A Casa Ranch

Allegation investigated: Staff violated clients personal rights. Staff failed to prevent fall

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. Upon arrival, LPA met with Administrator Designee Maria Cuevas/Sola and explained the reason for the visit. During the initial visit on 09/9/26 LPA interviewed administrator, designee administrator, staff, and residents and conducted a physical plant tour. During the investigation LPA reviewed relevant documentation and took images of areas of concern. On the allegation: Staff violated clients personal rights. It was alleged that on the morning of 9/7/2026, staff were pushing Resident 1 (R1) backwards in their wheelchair out of the bathroom area when the wheelchair became stuck on an object, causing R1 to fall backwards. During this time it was alleged that a second resident attempted to assist staff during the fall on 9/7/2026 and staff yelled “Get away!” at the resident, frightening them. It was also alleged that on either 8/24/2026 or 8/31/2026, Substantiated staff was observed attempting to transfer R1 from their wheelchair to a chair, during which staff dropped R1 who then fell to their knees. It was also stated that residents were not receiving PRN medication when requested and that residents were left in soiled clothing for extended periods. Regarding the 9/7/26 incident, staff demonstrated that R1 had been seated on a walker with a built in seat rather than a wheelchair. When maneuvering the resident over a raised ledge between the bathroom and hallway, R1 fell backwards. Use of the walker as transport equipment was not appropriate and does not meet safe transfer practices. It was alleged that resident was dizzy and their head hurt, 911 was called, R1 was later discharged from the hospital with diagnosis of “closed head injury and scalp contusion.” Instruction to take Tylenol for pain. Home Health Nurse notes dated 9/1/26 documented R1 complaining of bilateral knee pain shortly after the alleged fall during a transfer supporting the possibility of a fall during transfer. Interviews with residents and staff could not verify a fall occurred. The LPA conducted resident interviews during visits on 9/9/26 and 9/15/26. One resident stated that a staff member sometimes raises their voice due to having a naturally loud tone. Some residents reported hearing staff raise their voice. Interviews done with other individuals involved in the oversight of the facility admitted that this has been brought up before, providing a history supporting the allegation that the staff member could have yelled at residents on 9/7/26. It is unclear if the yelling was for urgency or directed in anger. Discussion with staff and designee about urging staff take their time off and ensure they are able to maintain their professionalism with residents and visitors. An audit of Medication Administration Records (MARs) showed that PRN medications were not consistently documented, and some PRN medications did not match their count therefore could not be explained when they were given. Due to incomplete documentation, the LPA was unable to verify when PRN medications were administered. On the allegation that residents are not assisted with changing soiled clothing, it could not be verified but was discussed with residents and staff. It was confirmed that staff have to assist R1 to use the restroom as they are unable to get up on their own and that most residents wear some form of brief. Continue on 9099-C Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Based on interviews and record review, the preponderance of evidence that the facility has violated the personal rights of residents in care has been met. Therefore, that allegation is SUBSTANTIATED. On the allegation: Staff failed to prevent fall It was alleged that on the morning of 9/7/2026 , staff were pushing Resident 1’s (R1) backwards in their wheelchair out of the bathroom area. The wheelchair became stuck on an object, causing R1 to fall backwards. On 9/8/26, the facility submitted an incident report as required, describing the incident referenced in the complaint. During the visit on 9/9/2026, the LPA asked staff to demonstrate what had occurred. Staff clarified that R1 had been seated in a walker with a built in seat, not a wheelchair. Staff demonstrated that a raised ledge between the bathroom and hallway required added force to maneuver the resident over it. When staff applied extra force, R1 began to fall backwards while seated in the walker. R1 hit their head on the floor during this event. It was stated that the resident was dizzy and their head hurt, 911 was called, R1 was later discharged from the hospital with diagnosis of “closed head injury and scalp contusion.” Instructed to take Tylenol for pain. During interviews with the administrator/licensee and designee, it was stated that the owner had recently renovated the restroom. The renovation resulted in a height difference between the restroom tile and the hallway wood flooring. To cover this area, the installer placed a raised three inch wide metal threshold, the threshold has a small slope and a lift of approximately ½ inch in height. The LPA observed that the ledge presents a safety risk for residents, as it may cause tripping and is particularly hazardous for individuals using walkers or with impaired eyesight. Continue on 9099-C Based on the interviews, observation, and record review there is a preponderance of evidence that R1 did fall while being transported due to inappropriate usage of equipment and the ledge installed therefore the allegation is SUBSTANTIATED at this time. Report was discussed with designee, copy of appeal rights and the report were printed and provided to designee.the state’s words, verbatim · CDSS document, Sep 15, 2026 · control 29-AS-20260908130120

