Atienza Residential Care

Allegation investigated: Staff did not answer residents calls for assistance timely Staff did not intervene when resident hit another resident

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to deliver findings on a complaint investigation regarding the above allegations. LPA met with Caregiver Rose Penilla and discussed the purpose of the visit. Regarding Allegation #1, that staff did not answer residents’ calls for assistance in a timely manner, LPA was unable to interview Staff #1 (S1) as they are no longer employed at the facility. However, interviews with current staff and the Administrator indicate that staff respond to residents’ calls for assistance in a timely manner. Regarding Allegation #2, that staff did not intervene when one resident struck another, interviews with staff and outside parties revealed that Staff #1 (S1) was also struck by Resident #2 (R2) while attempting to intervene in the altercation between R1 and R2. Additional staff interviews confirmed that when an altercation is observed, it is staff’s duty to intervene Based on LPAs observations, record review, and interviews, the above allegations are Unsubstantiated; meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and a copy was provided to Caregiver Rose Penilla at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 21, 2026 · control 56-AS-20260319083310

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: May 22, 2026

87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility...(2)The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation... to the nearest available medical...facility which will meet the resident's need...The facility did not meet this requirement Licensee/Administrator did not comply with the regulation above by not providing medical care to R1 after being struck in the back by another resident, which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Administrator will conduct training to all staff reviewing the regulation and provide proof of training and understanding with signatures to LPA by POC due date

Allegation investigated: Facility staff are not properly trained to meet the needs of the clients Staff are not properly assisting residents with personal hygiene Staff are not meeting residents dietary needs

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to deliver findings on a complaint investigation regarding the above allegations. LPA met with Caregiver Rose Penilla and discussed the purpose of the visit. Regarding Allegation #1, that facility staff are not properly trained to meet the needs of the clients, a review of staff training records indicates that staff have received the required training to meet client needs. LPA did not observe any staff who appeared unable to perform their duties or meet client care requirements. Regarding Allegation #2, that staff are not properly assisting residents with personal hygiene, interviews with staff revealed that most residents receive hygiene assistance through home health services. However, staff stated they provide assistance upon resident request and when it is observed to be necessary. Regarding Allegation #3, that staff are not meeting residents’ dietary needs, interviews with staff indicated they follow residents’ prescribed dietary requirements. Based on LPAs observations, record review, and interviews, the above allegations are Unsubstantiated; meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and a copy was provided to Caregiver Rose Penilla at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 21, 2026 · control 56-AS-20250527140213

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(2) · Plan of correction due date: May 22, 2026

87615 Prohibited Health Conditions (a) Persons who require health services...shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes. This was not met as evidenced by: Based on interviews, the Licensee did not comply with the section cited above by accepting a resident with a prohibited health condition, which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Administrator will conduct a training with staff and read the regulation being cited provide proof of training with signatures to LPA by POC due date

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Caregiver Rosalinda Penilla, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (1). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility does not have a swimming pool or similar bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities. The facility is equipped with operating smoke detectors/carbon monoxide alarms, working laundry equipment, and telephone service. The facility does not have charged fire extinguishers, the two (2) on display are dated from year 2020, deficiency issued. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in one (1) resident bathroom measured 124 degrees F, with a sign stating the hot water measures over 120 degrees F. Three (3) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting, however closet doors in bedrooms #2 & #4 are in disrepair; deficiency issued. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, emergency telephone numbers, resident rights, facility hours, menu, activities, CCLD complaint poster, and Ombudsman poster. Continuation on LIC – 809C: Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient perishable food supply for residents in care, LPA observed expired non-perishable foods, deficiency issued. Sharps were not kept locked and inaccessible to residents in care, deficiency issued. Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff working had a current CPR/first aid training. Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet, no MAR or documentation showing centrally stored medication for resident #1 (R1) and when PRN was administered, deficiency issued. Record Review: One (1) Staff file reviewed was observed to be complete. One (1) Resident file reviewed was observed to be incomplete, a needs and service plan missing, deficiency issued. Caregiver was unable to provide liability insurance, disaster drills, first aid kid and manual, infection control plan, emergency disaster plan, deficiencies issued. Based on observations and record review deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report along with LIC 809D, and Appeal Rights were discussed and provided to Caregiver Rosalinda Penilla at the conclusion of the visit. .the state’s words, verbatim · CDSS document, Mar 25, 2026

