Reesejoy Care Home

Allegation investigated: Staff restric resident's mobility at the facility

At 11:20 a.m. Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit to deliver findings for the allegation listed above. Upon arrival the LPA met with staff and explained the reason for the visit. Administrator Roberto Ramirez arrived shortly thereafter and the reason for the visit was explained. On 09/05/25, the LPA conducted a file review and obtained copies of pertinent documents relevant to the investigation, conducted an interview with the Administrator, one (1) witness, and attempted to interview all four (4) residents present, however two were asleep. On 12/09/25, the LPA conducted a file review and obtained copies of pertinent documents relevant to the investigation, conducted an interview with the Administrator, one (1) staff, and five (5) residents. On 03/16/26, the LPA conducted a file review and obtained copies of pertinent documents relevant to the investigation, conducted phone interviews with one (1) former staff, one (1) witness, and attempted to conduct phone interviews with one (1) additional former staff and one (1) additional witness. Report will continue on LIC9099-C, 2nd page. Substantiated Regarding the allegation, “Staff restrict resident's mobility at the facility,” the Reporting Party (RP) expressed concern that Resident 1 (R1) was not permitted to move freely within the care facility. During an interview with Administrator Roberto Dela Vega Ramirez, they explained that the believes the situation stemmed from a misunderstanding regarding a bed rail. The administrator admitted that a full bed rail was utilized for R1 because R1 was restless and considered a high fall risk, though R1 was not on hospice care. He noted that an outside visitor subsequently advised him that a full bed rail constitutes a form of physical restraint. A review of R1's facility file confirmed there was a physician's order for a full bed rail due to a history of multiple falls out of bed; however, the resident was not under hospice services. Additionally, the administrator stated that when R1’s family requested physical or occupational therapy services, he informed them that therapy must be provided externally by Kaiser or other outside agencies. Additionally, during a phone interview with a former staff revealed that they were not allowed to do exercises with R1 and R1 was always in bed and they just repositioned R1 every 2 hours. Because the facility actively utilized a full bed rail, which can serve as a physical restraint restricting voluntary mobility on a non-hospice resident, the evidence confirms a regulatory violation occurred. Therefore, based on the information obtained, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D). A copy of this report and appeal rights was provided. Regarding the allegation, “Staff does not attend to resident's pain management care needs,” it was reported by the Reporting Party (RP) that the facility failed to provide appropriate care and did not adequately respond when Resident 1 (R1) was in pain. Additionally, the RP noted that R1 disliked their medication because it was ineffective at managing their pain levels. However, during an interview with the Licensing Program Analyst (LPA), the RP disclosed that they only saw R1 once and could not verify the accuracy of the reported information. Facility staff interviews revealed that current employees were unfamiliar with R1, and three former staff members who cared for the resident are no longer employed at the facility. Interview with one former staff revealed that they would assist with medication when R1 complained of pain, and if the medication did not work they would informed the Administrator, home health nurse or family. Administrator Roberto Dela Vega denied the allegation, stating that staff actively attended to all of R1's care needs. Furthermore, interviews with residents indicated that staff are helpful, with one resident noting that staff transport them to the hospital if they experience severe pain. A witness who visits the facility also praised the staff as highly attentive, noting they meticulously document all physician instructions and have had no issues with resident medications. Based on the information obtained, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time. A copy of this report and appeal rights was provided.the state’s words, verbatim · CDSS document, Sep 16, 2026 · control 29-AS-20250903113332

