Bernadette Home Care IV

Allegation investigated: Staff leave resident in bed for an extended period of time Staff do not administer medication as prescribed Staff falsify medication administration records Staff do not ensure that medication is stored in its originally received container Insufficient staffing Facility staff did not provide meals at appropriate time frames

Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. At 12:00 P.M. LPA met with Janette Villapando, Administrator and explained the purpose of the visit. Today, a brief tour was conducted. Entrance interview conducted. Throughout the course of the investigation, LPA reviewed all documents obtained and the following was determined: Continued on LIC 9099-C Substantiated Continued from LIC 9099 Regarding allegation of “Staff leave resident in bed for an extended period of time” and “Insufficient staffing” it was alleged that on 4/29/2026 and 4/30/2026 residents were placed in bed as early as 4:30 P.M. due to what seems like short staffing. Interview with the licensee and staff indicated that some residents become restless during the day due to their conditions and are placed in bed early. However, three (3) out of five (5) residents interviewed stated that residents are often placed in bed earlier than preferred due to short staffing and indicated that they would prefer to remain out of bed longer at times. Adding that once placed in bed they are not assisted out of bed until approximately 7:00 A.M. to 8:00 A.M. the following morning. When asked about the NOC shift, residents stated that the same staff members are regularly assigned to provide care during all of the shifts, adding that they have not observed the owners working the NOC shift. Two (2) residents could not be interviewed due to cognitive limitations that prevented effective communication. LPA requested and reviewed staff timesheets, resident care plans, and other documentation presented by the Licensee. The timesheets showed that on 4/29/2026, two staff were scheduled. Staff #1 worked from 8:00 A.M. to 6:00P.M., with a lunch break from 12:00 to 1:00 P.M. Staff 2 worked from 3:00 P.M. to 1:00 A.M. with a lunch break from 7:00 to 8:00 P.M. The reviewed timesheets reflected periods when no staff were scheduled to be on duty, including during staff meal breaks and after 1:00 A.M. The Licensee stated that the residents sleep throughout the night and do not require supervision or repositioning during those hours. The licensee further stated that they live very close to the facility, and could respond within minutes in the event of an emergency and that staffing gaps could be covered by NOC staff. Licensee did not provide NOC shift staff scheduled and stated that staff are verbally assigned to the NOC shift. The licensee stated that any additional time worked would be documented on a separate worksheet. LPA requested the additional worksheets; however, the Licensee stated that no staff claimed additional hours for the month of April 2026. Review of the residents’ care plans revealed that three (3) residents are wheelchair-bound and require a 2-or-3-person assistance when transferring. Based on observations, documentation, and interviews, the preponderance of evidence standard has been met, therefore the above allegations, “Staff leave resident in bed for an extended period of time” and “Insufficient staffing” is deemed Substantiated at this time. Continued on LIC 9099-C Continued from LIC 9099-C Regarding allegation of “Facility staff did not provide meals at appropriate time frames” Interview with the Licensee revealed that dinner is served at around 5 P.M. every evening and breakfast is served at 7 A.M the next morning, adding that snacks are always available. Interviews with staff revealed that they follow a daily routine, however, they were not sure exactly when dinner is served daily as times varies. Three (3) out of five (5) residents interviewed revealed that periods without food are long and occasionally, dinner is served too early. Regarding snacks, residents stated that they are not often offered. LPA was unable to interview the other two (2) residents as they were unable to effectively communicate due to loss of cognitive abilities. Records reviewed including but not limited to the admission agreement, incident reports and correspondence provided by the Licensee, ratified that facility staff are putting residents to bed at around 4:30 P.M. and dinner is being served before 5:00 P.M. Based on observations, documentation and interviews, the preponderance of evidence standard has been met, therefore the above allegations, “Facility staff did not provide meals at appropriate time frames” and “Staff falsify medication administration records” is deemed Substantiated at this time. Regarding “Staff do not administer medication as prescribed” and “Staff falsify medication administration records”, the RP expressed concern that Resident #1 (R1) was placed in bed at approximately 4:30 P.M., after dinner, although R1’s prescribed medication was scheduled to be administered at bedtime (around 7:00 or 8:00 P.M.), adding that the Medication Administration Record (MAR) reflected staff initials indication that R1’s medication was administered at 7:00 P.M. During an interview, the Licensee confirmed that R1’s medication was administered at approximately 4:30 P.M. rather than at the prescribed administration time. Staff stated that the medication was administered early because R1 usually is difficult to wake when it is time for the bedtime medication. Interviews further revealed that staff were not aware that R1’s medication had an order allowing it to be crushed. Medical documentation review confirmed R1 has an order dated 10/15/2025 stating that R1’s medication “may be crushed” and a text message, from the Licensee to the current staff, containing this information was sent on the same date. Continued on LIC 9099-C Continued from LIC 9099-C Additionally, an incident report submitted by the Licensee to CCL, ratified that staff assisted in the self-administration of Quetiapine earlier than the prescribed time before being put to bed at 4:30 P.M. Furthermore, based on the interviews and documentation reviewed, the MAR did not accurately reflect the time R1’s medication was administered. Per staff and licensee, medication was administered at approximately 4:30 P.M., while the MAR indicated administration at 7:00 P.M. Licensee, explained that due to these incidents, a written memo/warning was issued to staff. Based on observations, documentation and interviews, the preponderance of evidence standard has been met, therefore the above allegations, “Staff do not administer medication as prescribed” and “Staff falsify medication administration records” is deemed Substantiated at this time. Regarding the allegation of “Staff do not ensure that medication is stored in its originally received container” it was the RP’s concern that staff pre-pours resident’s medication in advance. During interviews, staff confirmed that medications are pre-poured, adding that medications are placed once a week in weekly organizers and in clear cups when the scheduled administration time arrives. LPA observed that prescribed medication has been removed from their original labeled container and pre-poured into pill organizers with resident names on them.Based on observations, documentation and interviews, the preponderance of evidence standard has been met, therefore the above allegation, “Staff do not ensure that medication is stored in its originally received container” is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited at this time (refer to LIC 9099-D) with civil penalty. Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report, civil penalties and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 29-AS-20260504093232

