Caring Hearts of Santa Paula

Allegation investigated: Staff did not address resident's change in condition.

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit to deliver findings for the above allegations. Upon arrival, LPA met with staff Eduardo Asuncion and explained the reason for the visit. Administrator Ramrush Go could not be present during today's visit and designated staff Eduardo Asuncion to review and sign the report. On 03/02/2026, between 11:00 a.m. and 3:45 p.m., the LPA interviewed the Administrator, Assistant Administrator, conducted one phone interview with Witness 1 (W1) and obtained copies of resident records and other pertinent documents relevant to the investigation. On 03/11/2026, between 10:30 a.m. and 4:15 p.m., the LPA interviewed the Assistant Administrator, two (2) staff, conducted a resident file review and obtained copies of resident records and other pertinent documents relevant to the investigation. On 03/12/2026, LPA conducted a phone interview with a hospice nurse. On 03/25/2026, the LPA conducted a phone interview with two (2) Hospice agency representatives.Report will continue on LIC9099-C, 2nd page. Substantiated On 04/14/2026, the LPA conducted phone interviews with two (2) family members of R1 including their POA. On the allegation, “Staff did not address resident's change in condition” it is the concern of the reporting party (RP) that staff did not adequately monitor Resident 1 (R1) or follow hospice nurse instructions regarding R1's care. It was reported that in early 2026 (exact date was not provided), a hospice nurse identified that R1 was constipated and instructed staff to notify the on-call nurse if no bowel movement (BM) occurred by the following day. Staff reportedly failed to provide this update. Family members later discovered R1 feverish, shaking, with cloudy fluid in their Foley bag and noted that R1 had not had a BM in seven days. The family, rather than staff, contacted the on-call nurse. To investigate the allegation the LPA conducted telephonic and in-person interviews, as well as record reviews of facility records. Interview with Assistant Administrator Abygail Go revealed that staff monitored R1’s condition and documented BMs. She noted that hospice instructions were to call after three days without a BM, though she admitted staff occasionally waited until the fourth day if a nurse visit was already scheduled or if R1 had a BM at night. Staff interviews revealed inconsistent protocols; while one staff member confirmed reporting to the Administrator and not hospice, another was unaware of who was responsible for BM tracking. During a telephone interview, Hospice Nurse 1 (HP1) confirmed that staff were verbally instructed to call after R1 had not had a BM after three (3) days and noted that while staff generally followed it, there was at least one instance where they waited five days to call. HP1 doubted R1 ever went seven days without a BM. Facility BM log for January and February 2026 contradict the seven-day claim but confirm inconsistencies in care. Logs show that in February, R1 went four consecutive days without a BM on two separate occasions (2/6–2/9 and 2/13–2/16), exceeding the three-day limit set by hospice. Based on staff interviews, admissions from the Administrator and file review, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the above allegation is deemed Substantiated at this time. The following deficiency was cited from the CA Code of Regulations, Title 22 (refer to LIC 9099-D). Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy provided. On 04/14/2026, the LPA conducted phone interviews with two (2) family members of R1 including their POA. On the allegations, “Staff mismanaged resident's medication and staff did not administer resident's medication as prescribed” it is the concern of the Reporting Party (RP) that on 02/20/2026, a family member of Resident 1 (R1) administered full doses of Morphine to R1. The reporting party expressed concern regarding whether the family member was authorized to administer this medication and whether staff had inappropriately deferred this responsibility. To investigate, the LPA conducted interviews with facility management, staff, the hospice agency, and R1’s family, and reviewed facility and hospice records. Interviews with the Administrators and staff revealed that facility staff do not administer Morphine; per protocol, only hospice nurses or family members were authorized to do so for R1. The Hospice Director and HR Director of R1’s hospice agency confirmed that family members are permitted to administer Morphine once they have received training from a hospice nurse and were aware that a family member of R1 had administered the medication. The family member in question confirmed they administered the Morphine during R1's end-of-life stage and verified they had been trained by the hospice nurse. R1’s Hospice Care Plan, confirmed that family members are able to administer medications. Furthermore, R1’s Power of Attorney (POA) stated they were fully aware of these procedures, had no concerns regarding medication management, and confirmed they were comfortable with the arrangement. Based on the information gathered, the department does not have sufficient evidence to prove the alleged violations did or did not occur; therefore the above allegations, are UNSUBSTANTIATED at this time. Exit interview held, appeal rights and report copy provided.the state’s words, verbatim · CDSS document, Apr 17, 2026 · control 29-AS-20260226100507

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Apr 24, 2026

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, funtioning... and that appropriate assistance is provided when such observation reveals unmet needs... This requirement was not met as evidence by: Based on records and interviews the licensee did not comply with the regulation above when R1 went 4 consecutive days without a BM on two occasions exceeding the 3 day notification limit set by hospice and assistant Administrator admitted staff ocassionally waited until the 4th day tothe state’s words, verbatim · CDSS document, Apr 17, 2026

Plan of correction: Administrator agreed to train staff on when to contact hospice when observing residents and when and how to track BMs log and provide proof of training with a list of staff to CCL by 4/24/25. notify hospice which posed a potential health and safety risk to persons in care.