Allegation investigated: Staff did not ensure that resident's room was free of pests Resident sustained bed sores due to staff improper care Staff refused to assist residents with diaper changes The Administrator is at the facility an insufficient amount of hours

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conclude the complaint investigation on the above allegations. LPA met with Caregiver, Rosalinda Penila, who was informed of today’s visit. The investigation consisted of LPA observations, reviewing pertinent records, and interviews with relevant parties. Regarding the allegation, Staff did not ensure that resident’s room was free of pest, two (2) residents interviews indicated that they have no pest in their bedrooms. The Administrator and three (3) staff interviews indicate that they do ensure resident’s rooms are free from pest. The licensee maintains a monthly service contract with a pest control company to ensure the facility is free of pest. Regarding the allegation, resident sustained bedsores due to staff improper care, review of Resident #1 (R1s) medical records and outside party interviews indicate not enough evidence to corroborate the allegation. R1 had been assessed with bedsores/wounds prior to being admitted into the facility and hospice provided wound care. Unsubstantiated Regarding the allegation, staff refused to assist residents with diaper changes, two (2) resident interviews indicate that there is enough evidence to corroborate the allegation that staff refused to assist residents with diaper changes. The Administrator and three (3) staff interviews indicate that they have not refused to assist residents with diaper changes. Regarding the allegation, the Administrator is at the facility an insufficient amount of hours, two (2) resident interviews indicate that the Administrator is present at the facility for a sufficient number of hours. The Administrator and three (3) staff interviews indicate that the Administrator is present at the facility for a sufficient number of hours and, when not at the facility, is available via telephone. Based on the Department’s investigation, the allegations are Unsubstantiated. A finding of Unsubstantiated means that 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. An exit interview was conducted where this report was discussed and a copy with appeal rights was provide to Caregiver Penila at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 56-AS-20250324120036

Allegation investigated: Facility does not provide adequate amount of incontinence supply

Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPAs met with Caregiver Rose Pinella, and discussed the purpose of the visit. Regarding Allegation above, LPA Serrano toured the facility and observed a sufficent amount of incontinence supplies. R1 receives incontinence supplies provided by Veterans Adminstration (VA). Based on LPAs interviewed two (2) of the three (3) residents receive incontinence care. Based on LPA’s observations, staff and resident interviews, and relevant documentation, the allegation is determined to be Unsubstantiated. An Unsubstantiated finding means that although the allegation may be valid or could have occurred, there is insufficient evidence to support that the alleged violation did or did not happen. An exit interview was conducted with Caregiver Rosalinda Pinella, and a copy of this report was provided at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 25, 2025 · control 56-AS-20251124133424

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Dec 1, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical... shall be developed by each facility...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. Licensee/Administrator did not comply with the regulation above by not having a Medication Administration Record (MAR) for all residents which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Licensee will submit proof of tracking distribution for all three (3) residents and train all staff in medication distribution and provide to LPA by POC due date

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Sarina Ramirez and Mary Rico conducted a health and safety visit to the facility. LPAs met with Staff, Rose Penilla, and informed the purpose of the visit. LPAs observed four (4) residents and two (2) staff at facility, one (1) resident was out in the community with S4. Based on record review S4 is not associated to the facility, citation and civil penalty issued. LPAs conducted a tour of the inside and outside of facility. The facility has sufficient food supply for residents, however LPA observed expired non perishable foods; deficiency issued. Air conditioning and bathroom equipment is running properly, however LPAs observed dirty water from the residents shower head and sink faucet. The facility does not have clean running water for the residents. In addition, the hot water measured over 120 degrees F, citation issued. Staff working stated that Adam Barone does not work or live at the facility. Resident files were not available for review, citation issued. LPA observed roaches in the main hallway near the dining room, citation issued. After reviewing the facility's floor plan, LPAs observed the Licensee converted their living room into a staff bedroom. During staff interviews S1 and S2 confirmed they sleep in the living room. Furthermore, the Licensee also converted resident's room number 1 into a personal bedroom for Licensee family, citation issued. Based on record review family member/S3 does not have a criminal record clearance, citation and civil penalties issued. An exit interview was concluded where this report, LIC 809D, LIC421BG, and Appeal Rights were discussed and a copy was provided to Administrator Caroline Armstrong at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87412(g) · Plan of correction due date: Sep 20, 2025