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Sep 17, 2026

87608 Postural Supports (a) ...Postural supports may be used under the following conditions. (5) ... (B) Bed rails that extend the entire length of the bed are prohibited except for... hospice care... This requirement is not met as evidenced by Based on interview, and file review the licensee did not comply with the section cited above as R1 had a full bed rails without a being on hospice which poses a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: R1 is no longer at the facillity and Administrator agrees to write a letter of understanding of regulation 87608(a)(5)(B) and ensure residents do not have a full bed rail unless under hospice care. Letter of understanding will be submitted by 09/17/26.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Esther Cortez conducted an unannounced Case Management -Deficiencies visit. The purpose of the visit is to issue citations for deficiency observed during the investigation of complaint control #29-AS-20250903113332. The LPA met with Administrator Roberto Dela Vega Ramirez and explained the reason for the visit. During the investigation of complaint control #29-AS-20250903113332 the following deficiency was observed: Today at 12:02 PM the LPA was in the first living room walking towards the kitchen/ dinning room/living room area and observed Staff 1 (S1) changing Resident 1 (R1) in the living room exposing R1 in front of two (2) other caregivers, one (1) other resident and the LPA. The LPA observed R1 with their pants down and turned around immediately. The LPA immediately after spoke about personal rights with the staff and best practices regarding incontinence care. Citation issued, exit interview, appeal rights given.the state’s words, verbatim · CDSS document, Mar 16, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(8) · Plan of correction due date: Mar 20, 2026

87625 Managed Incontinence (b)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(8)Privacy shall be afforded when care is provided.This requirement is not met as evidence by: Based on observation during todays visit LPA observed staff assisting resident #1 with incontinent care in the living room without taking any precaution to protect the privacy of resident.the state’s words, verbatim · CDSS document, Mar 16, 2026

Plan of correction: Administrator agreed to provide in-service training pertaining to incontinent care assistance and residents privacy. Submit copy of in-service training record to LPA by due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 02:00 p.m. The LPA was greeted by staff, and explained the reason for the visit. Staff contacted the Administrator via telephone to inform them of the visit. Administrator Roberto Ramirez arrived shortly thereafter and was explained the reason for the visit. At 2:20 p.m. the LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Carbon monoxide and smoke alarms were tested and functioned properly. The fire extinguisher appeared fully charged and was last serviced on 1/6/2026. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. BEDROOMS: There are a total of four (4) resident bedrooms, of which two are shared and two (2) single occupancy, and one (1) staff bedroom. The resident bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: There are two restrooms for resident use. Restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Hot water temperature in resident restroom next to room #1 was within regulatory requirements (105*F-120*F); it was measured at 111.4*F. Report will continue on LIC809-C, 2nd page. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common hallway. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. Laundry room was locked and contained storage cabinets for laundry supplies. The garage was observed locked. Record Review: At 3:00 p.m., a review of facility files was initiated. Facility records are stored in a locked cabinet. The LPA observed documentation of Disaster prevention and last Disaster drill (conducted on 1/10/2026). The LPA obtained Resident Roster, Staff Roster, Infection Control Plan and Insurance liability. The LPA reviewed five (5) out of five (5) resident files and the following was observed: One (1) resident (R1) did not have a negative TB test on file, two (2) residents (R2, R3) had appraisal/ needs and services that were over a year old, and R2 did not have documentation of annual routine visit on file, or documentation of the residents refusal to receive an annual routine visit on file. Otherwise everything else was current. INTERVIEWS: LPA interviewed one (1) resident no concerns noted. Due to time constraints the LPA will return at another date to complete the annual. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator.the state’s words, verbatim · CDSS document, Feb 18, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Resident developed pressure injuries that worsened due to neglect.

