R1 on June 21, 2019, as S1 left R1 unattended in the bathroom. R1 was deemed high risk for falls and required a one-person assist. R1 sustained two (2) broken ribs, a right femur fracture, and experienced severe pain. Today, 3/4/2024, the Department is issuing a civil penalty per Health and Safety Code §1569.49(f) in the amount of $10,000 for a violation that the Department constitutes as serious bodily injury. However, since an immediate civil penalty of $500 was previously issued on February 25, 2020, the amount of the civil penalty issued is reduced to $9,500. A copy of the LIC 421D was given to the administrator and originals were signed. Exit interview conducted. A copy of the report issued. Appeal Rights provided. The administrator's signature on this report acknowledges receipt of the Appeal Rights, found on page two (2) of LIC 421D.the state’s words, verbatim · CDSS document, Mar 4, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 10:15 a.m. The last annual conducted at this facility was on 09/30/2022. When the LPA arrived, there were three (3) staff and four (4) residents present. The LPA was greeted at the door by staff and the reason for the visit was explained. The Administrator, Irma Carmona arrived at 10:50 a.m. Entrance interview conducted. At 10:55 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPA inspected the kitchen/food service area at 11:01 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The knives and sharps were observed in a locked drawer next to the refrigerator. Cleaning supplies and disinfectants are stored in a cabinet next to the dishwasher inaccessible to residents. At 11:04 a.m., the water temperature was tested in the kitchen faucet, and it measured 111.3 degrees Fahrenheit. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 11:11 a.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed fully charged and last serviced on 3/26/2023. (Report Continued on LIC 809C...) (Report Continued from LIC 809...) The washer and dryer are located in a closet next to bedroom #1. The LPA observed detergents and toxins in a locked cabinet above the washer and dryer. The facility has emergency food and water which was observed to be in good condition. The facility has at least a 30-day supply of Personal Protection Equipment (PPE). The last emergency disaster drill was conducted on 09/20/2023. The LPA observed a closet with additional cleaning supplies and personal hygiene products locked and inaccessible to residents in care. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There is one gate that self-latches. No bodies of water noted at the time of the visit. BEDROOMS: There are six (6) resident bedrooms. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is a staff room on premises. The LPA observed a closet with extra towels and linens. RESTROOMS: There are six (6) resident restrooms. Each bedroom has their own bathroom. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in resident bathrooms and were compliant between 105- and 120-degrees Fahrenheit at the time of the visit. RECORDS: Records review began at 11:20 a.m.; four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All resident files were in order. (Report Continued on LIC 809...) (Report continued from LIC 809C...) Three (3) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All personnel files were in order. The current Administrator’s file was also reviewed, and it was in order. At the time of the visit, the LPA obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster, the emergency disaster plan, and a copy of the limited liability insurance. The LPA conducted interviews with four staff members between 12:50 p.m. and 1:20 p.m. MEDICATIONS: Medications review began at approximately 1:25 p.m.; medications are centrally stored and locked in a closet adjacent to the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Exit interview conducted. No deficiencies issued. Report was reviewed and a copy was issued.the state’s words, verbatim · CDSS document, Nov 16, 2023