Amalia's Residence II

Allegation investigated: Facility staff did not provide resident’s medication as prescribed

On 10/28/2025, at 9:00am, Licensing Program Analysts (LPAs) Haner-Tomasko and Rankin arrived unannounced at the facility to conduct a subsequent complaint visit to deliver findings to the above allegation. LPAs met with Licensee/Administrator Dexter Price and explained the purpose of the visit. On 11/26/2024 LPA Rankin conducted the initial complaint investigation, collected documentation, and conducted interviews. On 10/9/2025 LPA Haner-Tomasko conducted a collateral visit for additional interviews and collection of other documents. On 10/9/2025 LPA also conducted an additional visit to this facility to further investigate the complaints listed above, collect additional documents, and conduct interviews. (Continued on LIC9099-C) Substantiated On the allegation, facility staff did not provide resident’s medication as prescribed. It was alleged that during Resident #1’s (R1’s) stay at the facility they were not provided with medications as prescribed by their primary care physician (PCP). Record review revealed R1 moved into this facility on 9/19/2024. R1’s physician orders as of 9/22/2024 reveal R1 was prescribed the following medications: Alpha lipoic acid 600mg one tablet by mouth daily; brimonidine tartrate ophthalmic solution 0.2% one drop into affected eye two times daily; brimonidine tartrate-timolol ophthalmic solution 0.2-0.5% one drop ophthalmically into affected eye two times per day; gabapentin capsule 300mg one capsule orally three times per day; oxybutynin chloride 5mg one tablet orally two times per day; quetiapine fumarate 25mg one tablet by mouth in the morning and two tablets by mouth at bedtime; sertraline 25mg one tablet orally daily; tramadol 50mg one tablet by mouth twice daily; trazadone 50mg one half tablet by mouth at bedtime. The facilities Centrally Stored Medication and Destruction Records (CSMDRs) for R1 list all the medications above except for the alpha lipoic acid prescribed on 9/22/2024. The CSMDRs list gabapentin 300mg filled on 1/2024 with a quantity of 90 and started on 9/19/2024. Records show R1’s PCP sent orders for the alpha lipoic acid and gabapentin to the pharmacy on 10/11/2024, these are not listed on the CSMDR. The facility staff could not provide documentation showing the alpha lipoic acid was ever given as prescribed. The facility could not show documentation of the gabapentin filled on 10/11/2024 was given as prescribed after running out of the medication on hand started on 9/19/2024. R1 moved out of this facility on 11/10/2024 indicating R1 went approximately 22 days without gabapentin from 10/20/2024 to 11/10/2024. Interviews revealed when R1's PCP wrote a new medication order it was sent to JDX pharmacy, JDX pharmacy fills the order and delivers the medication to the facility. Licensee stated they do not know why they do not have documentation of these medications and realizes they should have ensured medications were given as prescribed. Interview and record review reveal R1’s PCP changed their trazadone order to 100mg one tablet by mouth at bedtime on 10/11/2024 and their quetiapine fumarate to 200mg one tablet by mouth at bedtime on 10/08/2024. The facilities Centrally Stored Medication Record (CSMDR) for R1 does list these changes to R1’s medications. LPA verified the remaining medications listed on all CSMDRs received, and all records were found to be accurate. (Continued on LIC9099-C) On the allegation, staff violated resident’s personal rights. It was alleged that facility staff would yell at Resident #1 (R1), “get back in your room,” push R1 back in their room, and take R1’s hearing aids, wheelchair, and walker away from them. It was also alleged that facility staff had a catheter placed in R1 because they did not want to change R1. Regarding R1’s catheter, LPA record review and Interviews reveal that on 10/18/2024 a foley catheter was placed in R1 by a home health nurse with an order from R1’s primary care physician (PCP). The catheter was placed due to staff reporting that the resident had not urinated in approximately 8 hours. On 10/9/2025 LPA attempted to interview R1 and was unable due to their current medical conditions. Regarding staff mistreatment of R1, LPA interviews revealed one witness who heard staff raising their voice at R1 while speaking with R1 over the phone. Additional visitor interviews revealed no observation or hearing of staff mistreating the residents or taking their personal devices. Staff interviews reveal that sometimes they need to raise their voice to be heard by residents, but they do not yell at them in a mean way, push them or take their things. Resident interviews reveal that staff have raised their voice when residents are hard of hearing, but residents have not heard or witnessed staff ordering residents around or taking their personal devices from them. Although the evidence obtained during this investigation did not meet the threshold for a citation, the facility has a history of similar complaints regarding staff interactions with residents and visitors, suggesting an ongoing concern that the licensee is encouraged to monitor and address. LPA reviewed Title 22, Division 6, Chapter 8, Article 08, regulation 87468.1(a)(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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.” Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. On the allegation, staff did not safeguard a resident’s personal belongings. It was alleged that after facility staff took R1’s hearing aids from them the hearing aids were never found. Review of a physician report dated 1/30/2024, approximately eight months prior to R1 moving into this facility, states R1 has hearing aids for auditory impairment and the report was signed by a physician R1 had been seeing for approximately six months. A physician report dated 10/23/2024 states R1 does not have auditory impairment and was signed by a different physician who R1 had been a patient of for approximately two months. (Continued on LIC9099-C) Interviews revealed that Staff #1 (S1) conducted the preplacement assessment of R1 at R1’s previous place of residence prior to moving into this facility. S1 stated that they never saw any hearing aids during visits to R1’s previous residence, no one ever mentioned hearing aids at the time and when R1 moved into this facility no hearing aids were documented or seen in R1’s personal belongings. Review of R1’s Resident Personal Property and Valuables (RPPV) form reveals a list of approximately 27 of R1’s personal items brought to the facility on the day they arrived, 9/19/2024. Hearing aids are not listed on R1’s RPPV. Interviews revealed the missing hearing aids were found on 12/20/2025 in a box of R1’s personal belongings that was moved with R1 out of this facility to their new place of residence on 11/10/2024. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated. On the allegation, staff did not assist resident with medical appointments. It was alleged that the facility was not taking R1 to their physician appointments, including the eye doctor. R1 moved into this facility on 9/19/2024. Staff interviews reveal that when R1 moved into the facility they had previously seen a different PCP, R1 wanted a new PCP, and facility staff helped R1 find one. Review of Central Coast Home Health and Hospice (CCHH) records for R1 reveal a referral for home health nursing was sent to CCHH by R1’s new PCP on 9/22/2024. R1 was seen by a home health nurse approximately 5 times while in care at this facility. On 10/9/2025 LPA attempted to interview R1 regarding their medical care while at the facility but was unable due to their current medical conditions. Staff stated they attempted to contact R1’s eye doctor but were unable to schedule R1 an eye appointment before R1 moved out of the facility on 11/10/2024. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, report signed, and report provided to Licensee/Administrator Dexter Price. Based on all interviews conducted and documents obtained, since the facility did not provide R1’s alpha lipoic acid and gabapentin as prescribed, at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, deficiencies cited on LIC9099-D page, report signed, appeal rights and report provided to Licensee/Administrator Dexter Price.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 29-AS-20241122092857