Licensing Program Analyst (LPA), Esther Cortez, conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Administrator, Roberto Dela Vega Ramirez, and explained the reason for the visit. On 11/14/2024, the Department received a complaint regarding an allegation of Resident developed pressure injuries that worsened due to neglect. On 11/15/2024, between 10:57 a.m. and 12:45 p.m., the LPA toured the physical plant, conducted a file review and obtained copies of pertinent documents relevant to the investigation. On 11/24/2025, the LPA conducted interviews with Administrator Roberto Dela Vega and one (1) witness (W1) telephonically. On 11/25/2025, the LPA conducted interviews with Administrator Roberto Dela Vega one (1) witness (W2) telephonically and attempted to contact R1’s Durable Power of Attorney (DPOA). On 11/26/2025, The LPA attempted to contact the Resident's DPOA telephonically but received no response and conducted one (1) witness (W3) interview telephonically. Report will continue on LIC9099-C, 2nd page. Substantiated On 12/08/2025, 12/10/2025, and 12/11/2025, the LPA conducted phone interviews with W3. On 12/17/2025, the LPA attempted to contact the Resident's DPOA telephonically again but received no response. During the investigation, hospital records and Home Health records were requested and reviewed. On the allegation "Resident developed pressure injuries that worsened due to neglect "; it is the concern of the Reporting Party (RP) that on 11/06/2024, Resident 1 (R1) was admitted to St. John’s Regional Medical Center, for treatment of severe pressure wounds. It was reported that on 10/16/2024, R1 was moved from a skilled nursing facility to Reese Joy Care Home. RP also states there are discrepancies in R1’s care as staff at Reese Joy Care Home reported that R1 did not have any wounds when they were placed in their care but stated R1 began receiving home health services on 10/19/2024. A review of the resident records revealed that R1 was initially admitted to the skilled nursing facility (SNF) on 08/18/2024 through 10/16/2024. A review of 10/16/2024 Summary and Post-discharge Plan of Care- V4 did not indicate any presence of pressure injuries. The discharge plan had a dedicated page to input any pressure injury information which was left blank. Additionally, R1 was discharged with an order to receive physical therapy, occupational therapy and speech therapy only as outpatient therapy services from Ease and Comfort Health. On 10/16/2024, R1 was discharged and admitted to Reesejoy Care Home. A review of R1’s admitting Preplacement Appraisal (LIC603) dated 10/16/2024, Appraisal/Needs and Services Plan (LIC625) dated 10/16/2024, and Physician’s Report (LIC 602A) dated and signed 10/14/2024 did not indicate any pressure wounds. R1’s LIC602A also indicated that there wasn’t any history of skin condition or breakdown. However, medical records reviewed indicated that on 11/06/2024, R1 was admitted to St. John’s Regional Medical Center for altered mental status/tremors. The Nursing Progress notes dated 11/07/2024, notated that R1 had sacrum/buttocks 12 x 6 x UTS cm 100% yellow/brown slough, peri wound erythema, small serous discharge, unable to stage pressure injury present on admission, left heel: 2 X 3 cm purple nonblanchable, dry, deep tissue injury present on admission, and left elbow: 1.5 X 1.5 cm, red, dry chronic pressure injury, present on admission. Wound care notes revealed that photos and measurements were taken on 11/7/2024, of R1’s wounds on their buttocks, left ankle, left heel, left forearm and left heel at the hospital. Report will continue on LIC9099-C, 3rd page. The Administrator stated that R1 had redness upon admission on the buttocks, on the hands and feet, and staff were the ones treating R1. The Administrator recalls paperwork that R1 was receiving wound care but did not recall seeing any nurses go into the facility and stated they were basing the information provided to the LPA from the paperwork and conversations they had with R1’s DPOA. The Administrator also revealed that they believed R1 had stage 1 pressure injuries although no medical professional evaluated R1. When asked if they ever ordered any home health wound care for R1, the Administrator stated no and that R1’s DPOA handled all R1’s medical care. The Administrator also indicated that R1’s DPOA provided the name of R1’s physician but with no contact information. The Administrator attempted to contact the physician by using Google to obtain the phone number and advise them of the pressure injuries but was unsuccessful in locating the physician and informed R1’s DPOA. The Administrator continue to state that on November 6, 2024, R1 was admitted to St. John’s Hospital. A review of R1’s LIC 602 indicates it was signed by a physician from the skilled nursing facility the resident previously resided at which is a different name the DPOA provided as R1’s physician. Interview with a representative (W1) from At Ease and Comfort Home Health whose contact information was listed on the skilled nursing’s discharge paperwork, revealed that R1 never received any home health care from the agency. However, interviews with a representative (W3) from Ease and Comfort Home Health with a different contact number which was listed on the medical records revealed that R1 only received one visit from them, at most two, was not able to provide information if there was any care rendered on those visits, and that it was difficult to scheduled visits to see R1 as their “caretaker” wanted to be present but scheduling a date was