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Aug 28, 2026

87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not comply with regulations as some residents needs 2-3 person assistance and the schedule/timesheets shows one on duty which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Licensee agreed to provide a plan of action explaining how staff will be properly scheduled to assist with all residents needs. Licensee will submit action plan to LPA prior to POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(1) · Plan of correction due date: Aug 28, 2026

General Food Service Requirements (b) The following food service requirements shall apply: (1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day... Not more than fifteen (15) hours shall elapse between the third and first meal. This requirement was not met as evidenced by: Based on record review and interviews, Licensee did not ensure that meals were given as schedule and more than 15 hours passed between dinner and breakfast which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Licensee will follow what's on their admission agreement regarding mealtimes for ALL residents. Write a statement of understanding regarding this regulation and submit it to LPA prior to POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Aug 14, 2026

Incidental Medical and Dental Care (c) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on interviews and records reviewed, Licensee did not comply with the above regulation as medication was not given as directed as R1's medication was not being crushed nor at the prescribed time which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Licensee conducted medication training with all current staff for R1. A copy of the training was provided to the LPA. POC cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Aug 21, 2026

87465 (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Observations revealed that Licensee was pre-pouring medications and removing them from its original container which poses an immediate health andthe state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Licensee will write a statement of understanding regarding this regulation. As of today, all medication is being kept in its original container. POC cleared.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:40 A.M. LPA met with Administrator Designee, Janette Villapando and explained the reason for the visit. At 9:52 A.M. LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Fire extinguishers are fully charged and last serviced 06/26/2025. At 10:26 A.M. the smoke detectors and carbon monoxide detectors are combined units; they were tested and functioned properly. The facility has two (2) fire doors to enhance safety and prevent the spread of fire. One in the hallway and one in room #1. This facility doesn’t have a staff room; facility will provide 24/7 care. BEDROOMS: There are four (4) private bedrooms and one (1) shared bedroom. All residents’ rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. BATHROOMS: There are two (2) bathrooms for residents’ use. One is located in a shared bedroom, and one is a shared bathroom located in the main hallway. Bathrooms were observed to be equipped with slip resistant surfaces and grab bars. Hot water temperature measured between 105 - 120 degrees Fahrenheit F which was within the required range. Continued on LIC 809-C Continued from LIC 809 COMMON AREAS: This includes the living room and dining room areas. LPA observed common areas to be clean and properly furnished at the time of the visit. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a of 70 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. The LPA observed the required postings in the common area and fireplace was observed adequately screened. KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. At 10:07 A.M. hot water measured 116.4 degrees Fahrenheit. Cleaning supplies are located in separate locked cabinets with additional supplies in the locked garage. Garage/Laundry room: Inside the locked garage, LPA observed the washer and dryer, emergency water and emergency food, cleaning supplies and disinfectants. The garage remains locked and inaccessible to the residents in care. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture, and the front porch is covered and equipped with furniture as well. Facility has one side gate; LPA observed the side gate to be self-closing and self-latching gate with clear passageways for emergency exit use. During the inspection the LAP observed a locked shed located in the backyard. There were no bodies of water on the premises. RECORD REVIEW: Between 10:53 A.M. and 12:45 P.M., staff and resident records were reviewed. Six (6) resident and five (5) personnel records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were observed to be complete. Continued on LIC 809-C Continued from LIC 809-C MEDICATION REVIEW: Between 1:07 P.M. and 2:00 P.M. Medications for six (6) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. The LPA obtained the following documents at the time of visit: Personnel Report (LIC500), Resident Roster (LIC9020), last emergency disaster drill, and a copy of the facility’s liability insurance. Additionally, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. Emergency disaster drills are conducted quarterly, with the last drill conducted on 04/02/2026. Exit interview conducted. No citations issued. