Alondra Guest Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced annual inspection visit. The purpose of the visit was explained to Administrator Joy Villaflores. The facility serves elderly residents ages 60 and older. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed and includes environmental cleaning and disinfection activities. Facility has sufficient Personal Protective Equipment. Operational Requirements: A hospice waiver for 1 resident is in place. A fire clearance was granted for 4 non-ambulatory and 2 ambulatory residents. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 7/13/2026. Physical Plant/Environment Safety: The facility is a single story home located off a major street. The facility is owner operated and consists of 5 resident bedrooms and 1 staff bedroom for Administrator, 3 bathrooms, living room, dining room, kitchen, outdoor covered patio area, outdoor laundry room, and a 2 car attached garage presently being used as a storage area. Smoke and carbon monoxide detectors were tested and are operational. The facility has one (1) fire extinguisher. Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and Manual. Cleaning supplies, knives, and toxic substances are inaccessible to residents. The last Emergency Disaster drill was conducted on 8/15/25. Exit door in room #3 was obstructed by R2's bed. Staffing: A total 4 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 8/2/2027. Staff have criminal background clearance and training. Four (4) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training is current. Resident Records/Incident Reports: A total two (2) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Medication Administration records are in place. Resident (R3) does not have a file. RCFE and Ombudsman complaint posters are posted in the main entryway of the facility. The RCFE poster is not the required size. A technical advisory was issued. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents do not have modified diets. Incident Medical and Dental: Centrally stored resident medications were reviewed. 30-day supply of medications was observed. Medical and dental transportation is provided by family or medical transport. R3's medications were observed unlocked next to their bed, and S3's medication pill box was unlocked in the garage. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. Residents with Special Health Needs: No residents receive hospice care or home health services. No residents have prohibited health conditions. Two residents have half bed rails for mobility assistance. Per Title 22, deficiencies were cited. An exit interview was conducted with Administrator Joy Villaflores. A copy of the report, appeal rights, and technical advisory was provided.the state’s words, verbatim · CDSS document, Sep 6, 2025

Allegation investigated: Staff serves expired food to resident. Staff does not provide resident with nutritious meals Staff is not meeting the resident's medical needs. Staff does not maintain adequate records for resident. staff mismanages resident's medications.

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Administrator Lourdes Villaflores and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 06/30/2025, LPA interviewed Administrator, staff (S1) and resident's R1-R2. LPA toured the facility kitchen, garage, and resident (R1’s) bedroom and obtained copies of the following documents: staff roster, resident roster, R1’ appraisal needs and service plan, physicians’ reports, admission agreement, identification information (LIC 601), medication record sheet, and hospital discharge paperwork. During today’s visit LPA Gutierrez delivered findings. SEE 9099C Substantiated In regard to the allegation “Staff serves expired food to resident’ and “Staff does not provide resident with nutritious meals”, it is alleged that facility keeps expired food and that residents are not being served nutritious meals. During interviews with Administrator and staff (S1) both stated that they do not have expired food and that both residents receive well balanced nutritional food. During interviews with residents R1 and R2 both stated that the food is okay. R1 stated that they don’t get enough food. LPA Gutierrez checked food supply and observed expired milk, cheese, sour cream, and molded cauliflower in refrigerator. LPA also toured garage and found a supply of vegetables and expired bread with gnats surrounding boxes. During visit LPA Gutierrez observed Administrator serve R1 tacos with the three month expired sour cream. LPA asked Administrator to throw away all expired food. In regard to the allegation “Staff is not meeting the resident's medical needs”, it is alleged that R1 was referred to an ophthalmologist and urologist in June of 2020 and was never taken. During interviews with Administered it was reveled that R1 was not taken to appointments because Administrator thought that home health care was supposed to arrange that, and the facility does not provide those services. S1 stated that he/she doesn’t take care of medical appointments. During interviews with residents R1 stated that he/she has only seen the doctor once and R2 stated that family takes he/she to doctors. In regard to the allegation “Staff does not maintain adequate records for resident”, It is alleged that R1’s file is not updated with current paperwork. During record review it was reveled that R1 has not seen a physician for an updated physicians report LIC 602 since 06/16/2020 with a diagnosis of Dementia, and the appraisal needs, and service plan was not completed, nor did it have R1’s signature or signature of person completing form. During interview with Administrator, it was revealed that home health care has been seeing R1 and no updated LIC 602 has been completed by physician. SEE LIC 809C In regard to the allegation “staff mismanages resident's medications”, it is alleged that facility did not have an updated centrally stored medication list since 2020. During record review it was reveled that facility did have current centrally stored medication log from May of 2025. LPA did a medication check and Atrovent Inhaler was missing for R1. Administrator stated R1 did not use inhaler, but doctor has never discontinued inhaler for R1. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Administrator Lourdes VillaFlores. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 28-AS-20250626142210