difficult. However, the representative stated that there was no wound care ordered for R1 and no wound care was ever provided to R1 by them during those visits. The representative was unable to state if the referenced “caretaker” in the home health records was a facility staff or R1’s DPOA and advised the LPA they were basing their information on the nursing visit notes which provides no name and only list contact as caregiver. R1 was sent to the hospital on November 6, 2024, and services with the agency stopped. Record review revealed the facility had no home health records for R1 which will be addressed under a separate report. A review of R1’s home health records obtained from Ease & Comfort Home Health revealed that R1 was seen by a home health nurse on 10/19/2024 and 10/29/2024. Report will continue on LIC9099-C, 4th page. The records indicated that R1 was assessed on 10/19/2024 for their start of care, and the assessment indicated that R1 had no pressure ulcers/injuries or no stageable pressure ulcer/injuries. Additionally, the records revealed that on 10/29/2024, a home health nurse conducted a skin assessment and indicated “there were signs of breakdown on coccyx area, pcg advised to turn patient every 2 hours, and use pillows to protect bony prominences to prevent from further deterioration, MD office notified, and continued monitoring was advised due to limited mobility and incontinence.” Wound care worksheet completed by the home health nurse on 10/29/2024, noted that R1 had a stage 1 pressure ulcer on their coccyx area that measured 4cmx 5cm (closed), a stage 1 pressure ulcer on their right hip and left hip (both closed), and a superficial skin tear on their left arm (scab). Furthermore, home health communication notes revealed that on 10/22/2024, and 10/26/2024, SN reported designated caregiver refused home health visits at this time due to limited availability, the caregiver will only approve nurse visits when their schedule permits, home health visits cannot be conducted in the absence of the caregiver, caregiver was informed by SN about the benefits and risks of home health visits and the risk associated with missed visits. On 10/29/2024, the physician’s office was notified via telephone and fax that R1 presents with a pressure ulcer and requires wound care evaluation, no treatment orders have been issued at this time. On 10/30/2024 and 10/31/2024, the physician’s office was contacted for the 2nd and 3rd time via telephone, and a message was left regarding wound care evaluation, and the caregiver was called and advised to contact the doctor because the home health was not able to get a hold of any staff. No treatment orders had been issued at that time, and caregivers were advised to seek emergency room for wound care treatment. On 11/1/2024, the home health agency attempted to contact R1’s caregiver to verify whether the patient has been transported to the hospital as the PCP had not been in communication with the agency. No return call had been received from caregiver at that time. On 11/2/2024, the SN reported that they were unable to reach “pcg” to schedule an appointment. On 11/06/2024, SN reported that upon calling to schedule appointment for R1 they were informed that R1 had been admitted to the hospital. Home health services placed on hold until further notice. On 11/15/2024, the home health agency reported that per following up with R1’s family, R1 was at the hospital, and they were making decision on patient’s care. R1 was discharge from home health services. Records did not indicate who the caregiver or family member they were in communication with was. The LPA attempted to contact R1’s DPOA on three different occasions, however was unable to interview the DPOA to clarify if they were the “caregiver” reference in the home health records as the Administrator alleged the DPOA was the person who was in contact with home health agency. Report will continue on LIC9099-C, 5th page. Based on the information gathered there is sufficient evidence to support that the allegation occurred. On 10/16/2024, R1 did not have any pressure injuries documented in the skilled nursing facility’s discharge paperwork or Reesejoy Care Home admissions paperwork. A review of home health records revealed the resident was assessed on 10/29/2024 with the presence of stage 1 pressure ulcers on their coccyx area that measured 4cmx 5cm (closed), a stage 1 pressure ulcer on their right hip and left hip (both closed), and a superficial skin tear on their left arm (scab). On 10/31/2024 HH records indicate they advised the caregiver that they were unable to get hold of the physician to obtain wound care orders and to take R1 to the emergency room. Although R1 was not taken to the hospital until 11/06/2024 for altered mental status/tremors. At the hospital R1 was diagnosed with unstageable pressure injury in their sacrum/buttocks, deep tissue injury present on their left heel and dry chronic pressure injury on their left elbow. The information gathered supports the allegation of Resident developed pressure injuries that worsened due to neglect as R1 was not receiving wound care and was not hospitalized until 11/06/2024. Therefore, the allegation “Resident developed pressure injuries that worsened due to neglect” is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). An immediate $500 civil penalty was also issued today. Administrator Roberto Dela Vega Ramirez was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted, copy of this report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 29-AS-20241114145935