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2)(6) · Plan of correction due date: Sep 17, 2026

87307 Personal Accommodations and Services(d)The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. (6)All…indoor passageways…shall be kept free of obstruction. This requirement is not met as evidenced by: Based on interview, observation, and record review, the licensee did not comply with the section cited above as Resident #1 (R1) sustained a fall due to the updated maintenance of the facility creating a hazard for transportation. This poses an immediate health and safety risk to people in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: The licensee must correct the flooring transition between the hallway and restroom to eliminate the raised ledge that creates a safety hazard for residents, staff, and visitors. The licensee shall repair, modify, or replace the threshold so that it is level and safe for mobility devices. Proof of correction, including photographs and/or invoices, must be submitted to the Department by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 97468.2(4) · Plan of correction due date: Sep 20, 2026

87468.2 Additional Personal Rights...(a)In addition to the rights listed in Section 87468.1, Personal Rights...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as Resident #1 (R1) was transported using incorrect equipment and procedures, and medications were not documented as required. This poses a potential health and safety risk to people in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Documentation of training for proper transfer techniques and proper equipment usage as well as a review of all medication requirements. The medication training will be documented on sign in sheets and topics and training references used will be submitted to LPA via email by 9/20/26. Administrator will schedule a training from a medical professional on proper transfer techniques and equipment usage, the date of the scheduled training must be provided to LPA by 9/20/26 and there training, if possible, must occur within 2 weeks, documentation of who was trained and the material used will be submitted via email to the LPA.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melisa Rankin arrived at 12:19 p.m. to conduct a 1-year required annual visit. LPA met with Maria Solla Back-up Administrator. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: LPA toured resident rooms and observed that rooms were tidy and free of odor. The lighting and lamps are sufficient for the use of the facility and for resident comfort and safety. Toilet, hand washing and bathing facilities are operational and secure grab bars are present. The showers have slip resistant mats/flooring. The pathways are clear of any obstructions. Disinfectant and cleaning solutions are locked inaccessible to residents in care in the garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. The fire extinguisher was last charged and inspected on 10/28/25. The facility has smoke and carbon monoxide detectors that were tested and working at time of visit. Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 1/12/26. The facility is approved for a capacity of 6. The fire clearance is granted for 6 non-ambulatory of which 2 may be bedridden. Hospice waiver approved for 4 residents. The facility currently has 6 residents in care, 2 on hospice. Continued 809C Personnel Records & Training: Files reviewed had 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator’s Certificate expires on 6/26/26. The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2025. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible. Food Service: The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed a sampling of residents’ medications, all medication were documented appropriately. Disaster Preparedness: The current emergency disaster forms were posted. Facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does not have delayed egress, locked doors or gates. Exit door alarms are working. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Dec 30, 2025

