We Care Elderly Care

Type of visit: Required - 1 Year

On 04/14/26 at 3:25 PM, Licensing Program Analyst (LPA) L Holmes conducted an unannounced 1-Year Required inspection. LPA met with Jeremy Tatum, Care Staff (S1) and explained the purpose of the visit. Administrator (ADM) Brittany White authorized S1 to act on her behalf and sign the reports. LPA observed administrator has a current administrator certificate # 7026223740 which expires 09/20/2027. LPA and S1 toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) bedrooms and two (2) bathrooms. A comfortable temperature is maintained at the facility. LPA observed adequate lighting for the comfort and safety of the residents in all rooms. The hot water temperature in the residents’ shared bathroom was measured at 118 degrees Fahrenheit. Residents’ bathrooms were equipped with grab bars, soap and were sanitary. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher observed full. First aid kit was observed to be complete and no bodies of water were present. Two (2) staff records were reviewed. LPA also reviewed four (4) resident records and they were current and complete. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 14, 2026

Allegation investigated: Staff do not administer medication(s) to resident(s) as prescribed.

On 05/13/25 around 3:30 PM, L. Holmes Licensing Program Analyst (LPA) arrived unannounced to deliver the findings for the above allegation. LPA met with Jeremey Tatum, Care Staff, and explained the purpose of the visit. During the course of the investigation and visits, LPA toured the facility, requested an updated staff and resident roster, reviewed staff schedules, ID/Emergency Information, Unusual/Incident Reports (UIRs), Physician’s Reports (LIC602s), Death Reports (DR), conducted interviews, and reviewed emails pertaining to Residents (R1, R2, R3, R4, R5, R6, R7). LPA reviewed R1’s Admissions Agreement, interviewed Staff (ADM, S1, S2, S3) and Witnesses (W1, W3, W4). Continued on LIC9099C... Substantiated ...continued from LIC9099. On 09/18/24, R1’s physician prescribed the application of Neosporin to R1’s left ear twice daily until healed. R1’s ear appeared to be red in color and chaffed from the photo W1 presented. On 10/30/24, W1 provided the prescription, additional photos and a medication discharge list dated 10/22/24 for R1. R1’s CSMDR and Medication Discharge list did not include Neosporin; furthermore, R1’s LIC602 additional notes states to notify MD if R1 experiences the above symptoms. Interviews and records reviewed revealed that R2’s medication discharge list dated 12/20/24 did not include R2’s remaining Oxycodone. R2 stated that he/she should have had about 20-25 pills remaining. R2 stated that S1 said the medication had to be thrown away, was wet or something like that. S1 submitted an LIC624 to CCLD on 12/19/24 stating the pills fell on the floor and had been documented for destruction. S1 did not indicate the number of pills destroyed on the LIC624. S1 documented what appeared to be 22 pills were disposed on 12/19/24. R2 stated that she was not provided with any remaining pills or the prescription bottle, not even the wet prescription bottle and top. Based on LPA’s observations, interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED. Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and a copy of this report provided to Jeremey Tatum, Care Staff ...continued from LIC9099A Allegations: Unsubstantiated Questionable Deaths. Two deaths occurred around the same time at the facility on 10/02/24 and 10/13/24. R6 and R7 both had preexisting illnesses and later a change in their existing conditions. R6’s death was reported to the facility by R6’s family after being admitted to the hospital on 09/26/26 for pneumonia. On 10/01/24, W5 confirmed that S1 requested hospice care for R7 who exhibited signs of declining health due to increased falls, lack of speech, and decreased appetite. R7 was diagnosed with failure to thrive before S1 was able to obtain hospice care services at the facility. Licensee does not ensure that residents are provided adequate care and supervision while in care. The allegation refers to R1 being unattended while using the bathroom at the facility. LPA attempted to interview W2 who witnessed the allegation. LPA confirmed W2’s contact information with W1. LPA attempted to make phone contact with W2 on two additional occasions throughout the investigation and was unsuccessful. R1’s LIC624 dated 09/20/24 states that R1 is unable to bathe, groom or care for his/her own toileting. LPA was unable to confirm or deny the allegation occurred. S2 stated that he/she was not aware of any problems and did not know R1 would not be returning to the facility when R1 was picked up on 10/16/24. S1 reported that W1 has never called or answered phone calls from the facility, nor did W1 verbalize having and grievances about the services rendered. As of today’s date, LPA has not been successful in contacting W2. Administrator is not on the facility premises a sufficient number of hours. LPA reviewed the facility’s staffing scheduled and confirmed S1 scheduled hours at the facility. S1 stated, “All staff collaborate to cover shifts that are open to ensure proper coverage for care of residents based on census.” If S1 is not available upon arrival when LPA is conducting a case management, complaint or inspection visit, S1 will arrive in 10-15 minutes upon request. Continued on LIC9099... ...continued from 9099C. Staff did not allow resident to have possession of their personal belongings. Interviews revealed that R1, R2, R3, R4, R5 and W3 did not have any complaints of not being in possession of resident’s personal belonging. LPA toured R2’s room, closet and dresser drawers. R2 was in possession of his/her shoes, clothing, toiletries items and memorabilia that was displayed on the walls. R3 stated that he/she loves art, has far too much, and had what R3 needed at the facility. W3 stated that R4 doesn’t always make the best choices, wants to move, but hasn’t had any other complaints from R4 or R5. Staff do not respond to residents' requests for assistance in a timely manner. After review of complaint and interviews with W1, W3, S1, S2, S3, R2 and R3, there was no mention of staff not responding to residents’ request for assistance in a timely manner. R3 stated. “There were sometimes I would have said, “I would like to be changed” but they were kind and would bring me things.” W4 stated he/she was not aware of any problems or issues at the facility; W4 speaks with R2 about once a month. Based on LPA’s observations, interviews and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided to Jeremey Tatum, Care Staffthe state’s words, verbatim · CDSS document, May 13, 2025 · control 15-AS-20241025113739