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 19, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to provide care and supervision resulting in R1's pressure injuries worsening which is an immediate health and safety risk to R1 in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Administrator agreed to submit an action plan on how to ensure staff adequately care and supervise residents and ensure they receive the appropiate care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(1) · Plan of correction due date: Dec 19, 2025

87405(d)The administrator shall have the qualifications...If the licensee is also the administrator, all requirements for an administrator shall apply.(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidence by: Based on interviews and records review the licensee did not comply with the section cited above as the Administrator did not demonstrarte sufficient knowledge, and qualifications as an Administrator, by not providing the required care to R1 which is an immediate health and safety riskthe state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Licensee agreed to review reg cited and submit a statement of understanding, along with a written plan on how they will ensure future compliance then send to LPA. to R1 in care.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Esther Cortez conducted an unannounced Case Management -Deficiencies visit. The purpose of the visit is to issue citations for deficiency observed during the investigation of complaint control #29-AS-20241114145935. The LPA met with Administrator Roberto Dela Vega Ramirez and explained the reason for the visit. During the investigation of complaint control #29-AS-20241114145935, the following deficiency was observed: Record review revealed the facility had no home health records for Resident 1 (R1) which was receiving home health care from an home health care agency. Citation issued, exit interview, appeal rights given.the state’s words, verbatim · CDSS document, Dec 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87609(b)(4)(A) · Plan of correction due date: Dec 19, 2025

(b)...care may be provided to residents through a licensed home health agency provided the following conditions are met:(4) The licensee and home health agency agree in writing on the responsibilities...(A)The written agreement shall reflect the services, frequency and duration of care. This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as R1 was on homehealth, but there were no records onsite available to review, which poses a postential health, safety or personal rightsthe state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Administrator agreed to review section cited and create a written plan on how they will ensure future compliance then send to LPA. risk to residents in care.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Esther Cortez arrived to the facility to conduct an unannounced Case Management – Deficiencies visit at the facility today. Upon arrival, LPA met with Administrator Roberto Dela Vega and explained the reason for the visit. During today’s visit, the LPA conducted interviews with five residents. At 3:56 p.m., while conducting interview with Resident 1 (R1) the LPA observed a container of medicine pills that had approximately 13 medicine pills in the residents table they had over their bed. When the LPA and Administrator enter the residents room there was no staff present. Upon observation, the LPA requested R1's Physician Report, which was dated 11/01/24 and indicated that R1 is not able to manage or store their own prescribed or PRN medications. Pursuant to Title 22, California Code of Regulations, the following deficiencies were cited (refer to LIC809-D). Exit interview conducted and copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Dec 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Dec 10, 2025

Incidental Medical and Dental (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible... This requirement was not met as evidenced by: Based on observation, Resident 1 had access to their medicine without any supervision, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Administrator removed the medication during the visit and agrees to submit a plan on how they will ensure they are in compliance with regulation 87465 to CCL by 12/10/25.

Allegation investigated: Facility did not issue a refund to a resident in care.