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(8) · Plan of correction due date: Jul 9, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. Based on observation facility had expired sour cream, milk, cheese, bread and vegetables in refrigerator.LPA observed gnats on food. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Administrator will purchase fresh fruit, meat and produce and send LPA pictures as proof. Administrator will create a log and check food for expiration dates and ensure food is free from gnats.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(a) · Plan of correction due date: Jul 9, 2025

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. Based on observation LPA observed Administrator serve R1 Three month expired sour cream for lunch. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Administrator will conduct a training for herself and staff of the importance of serving a nutritional well-balanced meal and send training to LPA by POC due date. Administrator also agrees to check for expiration dates before serving residents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Jul 22, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. Based on record review R1 was given two referrals for ophthalmologist and urologist appointments were never made which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Administrator will contact physician for new referrals and send LPA dates for appointments.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jul 29, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Based on record review R1 has not had an updated physician’s (602) report since 2020. R1’s appraisal needs, and service plan is incomplete.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Administrator will submit new physicians report LIC 602 and complete an appraisal needs and service plan by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 9, 2025

87465 Incidental Medical and Dental Care a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. Based on record review R1 di not have Atrovent NFA Inhaler 2 puffs by mouth every 4 hours with spacer (routinely). This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Administrator will contact pharmacy for inhaler and send LPA picture once inhaler is received.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christian Gutierrez generated this Case Management - Deficiencies report in conjunction with complaint control 28-AS-20250626142210 pertaining to observations during record review. The purpose of the report was explained to Administrator. During complaint investigation, LPA Gutierrez reviewed R1’s medication record and it was revealed that R1 only takes three medication for his seizures and not all medication prescribed. When LPA asked Administrator why R1 only takes three medications it was stated that R1 refuses other three. LPA spoke to Administrator, and it was revealed that no special incident reports (SIR) have been submitted to the department or to physician. Based on observation, a citation is being issued. See LIC 809D. An exit interview was conducted, and a copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jul 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1 · Plan of correction due date: Jul 22, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Based on record review R1 refuses to take Famotidine 40 MG one tablet daily, Docusate 250 MG once daily, and Constulose twice a day and Facility has never reported to licensing or to R1’s physician. which poses a potential risk to resident in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Administaror agrees to complete an special incident report (SIR) and fax to licensing when R1 refuses medication and to contact physician.

Allegation investigated: Staff did not seek medical attention for resident in a timely manner