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 11, 2025

Incidental Medical and Dental Care (a) A plan for incidental medical... care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not provide R1’s medications as prescribed which poses a potential Health, Safety, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Licensee stated they will update/create a procedure to ensure new or changed medication orders are given as prescribed, including a physician visit form to document these medication changes and email these documents to the LPA on or before 11/11/2025.

Allegation investigated: Staff did not give a copy of the admission agreement to the authorized representative

Licensing Program Analysts (LPAs) Rankin and Haner-Tomasko conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Dexter Price and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 10/18/25, where LPA conducted interviews with administrators and obtained relevant documents. Collateral visit was made on 10/17/25 and additional documents were reviewed and relevant documents collected. Interviews with witnessing parties were held on 10/17/25, 10/21/25, and 10/23/25. Continued on 9099-C Substantiated On the allegation: Staff did not give a copy of the admission agreement to the authorized representative It was alleged by reporting party that a copy of the documents signed, including the admission agreement, was not provided to them. Licensee stated they give the representatives the binder with the agreement to review and sign, so they have time to review documents when the documents are returned, if the representative asks for a copy the facility provides a copy, but stated, if they didn’t ask for a copy, then the facility does not provide copies. Licensee was unsure if representative asked for a copy. Title 22 regulations 87507 (e) states “The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative… immediately upon signing the admission agreement…” Based on interviews conducted, the administrator was not certain if copies were given and the representative stated they were not provided with copies of admissions agreement paperwork. At this time the above allegation was found to be substantiated. Copy of report and Appeal Rights issued at the time of the visit. On the allegation: Staff denied visitation during mealtime It was alleged that visitors would be asked to leave during mealtimes. The response of being asked to leave during mealtime was consistent with those interviewed. LPA reviewed the visiting policy hanging on the wall as well as the admission agreement, both state visits is from 9 am to 8 pm. Licensee stated the residents like to eat together, and it is for the rights and comfort of other residents that they do not have visitors join at the table. Licensee stated that families can have meals with their resident if they want, but it would be done away from the main table. Licensee stated that the family wanted Resident 1 (R1) to join the other residents during meals so licensee would ask the visitors to leave. Those interviewed did not state that visitors were required to leave, but that the visitors believed it was a rule and did not push to stay. Alternatives such as the option to stay and eat privately in the rooms with residents were not mentioned when LPA asked about alternatives. Interviews were consistent, in that they would be told it was mealtime and they would be asked to leave. Visitors stated that the “contract…states that between 11 – 12 lunch and 4 – 5 dinner, they want the residence to eat meals together.” LPA could not find documentation to support this rule. Although information obtained through interviews and discussions during this investigation did not meet the threshold for a citation, the facility has a documented history of similar complaints regarding visits and staff interactions with residents and visitors. This ongoing pattern raises significant concern and underscores the need for the licensee to actively monitor, and address staff conduct to ensure a respectful and safe environment. The facility is reminded of Health and Safety code 1569.313 which states: The facility's policy concerning family visits and communication shall be designed to encourage regular family involvement with the resident client and shall provide ample opportunities for family participation in activities at the facility. Based on admission agreement verbiage, signage, and interviews, the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Continued on 9099-C pg2 On the allegation: Facility staff did not assist resident with medications as prescribed It was alleged that medication was not given as prescribed, that trazadone medication was missing when given to the new facility, which caused concerns of overmedicating R1, that over-the-counter medications such as a laxative was given to resident without physician’s order. On 10/17/25 LPA collected Centrally Stored Medication and Destruction Record (CSMDR) from facility, then LPA conducted a collateral visit to the new facility and was able to review bottle 1 of trazadone medication that was listed on the CSMDR from the first facility. The medication counts for bottle 1 was correct. LPA noted that bottle 1 stated there were 3 refills and realized that new facility had a new filled order that stated 1 refill. The allegation stated that a 90-count bottle of Trazodone (Bottle 2) was delivered to the original facility on 9/29/25 but was not transferred to the new facility, raising concerns of potential over medication. On 10/18/25, LPA contacted the original facility to recheck the medication inventory. Bottle 2 was located, an image was sent to LPA, images shows filled 9/25/25 with 2 refills remaining, Rx # matches. LPA requested bottle 2 be taken to new