87412 Personnel Records (g) All personnel records shall be maintained at the facility. Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having personnel records for Residents 2,3,4,&5 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee has agreed to provide LPA with all required documents for all residents by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(a) · Plan of correction due date: Sep 19, 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 ... All food shall be selected, stored, prepared and served in a safe and healthful manner. Based on observation, interview, and record review, the licensee did not comply with the section cited above by having expired non perishable foods which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: LPA had Caregiver toss the expired food LPA observed, Licensee has agreed to go through the rest of the pantry to toss out anymore expired non perishable foods and conduct a training for all staff and provide proof to LPA by due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Sep 20, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on observation, the licensee did not comply with the section cited above, by having live crockroaches in the main hallway near the dining room and not ensuring resident shared bathroom is providing clean water which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee has agreed to call a pest control company to conduct an inspection and a plummer to inspect the facilities water and provide a schedules appointment along with an invoice to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(e)(3) · Plan of correction due date: Sep 20, 2025

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. Based on observation the licensee did not comply with the section cited above by not identifying tap water that delivers water above 125 degree F by warning signs which poses/posed a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee stated to put a warning sign on tap water that delivers hot water above 125 degree F and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a) · Plan of correction due date: Sep 20, 2025

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: Based on observation and interviews, the licensee did not comply with the section cited above by using the living room and a residents' bedroom as a staff bedroom/living area which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee has agreed to clean the living room and staff befroom to it's original state reflecting the floor plan.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(2) · Plan of correction due date: Sep 20, 2025

87303 Maintenance and Operation(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained ...a temperature of not less than 105 and not more than 120 degree F. Based on observation the licensee did not comply with the section cited above by not ensuring the hot water temperature maintained 105 and not more than 120 degree F which poses/posed a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee has agreed to adjust the water temperature to ensure it is in complaint of 105 to 120 degree F and provide proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87355(e) · Plan of correction due date: Sep 20, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Based on observation, record review, and interviews the Licensee did not comply with the section cited above by not having a background clearance for S3the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee will obtain a background clearance for S3 and provide proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC87355(e)(4) · Plan of correction due date: Sep 20, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review ...(4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. Based on observation, record review, and interviews the Licensee did not comply with the section cited above by not having S4 associated to the facilitythe state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee has agreed to associate S4 to the facility and provide proof to LPA by POC due date.

Allegation investigated: Staff were over medicating resident

On 09/15/2025 at 9:30AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegation. LPA discussed the purpose of the visit with staff and staff contacted Licensee/Administrator Caroline Armstrong via telephone and the Administrator arrived at the facility later. LPA observed two (2) staff and four (4) residents in care during the visit. In regards to the allegation of staff were over medicating resident: LPA interviewed three (3) staff and (3) residents. Staff denied over medicating resident(s). Staff stated that the Administrator will administer medication or staff give the medication according to the physician's orders. LPA did not observe Resident 1's (R1) files or any medication records. The Administrator stated that they would have the staff look for the file, however staff was unable to provide it for review. LPA also interviewed relatives of R1 and was not able to obtain documentation to futher support the allegation. Based upon interviews, record review and insufficient information, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 was discussed and a copy was provided to staff. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 15, 2025 · control 56-AS-20240911092746

Type of visit: Case Management - Deficiencies

On 09/15/2025 at 11:30AM Licensing Program Analyst (LPA) arrived unannounced to the facility to conduct a case management visit. LPA identified self, met with staff Rosalinda Pinella, stated the purpose of the visit and the Administrator Caroline Armstrong was informed of the visit via telephone and arrived at the facility later. During the course of the investigation of complaint #56-AS-20240911092746, LPA observed that the Administrator/Licensee Caroline Armstrong did not report the death of resident 1 (R1) to the Department, the resident file for R1 was not at the facility and available for review, and there was no record of staff training on hospice. In addition, during today's visit, LPA observed the medication cabinet to be unlocked. Four (4) deficiencies were cited during today's visit. An exit interviews was conducted where this report LIC809, LIC809D, and Appeal Rights were discussed and copies were provided to Administrator, Caroline Armstrong.the state’s words, verbatim · CDSS document, Sep 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Sep 16, 2025

Incidental Medical and Dental Care 87465(h)(2) The following requirements shall apply to medications: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible... This requirement was not met as evidenced by: Based upon observation, LPA requested to audit medications and observed the medications cabinet to be unlocked. The staff did not ensure that the centrailly stored medications were locked and inaccessible to residents, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Administrator will conduct a staff training on centrally stored medications, review section 87645 and sign a Statement of Understanding and submit proof to LPA by the Plan of Correction due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87633(f)(1) · Plan of correction due date: Sep 16, 2025