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the above allegation. LPA met with Administrator Joy Lourdes Villaflores and discussed the purpose of the visit. The investigation consisted of LPA interviewing Administrator S#1, two residents (R#1-R#2) and two (2) witness (W#1-W#2). LPA reviewed staff and resident rosters ,R1 LIC 602 and R1 hospital discharge paper work. The Investigation revealed that R1 had a fall at around 5:00am on September 24th and hit R1 head. S1 stated S1 asked R1 if R1 wanted to go to hospital and R1 refused. On September 25th, 2024, S1 again asked if R1 wanted to go to hospital and R1 refused and S1 provided R1 with Tylenol. On September 26, 2024, R1 agreed to go to hospital and S1 began to arrange for transportation for R1. At first, the medical transportation company Vital Care agreed to pick R1 up at 2 p.m. on September 26, 2024, then it was pushed back to 4 p.m. and then pushed back one more time to 10 p.m. Finally, the hospital contacted facility and explained that there was no bed and to transport R1 tomorrow September 27, 2024 (continued) Substantiated On September 27 2024 Vital Care Transportation arrived at 8:15 a.m. and they asked S1 to call 911 due to R1 blood pressure being out of range. S1 called 911 and R1 was transported to Norwalk Community Hospital where R1 was admitted until R1 was discharged on September 30, 2024. LPA asked S1 why S1 did not call 911 right away when R1 had fall and S1 stated because R1 refused and R1 condition did not appear too serious. LPA asked S1 if she had medical background to make that determination and S1 said no. LIC602 dated 6/20/2020 indicates that R1 is not able to make decisions or exercise good judgment. R1 was inconsistent in R1 answers. R2 could not corroborate the allegation. W2 who is family member stated that W2 was informed of fall and resident refusal. W2 did not remember that day or time of notification. S1 did not notify department of R1 fall, refusal to get medical attention, and hospitalization for three (3) days. S1 did not call 911 for R1 to get medical attention when R1 fell and hit head until three days later on September 27, 2024 on the request of the Vital Care transportation company. Based on LPA observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. A copy of report, LIC9099D and appeal rights was provided during the exit interview.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 28-AS-20240927115204

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Oct 2, 2024

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement is not met as evidence by: R1 had a fall on the September 24, 2024 and S1 did not call 911 until 3 days later. The resident was not given immediate medical attention for the injuries which poses/posed health and safety hazard to people in care.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Administrator will read section 87465(g) and send letter to LPA by POC date stating she understand section 87465(g) and what Administrator will do to prevent this from happening again. .

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alberto Lopez made unannounced visit for a complaint investigation and met with Administrator Joy Lourdes VillaFlores and discussed purpose of this CM report. LPA and Administrator observed ants and spiders in residents room that pose a health and safety hazard to resident. deficiency cited on 809D Exit interview and copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 1, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 4, 2024

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by; LPA and Administrator observed ants, spiders and spider webs in residents room which pose/poses a health and safety hazard to people in care.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Administrator will do a deep clean and send LPA proof in form of pictures and write a statement that the ants and spiders have been addressed and no longer in resident's room or facility.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with administrator Joy Villaflores and the purpose of the visit was explained. The following CARE tools domains were utilized during the inspection. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Visitors are no longer screened for COVID-19 or required to sign in. The facility has an Infection Control Plan and COVID-19 Mitigation Plan. Physical Plant/Environment Safety: The facility is a single-story house located in a residential neighborhood. Facility has three resident rooms; room #2 #3 and #5. Resident room #5 contains a private bathroom, three staff rooms; room #1, #4 and #6. Room #4 contains a private restroom for staff. There is (1) common bathroom for all residents to use. Total bathrooms is (3). Facility has a dining room, a kitchen, a front and back yard patio area which held a storage shed and the facility’s washing and drying machines, and an attached garage which held the facility’s emergency food supply and cleaning supplies. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Water temperatures measured within Title 22 requirements. The facility has one (1) fully charged fire extinguisher. Operational Requirements: The facility has a Dementia Waiver on file. A Hospice Waiver for up to (1) Resident is approved. Facility as an approved fire clearance to serve total of six (6) residents age 60+ of which four (4) may be non-ambulatory. Required Liability Insurance is in place. A surety bond is not applicable. Facility does not handle resident's money. Continued on LIC 809-C Incident Medical and Dental: LPA reviewed medications for three (3) Residents. 30-day supply of resident medications were observed. The medications are centrally stored in locked cabinet. Centrally Stored Records for medications are kept. Medication stored matches the medication record for each resident. Staffing: Sufficient caregiver staff provide care and supervision to the residents. Personnel Records/Staff Training: Administrator certificate is current. Personnel files were reviewed. LPA reviewed a total of three (3) Staff files. LPA observed required documents for each. Proof of staff training was reviewed. 1st Aid/CPR records are current. Resident Records/Incident Reports: A total of three (3) resident files were reviewed containing admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment, and emergency information forms were observed. Appraisals on file are over a year old for each resident. Residents Right-Information: RCFE complaint poster and Personal rights were observed and its posted near the entrance. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed. The facility does not have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place and was posted today. There is currently no Dementia resident residing in the facility. Residents with Special Health Needs: No residents receive home health services. Postural support observed. (1) resident with half bed rails. No residents are on hospice. No residents have prohibited health conditions. No residents have restricted health conditions. Per title 22 regulations, a deficiency is being cited on todays visit. Please see attached 809-D page. Exit Interview conducted. Appeal rights discussed. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 20, 2024