Allegation investigated: Staff are not properly trained.

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial 10-day complaint visit for the above allegations. Upon arrival, LPA met with staff and explained the reason for the visit. Administrator Ramrush Go and Assistant Administrator Abygail Go arroved shortly after and were explained the reason for the visit. During today's inspection, between 11:00 a.m. and 3:45 p.m., the LPA interviewed the Administrator, Assistant Administrator, conducted one phone interview with Witness 1 (W1) and obtained copies of resident records and other pertinent documents relevant to the investigation. Report will continue on LIC9099-C, 2nd page. Substantiated On the allegation, “Staff are not properly trained” it is the concern of the reporting party (RP) that caregivers appeared inexperienced and insufficiently trained. It was further reported caregivers are not trained on how to contact hospice if needed. To investigate the complaint the LPA conducted a file review and interviews. File review revealed that two (2) out of two (2) caregivers were missing nine (9) out of ten (10) initial medication training. Interview with the administrator revealed that all of the staff training was in the files and a copy of the staff training was given to the LPA. Based on staff interview and file review, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the above allegation is deemed Substantiated at this time. The following deficiency was cited from the CA Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy provided.the state’s words, verbatim · CDSS document, Mar 2, 2026 · control 29-AS-20260226100507

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.69(a)(2) · Plan of correction due date: Mar 13, 2026

1569.69 Employees assisting residents with self-administration of medication: training requirements (a)(2)... shall complete 10 hours of initial training.. 6 hours of hands-on shadowing training, .. and 4 hours of other training or instruction.. This requirement is not met as evidence by: Based on record review and staff interviews the Licensee did not comply with the regulation cited above as staff was missing 9 hours of medication training which possess a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: Assistant Administrator agreed to hold training for all staff on H&S code 1569.69 by a third party and provide staff missing any of these requirements with medication training, provide proof of training to LPA by 03/13/26

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.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Esther Cortez conducted a pre-licensing visit to this property at 11:20AM. LPA met with Applicant Ramrush Go and Assistant Administrator Abygail Go. This application is for a Change of Ownership Application (CHOW) and the current licensed facility has clients in care. A dementia program was included in the plan of operation. A hospice waiver for six (6) applicants was requested. Component III was completed during the inspection with the applicants. The facility is one story. At 2:15 p.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for a capacity of six (6) bedridden residents in the facility in rooms #1-6. All bedrooms will be private resident bedrooms. There is one (1) staff room and one office. The facility has fire sprinklers. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. There are a total of three (3) full bathrooms and one (1) half bathroom in the facility. One (1) full bathroom is in resident room #5; One (1) full restroom is designated as a staff bathroom; Third full bathroom is designated as the communal resident bathroom. All bathrooms have toilet and shower grab bars. Report will continue LIC809-C. The hot water temperature was measured as follows: resident’s bathroom was 109.8 *F and the kitchen – 111.9 *F, which fall within the allowable range of 105*F to 120*F. Resident and staff records are stored in a locked cabinet, which is located in the dining area. Medications are centrally stored in a locked hallway closet . The first aid supplies were complete, with the exception of current version of a first aid manual. Kitchen knives are stored in a locked drawer in the kitchen. Stove did not have protective mechanism to prevent access. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinets located in the kitchen and a locked cabinet in the laundry room. No flies or other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, magazines and/or activity supplies in the hallway. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non private bathrooms. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights. The facility has a furnace and A/C, which is able to heat and cool the rooms that residents occupy to a minimum of 68 degrees Fahrenheit and maximum of 85 degrees Fahrenheit. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There is one (1) fire extinguishers in the house. It was fully charged and did not exceed the expiration date. There is a functioning telephone on the premises. All required postings are posted on the wall of the entryway. Report will conitinue on LIC809-C. The exterior passageways were clean and clear of any obstructions. There is a canopy covered patio area at the back of the house with chairs and one table. The entire property is fenced. There is a locked storage shed in the back yard. There are no bodies of water on the premises at the present time. The following items need to be corrected and proof sent to CCL prior to licensure: - Facility needs current first aid manual. -Facility needs protective mechanisms for kitchen stove. -Facility needs backyard to be accessible to all residents, Licensee does not have key to locked fence. -Staff room door knob needs to be changed, This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.the state’s words, verbatim · CDSS document, Jan 16, 2026