87633 Hospice Care of Terminally Ill Residents (f) The licensee shall maintain a record of all hospice-related training provided... (1) The record of each training session shall specify the names... This requirement was not met as evidenced by: Based upon record review, LPA did not observe staff training specifically related to hospice care. The facility did not ensure that staff were trained in hospice care which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Administrator will make arrangements with the Hospice agency to provide training for staff and submit proof to LPA by Plan of Correction (POC) due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(1)(A) · Plan of correction due date: Sep 19, 2025

87211 Reporting Requirements(1)(A) (1) A written report shall be submitted to the licensing agency... (A) Death of any resident from any cause regardless of where the death occurred... This requirement was not met as evidenced by: Based upon record review, LPA did not observe a Death Report. The Administrator did not ensure that the death reporting requirements were followed which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: The Administrator will review the Reporting Requirements and submit a Statement of Understanding to LPA by Plan of Correction (POC) due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Sep 19, 2025

87506 (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a centrally... This requirement was not met as evidenced by: Based upon a request to review records, LPA observed a few of the current resident files but not the requested file. The facility did not ensure that all residents files were available for review which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Administrator will locate Resident 1 (R1) file and provide a copy to LPA by Plan of Correction (POC) due date.

Allegation investigated: Staff did not properly maintain facility sinks

On August 18, 2025, Licensing Program Analyst (LPA) Eldin Serrano visited the facility to investigate the mentioned allegation and deliver findings. LPA met with Caregiver Rosalinda Pinella to discuss the purpose of the visit. The investigation consisted of observation and interview of staff. The allegation indicates that Staff did not properly maintain facility sinks. LPA observed that the faucets on the facility kitchen sink and resident bathroom sink are both leaking water. Interview with staff revealed that both faucets were leaking for a while and the landlord fixed it but now the faucet is back to leaking again. Citation will be issued. Based on observation and interview, the preponderance of evidence standard has been met, therefore, the allegation is substantiated under the California Code of Regulations (Title 22, Division 6 & Chapter 1). An exit interview was conducted, where this report, LIC9099, and LIC9099D along with appeal rights, were provided to the Caregiver Rosalinda Pinella. Substantiatedthe state’s words, verbatim · CDSS document, Aug 18, 2025 · control 56-AS-20250812104335

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a) · Plan of correction due date: Aug 29, 2025

80087(a)Buildings and Grounds:(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by: Based on observation the faucets on the facility kitchen sink and resident bathroom sink are both leaking water. The licensee did not ensure that the faucets are in good repair for the safety and well being of clients, employees and visitors.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: The licensee will submit proof that the facility kitchen sink faucet and residents bathroom sink faucet are fixed. Licensee will provide receipts/invoice from a licensed plumber that both faucets are fixed on the plan of correction (POC) due date.

Allegation investigated: Staff do not keep the facility clean a sanitary Staff do not provide residents with comfortable living accommodations Staff does not provide resident's medication as prescribed

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto spoke with licensee Caroline Armstrong, who was unable to arrive and designated staff Remi Gallego to address the matters during this investigation. LPA Prieto toured the facility and interviewed resident #1 (R1), R2, R3, and R4 as well as staff #1 (S1) and S2. LPA observed that the dresser drawers in R1's room does not close, scuffs on the walls and stained carpet. LPA also observed a small roach in the bedroom of R1. LPA observed a poorly repaired door T strike plate. LPA observed spiders and their webs in the corners of the living room walls, broken door stopper in the bedroom of R2. LPA observed a plastic drawer in room of R3 and R4 that was not in good repair. Facility entrance door has old painter's tape with dirty baseboards. Substantiated Review of R1's medication reveals that R1 is not receiving two medications as prescribed. Facility staff did not refill medication for R1, causing R1 not to sleep comfortably through the night. Interview with R1 concurred the the medication was not refilled and not taken. Based on LPA’s observations and interviews which were conducted by Javier Prieto, the preponderance of the evidence standard has been met, therefore the above allegation is found to be Substantiated, California Code of Regulations Title 22 is being cited on the attached LIC 9099D. This report was signed by LPA Prieto and staff Delledo and a copy was left at the facility.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 56-AS-20250328140322