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: May 13, 2025

87465 Incidental Medical and Dental Care e) For every prescription...the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. -This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not properly administering medication and documenting it's destruction.the state’s words, verbatim · CDSS document, May 13, 2025

Plan of correction: Licensee/ADM to provide CCLD vendored training (TBD) to all staff and provide proof by POC date.

Type of visit: Required - 1 Year

On 4/22/2025 at 1:25 PM, Licensing Program Analyst (LPA) L Holmes conducted an unannounced 1-Year Required inspection. LPA met with Earnest Manning, Care Staff (S1) and explained the purpose of the visit. Administrator (ADM) Brittany White, arrived around 20 minutes later. LPA and S1 toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) bedrooms and two (2) bathrooms. A comfortable temperature is maintained at the facility. LPA observed adequate lighting for the comfort and safety of the residents in all rooms. The hot water temperature in the residents’ shared bathroom was measured at 119.2 degrees Fahrenheit. Residents’ bathrooms were equipped with grab bars, soap and were sanitary. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher observed full. First aid kit was observed to be complete and no bodies of water were present. Disaster drill last completed 04/2025. Three (3) staff records were reviewed. LPA also reviewed four (4) resident records and they were current and complete. Exit interview conducted. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Apr 22, 2025

Type of visit: Case Management - Deficiencies

On 10/29/24 around 09:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a Case Management (CM). Upon arrival, LPA met with Lurinza Bean, Licensee (S1) and spoke with Brittany White, Administrator (ADM) by phone and explained the reason for the visit to both. -At around 10:35 AM, LPA and S1 toured the facility including, but not limited to bathrooms, kitchen, common areas, laundry area, dining area, garage, staff room, and backyard. LPA observed and confirmed that there is an Additional Dwelling Unit (ADU) in the backyard and it does not have a City of Richmond building permit for use per S1 and W1. Deficiency is cited on the attached LIC 809D. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided to Lurinza Bean, Licensee.the state’s words, verbatim · CDSS document, Oct 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87305(a) · Plan of correction due date: Nov 5, 2024

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. -This requirement is not met as evidenced by: Based on observation, interviews and records reviewed, the licensee did not comply with the section above by not having the ADU permitted which posed or poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Licensee to apply for building permit and provide proof to CCLD by POC; Licensee to self certify that regulation has been reviewed and update CCLD biweekly throughout the application and approval process.