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial 10-day complaint visit for the above allegation. Upon arrival, LPA met with staff and explained the reason for the visit. Administrator Roberto Dela Vega Ramirez arrived at approximately 11:30 a.m. and was explained the reason for the visit. Entrance interview conducted. During today's inspection, the LPA interviewed the Administrator, one (1) staff, conducted phone interviews with R1 and R1's family member, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. Report will continue on LIC9099-C, 2nd page. Unsubstantiated On the allegation “Facility did not issue a refund to a resident in care” it is the concern of the Reporting Party (RP) that Resident 1 (R1) paid $6500 on 10/16/25 to live at the facility for thirty days, however R1 moved out on 10/20/25, requested a refund for the days they did not live at the facility and R1 did not receive a refund. A review of R1’s Admission agreement revealed that under the Facilities refund policy the facility requires a thirty (30) day notice of intent to vacate from the resident or resident’s responsible party unless agreed in writing and in advance with the administrator. The admission’s agreement was signed and dated by R1 on 10/16/2025. Interviews with staff and R1 confirmed that even though R1 left on 10/20/25, R1 did not give a 30 day notice of intent to vacate. Additionally, the Administrator revealed that they are willing to work with R1 to issue a proportional refund. Based on the information gathered, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “facility did not issue a refund to a resident in care” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of today's report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 29-AS-20251106085351

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Esther Cortez arrived to the facility to conduct an unannounced Case Management – Deficiencies visit at the facility today. Upon arrival, LPA met with staff and explained the reason for the visit. Administrator Roberto Dela Vega Ramirez arrived at approximately 11:30 a.m. and the reason for the visit was explained. Entrance interview conducted. During today’s visit, the LPA conducted a file review of Resident’s 1 (R1) records. R1’s file review revealed that R1’s Admission Agreement noted that if the resident is admitted any day after the first of the month, payment will be based prorated based on the remaining days of the month. However, R1 moved into the facility on 10/16/25, and was overcharged and paid the total monthly cost of Basic services of $6500. Interview with the Administrator revealed that the Resident’s monthly fee would be due every 16th of every month since the amount was not prorated. However, there is no documentation to confirm their statement. Pursuant to Title 22, California Code of Regulations, the following deficiencies were cited (refer to LIC809-D). Exit interview conducted and copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Nov 13, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87507(f) · Plan of correction due date: Dec 5, 2025

87507 Admission's Agreement (f)The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidence by: Based on records review and interviews, licensee did not comply with section cited as the facility failed to comply with the specific terms written in its own resident admission agreement, by charging R1 a full month instead of a prorated amount which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Administraor agreed to calculate the correct prorated amount based on the date R1 was admitted to the facility and issue a refund. Administrator will submit proof of refund to the LPA by 12/05/2025.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Esther Cortez conducted an unannounced Case Management -Incident visit, The purpose of the visit is to follow up on an elopement Incident reported to the LPA on 04/15/25. The LPA met with staff and the reason for the visit was explained. Administrator Roberto Dela Vega arrived at 4:05 p.m. It was reported that on 04/11/2025, at approximately 4:00 a.m. when facility staff was getting ready to prepare breakfast and clean up they found out that Resident #1 (R1) was not in their bed. Staff searched for R1 and could not find them, they reported to the Administrator and police. Police notified the Administrator that the resident had been found and was at St. John's hospital. The Administrator brought R1 back to the home around 5:30 a.m. On 04/18/25, the LPA conducted a phone interview with Administrator Roberto and requested hospital discharge documents. During the phone call, the Administrator revealed that R1 had sustained a bruise in the left eyebrow. On 04/20/25, the LPA received R1's hospital discharge documents, and a photo of R1's face. Discharge documents revealed that R1 had sustained a fall, and discharge diagnosis were listed as" closed head injury, nasal bone fracture and facial laceration. Photo of R1 showed R1's face, with a stitched laceration above their left eye, and yellow and purple discoloration around both cheek bones. During today's visit the LPA interviewed R1, two staff and the administrator. R1 was not able to fully explain what happened to them, however they revealed they feel safe at the home. Both staff revealed that R1, had exhibited wandering and elopement behaviors prior to R1's elopement. Report will continue on LIC809-C, 2nd page. Staff further revealed that R1's prior roommate had stated to the police they went to the restroom at 1:00 a.m. and they did not see R1 in the room. Staff also revealed that even though they have auditory alarms on the doors, they cannot hear them when they are in a deep sleep and the last time they checked on R1 was at 10:30 p.m. Hospital records indicate that R1 was at the hospital on April 10, 2025 23:11 PDT. Pursuant to Title 22 of CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued to Administrator Roberto Dela Vega.the state’s words, verbatim · CDSS document, Apr 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Apr 22, 2025