Allegation investigated: Staff do not respond to resident's requests for assistance in a timely manner. Staff leave resident in soiled condition for an extended period of time. Staff do not treat resident with respect.

Licensing Program Analyst(LPA) Nicol Wesley conducted an unannounced 10 day complaint visit at the facility and met with Administrator Joy Villaflores to discuss the purpose for todays visit. During the visit, LPA Wesley requested a copy of the staff and resident roster,toured the residents rooms, interviewed the residents, and request copies of specific documents. Regarding allegation- Staff do not respond to resident's requests for assistance in a timely manner. LPA Wesley interviewed 4 out of 5 residents who incated that staff responds to them in a timely manner when they are called. The 5th resident is can not be interviewed, they cant speak and is on hospice. Continued LIC 9099C. Unsubstantiated Regarding allegation- Staff leave resident in soiled condition for an extended period of time. LPA interviewed 4 out of 5 residents who indicated staff does not leave them in a soiled condition for an extended period of time. The 5th resident can not be interviewed, they cant speak and are on hospice. LPA Wesley interviewed the administrator who said resident #1 has an overactive bladder and They went without medication because they canceled their 02/26/24 appointment and the prescriptions were non refillable. Administrator also stated resident #1 enjoys staying outside in the backyard area so they can smoke and when they try to change resident #1, they'll say wait a minute, I'm not done smoking. Administrator also indicated that Resident #1 is always worried about soiling up their diapers and say I only urinated twice, and doesn't want to be changed. Regarding allegation- Staff do not treat resident with respect. LPA Wesley interviewed 4 out of 5 residents who said the staff treats them with respect, resident #3 said if they didn't, I know what to do. The 5th resident can not be interviewed, they cant speak and are on hospice. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of the LIC 9099, LIC 9099C was given during the exit interview.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 28-AS-20240308153616

Allegation investigated: Facility staff are allowing cameras in a resident's room.

Licensing Program Analyst(LPA) Nicol Wesley conducted an unannounced 10 day complaint visit at the facility and met with Administrator Joy Villaflores to discuss the purpose for todays visit. During the visit, LPA Wesley requested a copy of the staff and resident roster,toured the residents rooms, reviewed the medication, and had a conversation with some of the residents. The investigation revealed the following: In regards to Facility staff are allowing cameras in a resident's room. it was revealed that there is a camera is room #2, The Administrator was informed that they know, they can't have a camera in any of the residents room, only the common areas. Continued on LIC 9099C. Substantiated Based on LPA observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations,Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Appeal rights were given. A copy of the LIC 9099/LIC 9099C/LIC 9099D/LIC 9099A was given during the exit interview.the state’s words, verbatim · CDSS document, Feb 2, 2024 · control 28-AS-20240129184828

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 2, 2024

Residents in all residential care facilities for the elderly shall have all of the following personal rights:To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement was not met as evidenced by During the tour of the facilty, LPA observed a camera with audio in resident #2's room, which pose a personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Administrator removed the camera from the resident #1 bedroom during visit. 02/02/24. Licensee/Administrator is to send a letter stating that Licensee will comply with section 87468.1 Personal Rights by not violating the residents privacy and send proof of service that your read this section by POC date 02/09/24.