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erika Miller arrived at 3:30 p.m. to conduct a 1-year required annual visit. LPA met with Aprilyn Soriano, Administrator. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has at least a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environment Safety: LPA toured resident rooms and observed that rooms were tidy and free of odor. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have slip resistant mats. The pathways are clear of any obstructions. Facility is well lit inside for safety. Disinfectant and cleaning solutions are inaccessible to residents in care and locked under the kitchen sink and in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. The fire extinguisher was last charged and inspected on 10/28/24. The facility has smoke and carbon monoxide detectors that were tested and inspected. Continued 809C Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 1/12/26. The facility is approved for a capacity of 6. The fire clearance is granted for 6 non-ambulatory of which 2 may be bedridden. Hospice waiver approved for 4 residents. The facility currently has 4 non-ambulatory and 1 one bedridden resident. Staffing: The facility currently employs 6 full time staff, 1 part time and 1 administrator. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator Certificate expires on 2/27/26 Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2024. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible. Food Service:. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. Continued 809-C Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired, and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility has 2 self-latching gates on side of the home. The facility does not have delayed egress, locked doors or gates. Exit door alarms are working. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Jan 10, 2025

Allegation investigated: Staff left resident unattended at facility

Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver final findings for the above allegation. LPA Olson interviewed Staff on 1/29/24 and 2/7/24, Residents and Administrator on1/29/24 and requested relevant documents. During today’s visit, LPA met with Caregiver and Administrator (over the phone) and explained the reason for the visit. On the allegation: Staff left resident unattended at facility. It was alleged that during the facility's Christmas party, a resident was left alone at the facility because all the staff left to go to the party. LPA interviewed all 4 residents on 1/29/24 who stated they have never been left alone at the facility. One resident interviewed stated they heard someone was left alone at the facility, they don’t remember who told them but they asked and staff said no one was left alone. Another resident stated Resident 1 (R1) was unable to go to the party and had to stay because they were too sick but Staff 1 (S1) was here and stayed with R1 the whole time. Continued on 9099-C Unsubstantiated LPA interviewed Administrator who stated the facility had a Christmas Party on 12/25/23 which started at 1pm. R1 was on Hospice and bedridden so they couldn’t go. Administrator stated R1 remained at the facility with S1 and S1 stayed with R1 the whole time. The administrator stated Staff 2 (S2) came from the other facility to help take residents to the party. Staff 3 (S3) stayed with the residents at the other facility, and Administrator and S2 took residents over one by one. Administrator also stated S2 brought food over for S1 and R1 and there were many witnesses that can prove S1 was not at the party, so never left. LPA interviewed S1 who stated they worked on 12/25/23 from 7am-5pm and could not go to the Christmas party because R1 was too sick. S1 stated they know the rules and stayed with R1 the whole time. LPA interviewed S2 who stated they came over to the facility to help take the residents one by one. S2 stated S1 stayed the whole time and never left R1. Based on the information obtained there is not enough evidence to substantiate, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of report issued.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 29-AS-20240122160108

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit at 3:53 p.m. When LPA arrived, there were two staff and five residents present. LPA was greeted Administrator and informed them of the reason for the visit. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Common areas: Living and dining room furniture were observed to be in good condition. At 4:20 p.m., carbon monoxide detector were tested and operational at the time of the visit. There is a fireplace in the living room, which is screened and inaccessible. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 11/2/2023. The backyard has a covered outdoor area equipped with furniture for resident use. No bodies of water noted. The washer and dryer are in the garage. The garage is unlocked. Restrooms: The three resident restrooms were clean and sanitary and in operating condition with non-skid mats. The bathrooms were sufficiently stocked with soap and paper towels. Bedrooms: There are five (5) resident rooms, which were furnished. A linen closet was located outside of the rooms, which stocked extra linens and towels. Records: LPA reviewed resident and staff records around 4:30 p.m. LPA reviewed five (5) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete. Continued on 809-C MEDICATIONS: Medications review began at 4:00 p.m. The medications are centrally stored and locked in a cabinet in the dining room. Medications are labeled and checked for expiration dates. LPA advised the Administrator to ensure that all the necessary information is properly documented on the CSMAR. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. At 5:10 p.m., LPA interviewed two (2) staff members and two (2) residents. During today’s visit, the LPA obtained copies of the following: staff roster and current liability insurance. Exit interview conducted and a copy of this report issued.the state’s words, verbatim · CDSS document, Dec 27, 2023

The state marks this report as 16 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.