(2) For facilities with fewer than 16 residents, ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through ...observation, to require awake night supervision. ...This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the above section by not having awake staff to ensure R1 did not elope the facility after observing wandering and eloping behavior, & elopement resulted in injury which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Apr 21, 2025

Plan of correction: Administrator agrees to place awake staff during overnight shifts and will submit schedule to CCL by 4/22/25.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 11:15 a.m. LPA was greeted by staff, and staff contacted the Administrator via telephone to inform them of the visit. Administrator Roberto Ramirez arrived at approximately 3:00 p.m. At the time the LPA arrived there were four (4) residents present, during the visit a fifth resident was admitted to the home. Record Review: At 11:20 a.m., a review of facility files was initiated. Facility records are stored in a locked cabinet. The LPA observed documentation of Disaster prevention and last Disaster drill (conducted on 1/20/2025). The LPA obtained Resident Roster, Staff Roster and Insurance liability. The LPA reviewed four (4) out of five (5) resident files and the following was observed: Three residents (R1, R2, R3) did not have the Identification and Emergency Information form (LIC601) and a signed Residents Personal Rights form (LIC613) on file. R2 ’s file contained a positive TB test. No chest x-ray was present at the time of the file review. The LPA reviewed four (4) out of five (5) staff files as one (1) staff's (S1's) file was missing. Additionally, S1 is not associated to the facility. There was no annual training on file for S2. S3 who was present during the visit is also not associated to the facility. At 1:30 p.m. the LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Carbon monoxide and smoke alarms were tested and functioned properly. The fire extinguisher appeared fully charged and was last serviced on 1/3/2025. BEDROOMS: The resident bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Two bedrooms are share bedrooms, and two are single occupancy. There is also a staff room. Report will continue on LIC809-C, 2nd page. (continued from 809) RESTROOMS: There are two restrooms for resident use. Restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. The LPA did not observed soap in both restroom. Hot water temperature was within regulatory requirements (105*F-120*F); it was measured at 108.3*F. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common hallway. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. Laundry room was locked and contained storage cabinets for laundry supplies. The garage was observed locked. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Medications: Medications review began at 2:40 p.m.; medications are centrally stored and locked in a cabinet near the kitchen; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. INTERVIEWS: LPA interviewed two residents and one staff; no concerns noted. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator.the state’s words, verbatim · CDSS document, Feb 21, 2025

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 11:34 a.m. LPA was greeted by staff, and staff contacted the Administrator via telephone to inform them of the visit. LPA met with Administrator Roberto De La Vega Ramirez and discussed the reason for the visit. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Carbon monoxide and smoke alarms were tested and functioned properly. The fire extinguisher appeared fully charged and was purchased 2/13/2024. Hot water temperature was within regulatory requirements (105*F-120*F); it was measured at 110.9*F. BEDROOMS: The resident bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Currently there are six residents in the facility. Two bedrooms are share bedrooms, and two are single occupancy. There is also a staff room. RESTROOMS: Restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap in each restroom. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common hallway. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. Laundry room was locked and contained storage cabinets for laundry supplies. The garage was observed locked. The emergency food supply was located in the kitchen cabinet. (continued on 809-C) (continued from 809) KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Medications were locked in a cabinet. INFECTION CONTROL: LPA spoke with the Administrator regarding the facility’s infection control practices. LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate. INTERVIEWS: LPA interviewed two residents and two staff; no concerns noted. RECORDS: LPA reviewed medications; they appear to be given as prescribed and documentation was complete. LPA reviewed files for residents which appeared complete. LPA reviewed staff files. All staff are fingerprint cleared and associated to this facility. All staff have appropriate training. Disaster drills are conducted quarterly with all facility staff. Exit interview was conducted. Report was reviewed with Administrator. Copy of the report was issuedthe state’s words, verbatim · CDSS document, Feb 21, 2024