facility, which was done and subsequently by 1:00 pm on 10/18/25. The receiving facility confirmed the bottle contained the full 90-count as prescribed. LPA also verified the remaining medications listed on the CSMDR, and all records were found to be accurate. At this time, all medication is accounted for. Based on record reviews and documentation obtained, the prescribed medication was administered as ordered. At this time, there is a lack of evidence indicating that any non-prescribed medication was given. Therefore, the above allegation is determined to be unsubstantiated. On the allegation: Staff violated residents personal rights It was alleged that staff neglected resident which led to resident getting a pressure wound, and edema’s, further concerns noted regarding declining in abilities, such as patient was able to walk and feed themselves prior to entering the facility. It was also alleged that administrator was not professional when handling and dealing with R1 and R1’s family members. Continued on 9099-C pg3 Documentation regarding pressure wound and walking difficulties: Face sheet from Health Center dated 2/3/25 stated “Pressure-induced deep tissue damage of sacral region” also noted “muscle wasting and atrophy…Difficulty walking.” Note from Initial home visit by physician dated 9/10/25, states “Pressure Ulcer of Sacral Region, Stage 1” also notes R1 is “able to ambulate with assist, but mostly wheelchair bound.” Intake Physical Therapy notes for 9/12/25, “significant mobility impairments requiring max-mod assistance. High fall risk with unsteady gait and weakness in extremities. Can only ambulate 5 feet with [front wheeled walker] and assistance.” Notes from Skilled Nurse evaluation on 9/15/25 says “wound care for stage 1pressure ulcer” note on 9/22/25 and 9/26/25 states “Wound Care no longer needed, Storage 1 pressure ulcer has resolved.” Interviews with family state R1 was able to feed themself and walk prior to being admitted to facility on 9/11/25. Review of health professionals’ documentation starting in February of 2025 through September of 2025 show R1 was limited in mobility, able to walk no more than 3 - 5 ft and requiring transfer assistance and mostly wheelchair bound. Documentation and interview with health agency notes that with facilities care, the wound healed within 2 weeks of admittance. Regarding staff being unprofessional, interviews state that administrator would be upset when asked to change R1, when questioned regarding care, and when visitors remained close to mealtimes. Although information obtained through interviews and discussions during this investigation did not meet the threshold for citation, the facility has a documented history of similar complaints regarding staff interactions with residents and visitors. This ongoing pattern raises significant concern and underscores the need for the licensee to actively monitor, and address staff conduct to ensure a respectful and safe environment. The facility is reminded of 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (8) To be free from…humiliation, intimidation, and verbal…abuse and (21) To consent to have their relatives and other individuals of their choosing visit during reasonable hours, privately, and without prior notice. Continued on 9099-C pg4 Based on interviews, record reviews, and documentation obtained, there is sufficient information from external agencies indicating that the medical concerns referenced in the allegation were ongoing prior to the resident’s admission to the facility. While the allegation regarding unprofessional staff conduct may have occurred, there is not a preponderance of evidence to determine whether the alleged violation did or did not take place. Therefore, the allegation is deemed unsubstantiated at this time. On the allegation: Staff put resident on a special diet without physician orders It was alleged that without physician orders R1 was put on a pureed diet. LPA interviewed licensee who was able to provide doctor orders for 9/17/25 that state “... change diet to pureed food.” Speech Therapy notes on 9/15/25 stated “Recommend downgrade of diet consistencies to pureed solids and nectar thick liquids. Also notes “Discussed pts status and POC with pts… [family relation noted, representative name noted].” Based on record reviews and documents obtained, at this time the above allegation was found to be unsubstantiated. On the allegation: Staff left resident in soiled briefs It was alleged that during a visit with a family member the family member noticed the smell of feces. Family members alleged they were there for a while and no one came to check on the resident until family member asked for the resident to be changed. Interview with licensee, they stated that they try multiple times a day to change residents, many residents are able to use the restroom. The licensee was unsure of what visit the allegations were referring to because R1 had many visits from family members over the short time they were there. Interview with witness stated they did not notice any odors or concerns while visiting resident. LPA also noted that facility and residents were free of odors and residents appeared clean and dry as they moved about the facility. Continued on 9099-C pg 5 Interviews only provided one occurrence where this was observed for R1. All other interviews did not stated other occurrences. Based on interviews, there is insufficient evidence to show that the resident was left in soiled briefs. There is no indication that this occurred frequently or over extended periods of time. Therefore, at this time, the above allegation is found to be unsubstantiated. Exit interview conducted, copy of report printed.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 29-AS-20251016095337