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 8, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:10 A.M. LPA met with Licensee/Administrator Janette Villapando and explained the reason for the visit. At 10:25 A.M. LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Fire extinguishers are fully charged and last serviced 07/19/2024. At 11:00 A.M. the smoke detectors and carbon monoxide detectors are combined units; they were tested and functioned properly. The facility has two (2) fire doors to enhance safety and prevent the spread of fire. One in the hallway and one in room #1. LPA observed hallway fire door functioning properly. This facility doesn’t have a staff room, facility will provide 24/7 care. KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food and water. LPA conducted a review of expiration dates on product labels. The LPA observed that four (4) items were past their expiration date. Administrator discarded all four (4) items during today’s visit. Technical Violation Issued. LPA observed sharps and knives locked in a kitchen drawer. At 10:35 A.M. hot water measured at 115.6 * F. Cleaning supplies are located in separate locked cabinets with additional supplies in the locked garage. Garage/Laundry room: Inside the locked garage, LPA observed the washer and dryer, emergency water and emergency food, cleaning supplies and disinfectants. The Garage remains locked and inaccessible to the residents in care. Continued on LIC 809-C Continued from LIC-809-C Garage/Laundry room: Inside the locked garage, LPA observed the washer and dryer, emergency water and emergency food, cleaning supplies and disinfectants. The Garage remains locked and inaccessible to the residents in care. COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 72 degrees. During the inspection, the LPA observed a hallway closet. On the upper shelves, the LPA noted an ample supply of linens. On the lower shelves, the LPA observed various bathroom items including but not limited to air freshener, Vaseline and shampoo. It was further observed that the magnetic lock intended to secure the closet was broken at the time of the visit. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. The LPA observed the required postings in the common area and fireplace was observed adequately screened. BATHROOMS: There are two (2) bathrooms for resident use. One is located in a shared bedroom, and one is a shared bathroom located in the main hallway. Bathrooms were observed to be equipped with slip resistant surfaces and grab bars. Between 10:49 A.M. and 10:53 A.M. hot water temperature measured between 105* - 120 *F which was within the required range. BEDROOMS: There are four (4) private bedrooms and one shared bedroom. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. During the inspection, the LPA observed that Room #1, an approved bedridden room equipped with a fire-rated door, had an industrial doorstop in place, propping the door open. The administrator explained that Resident #1 prefers door to remain open, however, administrator immediately removed the doorstop during today’s visit and acknowledged that the door will remain closed at all times in compliance with fire safety requirements. Continued on LIC-809-C Continued from LIC 809-C OUTDOOR SPACE: The backyard has a covered patio area with patio furniture and the front porch is covered and equipped with furniture as well. Facility has one side gate; LPA observed the side gate to be self-closing and self-latching gate with clear passageways for emergency exit use. During the inspection the LAP observed a locked shed located in the backyard. Upon entry, LPA noted the presence parts of a bed frame, a couch and various clothing items hanging on hangers inside the shed. The LPA remined the facility administrator that, in accordance with fire safety regulations, no individual is permitted to sleep or reside in the shed. There were no bodies of water on the premises. RECORD REVIEW: Between 11:38 A.M. and 1 P.M., staff and resident records were reviewed. LPA observed Resident #1 and Resident #2 to be at risk if allowed direct access to personal grooming and hygiene items. All records were observed to be complete. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill documented on 04/08/2025. MEDICATION REVIEW: Between 1:10 P.M. and 2:30 P.M. Medications for five (5) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 11:00 a.m. LPA met with Licensee/Administrator Janette Villapando and explained the reason for the visit. At 11:10 a.m. LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Fire extinguishers are fully charged and last serviced 5/15/2023. The smoke detectors and carbon monoxide detectors are combined units; they were tested and functioned properly. The facility has a fire door in the hallway which also functioned properly. No fire clearance concerns were observed. KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food and water. Cleaning supplies are located in separate locked cabinets with additional supplies in the locked garage. COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. Exit doors contain alarms and were functional at the time of the visit. BATHROOMS: There are two (2) bathrooms for resident use. One is located in a shared bathroom and one is a shared bathroom located in the hallway. Bathrooms were observed to be equipped with nonskid surfaces and grab bars. The water temperature measured 105*F which was within the required range. BEDROOMS: There are four (4) private bedrooms and one shared bedroom. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. (continued on LIC809C) (continued from LIC809) OUTDOOR SPACE: The backyard has a covered patio area with patio furniture and the front porch is covered and equipped with furniture as well. All passageways were observed to be clear. There were no bodies of water on the premises. RECORD REVIEW: Staff and resident records were reviewed. The files all appeared complete. INTERVIEWS: Two (2) staff were interviewed; no concerns noted and staff answered questions appropriately. During today's visit, LPA attempted to interview residents, however due to medical conditions, interviews were not possible. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly. MEDICATION REVIEW: Medications for two (2) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. No deficiencies cited. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Apr 4, 2024