Type of visit: Case Management - Health Checks

On 10/29/24 around 09:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and Health and Safety Check. Upon arrival, LPA met with Lurinza Bean, Licensee (S1) and spoke with Brittany White, Administrator (ADM) by phone and explained the reason for the visit to both. Upon arrival LPA observed one (1) Care Staff monitoring the facility and attending to the residents that were in there room. LPA and S1 toured the facility including, but not limited to bathrooms, kitchen, common areas, laundry area, dining area, garage, staff room, and backyard. The facility consists of 4 (four) bedrooms. All outdoor and indoor passageways are free of obstruction. There were no bodies of water. A comfortable temperature was maintained however the residents preferred 63 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. Hot water temperature in the shared residents' bathroom was measured at 113.9 degrees (F). All toilets, hand washing, and bathing areas were safe, sanitary and in operating condition with paper towels, and soap observed at all hand washing stations. Linen and hygiene products available for all residents. PPE, sanitizer, and paper goods remained sufficient. Fire extinguisher last inspected 03/03/24 and smoke/carbon monoxide detectors were operational. Exit interview conducted and a copy of this report provided Licensee.the state’s words, verbatim · CDSS document, Oct 29, 2024

Type of visit: Case Management - Other

On 10/23/24 around 9:45 AM, L. Holmes Licensing Program Analyst (LPA) arrived unannounced to conduct a case management regarding an Unusual/Incident Reports (UIR) and Death Report (DR) for Resident (R1) LPA met with Lurinza Bean, Licensee (S2) and explained the purpose of the visit; ADM Brittany White arrived shorlty after. On 10/01/24 ADM reported the following, “On 9/26/2024 R1 was having a virtual MD appointment, and We Care is requesting the primary care MD approve a request for a hospice evaluation due to recent decline. During appointment, the MD verbally instructed that Licensee, S2 to send R1 to ER for evaluation due to noted change in condition. 911 was alerted. Upon arrival to community, they successfully transported pt to ER for further medical evaluation. Pt conservator informed. Permission given for Hospice Evaluation Continue communicating to St. Mary's Hospital that pt needs a hospice evaluation.” During the visit on 10/09/24, LPA reviewed the file for R1 including but not limited to R1's After visit summary for 09/2024 & 07/2024, and Identification and Emergency Information. On 10/14/24, ADM sent R1’s Physician’s Report (LIC 602) and DR for death dated 10/13/24. After careful review of R1’s medical history with LPM Y. Flores-Larios, LPA returned to review R1’s Medication Administration Records (MAR) and Centrally Stored Medication and Destruction Record )LIC 622) for accuracy. ADM stated that she will provide additional faxes and emails to support the change in R1's condition. -At around 10:59 AM, LPA found that the records were inaccurate for a sample of seven (7) out of eleven (11) medications on the MAR and LIC 622 when compared to the after visit summary medication list on 06/04/2024. Deficiencies are cited on the attached LIC 809D. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided to Licensee, Brittany White, Administratorthe state’s words, verbatim · CDSS document, Oct 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87475(e) · Plan of correction due date: Oct 25, 2024

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription...shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication... -This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the section above by not having R1’s medication to be administered available which posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 23, 2024

Plan of correction: Licensee and ADM to have physicians consolidate/update medication lists for all residents by 10/30/24. All residents' medication shall be available. Document refusals date and time, follow physician’s orders, and perform staff training for all personnel that administer medication by 10/25/24; submit proof of training with names of attendees to CCLD on or before 10/25/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87506(b)()14 · Plan of correction due date: Oct 23, 2024

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services.-This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the section above by not having all of R1’s medications recorded on the LIC 622 which posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 23, 2024

Plan of correction: Licensee and ADM to audit all residents LIC 622s, follow physician’s orders, and perform staff training for all personnel that administer medication by 10/25/24; submit proof of training with names of attendees to CCLD on or before 10/25/24.