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Nov 14, 2025

87507 Admission Agreements (e)The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative...immediately upon signing the admission agreement or modification. This requirement is not met as evidenced by: Based on interviews, and record reviews, the licensee did not comply with the section cited above in that a copy of the admission agreement was not provided to the resident or representative which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Administrator will mail a copy of the admission agreement and all subsequent signed documents to the residents representative, all future residents/representatives will recieve copies immediately upon signing the admission agreements.

Type of visit: Required - 1 Year

At 10:38am, on 10/9/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Licensee/Administrator Dexter Price, announced who he was and the reason for the visit. Licensee and LPA conducted a full tour of the facility. This facility is a two story residential home. On the first floor there are four resident bedrooms (two are single occupancy, two are dual occupancy) and one full shared/public bathroom. There is a living room, dining area, and a kitchen. Access to the laundry room and garage is through locked exterior doors for resident safety. The second floor is for staff only and contains three staff bedrooms and a full bathroom. LPA noted that the backyard has seating and shade for residents and visitors. LPA noted fresh fruit and snacks on the dining table for residents to enjoy freely. The facility has battery operated dual smoke/carbon monoxide detectors in each room that are all working. LPA observed a fire extinguisher near the dining area that was tagged current and in the green compression range, serviced on 4/18/2025. LPA tested facility hot water at 110*(f), within regulation temperatures 105*-120* (f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility is clean and in good repair with no obstructions in hallways, doorways or exits. Staff/resident files and medications are locked in a cabinet in the dining area. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records, finding no violations. LPA conducted a staff and resident file review. LPA and Licensee conducted a review of the annual care tool modules. There were no deficiencies cited at this time. Exit interview conducted, report signed, and report provided to the Licensee.the state’s words, verbatim · CDSS document, Oct 9, 2025

The state marks this report as 8 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erika Miller and Licensing Program Manager (LPM) Kelly Burley arrived at 10:30 a.m. to conduct a 1-year required annual visit. LPA met with Dexter Price, 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 and LPM were authorized to enter and inspect facility. LPA toured resident rooms and 1 vacant room 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 non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside 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 January 31, 2024. The facility has smoke and carbon monoxide detectors that were tested and inspected. Continued 809-C 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 7/1/25. The facility is approved for a capacity of 6. The fire clearance is granted for 6 non-ambulatory of which 1 may be bedridden. Hospice waiver approved for 4 residents. The facility currently has 3 non-ambulatory residents and 1 hospice. Staffing: The facility currently employs 3 full time staff 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 4/18/25. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023 and 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 3 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, (TCRC IPP) Emergency and ID forms, all forms were legible, and records are kept confidential. 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 thCentrally 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. The facility last conducted a quarterly disaster drill/training on July 20, 2024. 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, Sep 10, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.