Type of visit: Case Management - Other

On 10/09/24 around 11:20 AM L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management regarding Unusual/Incident Reports (UIRs) for Residents (R1, R2) and a Death Report for R2. LPA met with Lurinza Bean, Licensee (S2) and explained the purpose of the visit. On 10/01/24 ADM reported the following, “On 9/26/2024 R1 was having a virtual MD appointment, and We Care is requesting the primary care MD approve a request for a hospice evaluation due to recent decline. During appointment, the MD verbally instructed that Licensee, S2 to send R1 to ER for evaluation due to noted change in condition. 911 was alerted. Upon arrival to community, they successfully transported pt to ER for further medical evaluation. Pt conservator informed. Permission given for Hospice Evaluation Continue communicating to St. Mary's Hospital that pt needs a hospice evaluation.” On 10/01/24 ADM reported the following, “On 9/26/2024 at approximately 12:30 PM R2 was observed in her bedroom unresponsive after x3 attempts of arousal by tapping shoulder and verbally calling out her name. Licensee, S2. 911 was alerted. Ambulance arrived and safely transported to Kaiser ER for further medical evaluation. Per ER, R2 will be admitted for further evaluation r/t Pneumonia. R2 remains admitted to hospital as of 10/1/2024. Continue to follow up with RP and Kaiser Hospital for patient’s current status.” On 10/03/24, LPA received a DR for R2; date of death 10/02/24. On 10/04/24 LPA extended condolences to the family and facility, requested a death certificate, LIC602 and any other relevant care notes that happened within the months prior to R2’s death. During the visit LPA reviewed the files for R1 and R2 including but no limited to R1's After visit summary for 09/2024 & 07/2024, R2's for 06/2024 & 09/2023 and Identification and Emergency Information for both. Continued on LIC809C... ...continued from LIC809. -At around 12:17 PM, LPA L. Holmes observed that R2 did not have an updated physician's report. The report in R2's file was dated 03/29/21. Deficiency is cited on the attached LIC 809D. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided to Licensee, Lurinza Bean.the state’s words, verbatim · CDSS document, Oct 9, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(c) · Plan of correction due date: Oct 11, 2024

87458 Medical Assessment (c) The licensee shall obtain an updated medical assessment when required by the Department. -This requirement is not met as evidenced by: Licensee did not provide CCLD an updated medical assessment when requested on 10/04/24 and 10/09/24 for R2.the state’s words, verbatim · CDSS document, Oct 9, 2024

Plan of correction: Licensee to review the regulation, certify in-service training for all staff, and provide the latest LIC602 for R2 by POC date. Death Certificate to be provide to CCLD upon receipt.

Type of visit: Required - 1 Year

On 4/2/2024 at 9:50am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Administrator/Caregiver Lurinza Bean, and explained the purpose of the visit. Administrator, Brittany White, arrived at 10:35am. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) bedrooms and two (2) bathrooms. LPA did not observe any bodies of water. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 114.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 03/03/2024. Emergency disaster plan last updated 5/24/2022. First aid kit was observed to be complete. Three (3) staff records were reviewed. LPA also reviewed five (5) resident records and they were current and complete. Continued on LIC809C. Continued from LIC809C. Deficiencies LPA observed: At 10:46am LPA Observed unlocked cabinets located in the hallway and kitchen which contained chemicals such as Ajax, Comet Awesome cleaner, Glade Carpet Cleaner, Fabuloso, WD-40, Lysol, Raid, 409, and a knife. At 10:50am LPA Observed 5 piles of wood planks located in the back yard. The following forms are to be updated and submitted to CCLD by 04/10/24: -Resident Roster -LIC500 Personnel Report -LIC308 Designation of Administrative Responsibility -LIC610 Emergency Disaster Plan The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Apr 2, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.