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 14, 2025

Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: LPA observed facility bedrooms with scuffed walls, dirty carpets, spiders and webs. LPA observed one small roach during inspection. Facility entrance door as dirty baseboardsthe state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: Licensee to clean and sanitized facility by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Apr 11, 2025

Personal Accommodations and Services The following space and safety provisions shall apply to all facilities: The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by: LPA observes broken dresser drawers, broken picture frames, broken door stops. LPA also observed poorly repaired door slate plate.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: Licensee to repair or replace items mentioned in this report by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(4) · Plan of correction due date: Apr 7, 2025

Incidental Medical and Dental Care The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by. Interview with R1 and medication review would reveal that medication Clonazepam and Trazodone were not refilled and not dispensed.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: Licensee to refill R1's medication and dispense medication by POC date. Proof to be texted to LPA.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Caregiver Rosalinda Penilla, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (4). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility does not have a swimming pool or similar bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities, however after observation and interviews no planned activities are implemented; deficiency issued. The facility is equipped with operating smoke detectors/carbon monoxide alarms, working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in one (1) resident bathroom measured 113 degrees F. Three (3) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, administrator certificate, facility sketch, emergency disaster plan and telephone numbers, CCLD complaint poster, and Ombudsman poster. Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient perishable food supply for residents in care, LPA observed expired non-perishable foods, deficiency issued. Sharps and chemicals were not kept locked and accessible to residents in care, deficiency issued. Continuation on LIC – 809C: Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff do not have current CPR/first aid training, deficiency issued. Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet, no MAR or documentation showing when medication was administered, deficiency issued. Record Review: Four (4) Staff files reviewed were observed to be incomplete, deficiency issued. Four (4) Resident files reviewed were observed to be incomplete, deficiency issued. Based on observations and record review deficiencies and technical assistance were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report along with LIC 809D, LIC 902, and Appeal Rights were discussed and provided to Caregiver Rosalinda Penilla.the state’s words, verbatim · CDSS document, Mar 11, 2025

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On September 17, 2024, LPAs Bernadette Allen and Lavette Farlow conducted an unannounced visit to investigate COMPLAINT CONTROL NUMBER: 56-AS-20240911092746 and during this visit, the following deficiencies were observed: During the investigation LPA requested files for staff members Rosalinda Antonio Penela and Carmelita Belveder Dedivas that could not be provided. LPA also requested files for residents R1, R2, R3, and R4 which were incomplete or could not be provided. LPA requested the special incident report LIC624 for the death of R1 which could not be provided during the visit. LPA informed the licensee by phone and support staff that Incident reports are required within 7 days of each occurrence. LPAs also observed medications were not in their original packaging and was being transferred between containers. LPA verified prior to the visit that the facility fees are not current and must be paid in full. Based on interviews and observations, citations will be issued for the licensee not having staff associated/cleared to work in the facility, not reporting incidents of the residents in care, for not having files for residents or staff members, for not having facility fees paid and for transferring medications between containers. LPA informed the licensee Caroline Armstrong by phone that she will be called in for a non-compliance meeting at the San Bernardino Regional office. An exit interview was conducted where this report was discussed and provided to staff member Rosalinda Penela at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Oct 2, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a)-(e) · Plan of correction due date: Oct 7, 2024

(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 This requirement is not met as evidenced by: LPA request files for resident 1, 2, 3, & 4 that could not be provided or the file was not complete for review. This is a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: The licensee has agreed to provide complete files for R1, R2,R3 ,R4 The administrator has also agreed to provide a written statement of understanding of the cited regulation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)-(b) · Plan of correction due date: Sep 30, 2024

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 ..... This is requirement is not being met as evidenced by: LPA requested special insident reports for R1 and R4 and there were no reports available for review. This is a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Licensee has agreed to provide incident reports for R1 and R4. The administrator has also agreed to provide a written statement of understanding of the cited regulation signed by all staff members.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a)-(h) · Plan of correction due date: Oct 7, 2024

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (h) All personnel records shall be retained for at least three (3) years following termination of employment....This requirement is not met as evidenced by: During the visit LPA Allen requested personnel files that could not be provided. This is requirement is not being met as evidenced by: S1 and S2 did not have a file for review. This is a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: The licensee has agreed to provide complete files for all staff members eligible to work at the facility. Administrator has also agreed to provide a statement of understanding of the cited regulation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87156(a) · Plan of correction due date: Oct 7, 2024

(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This is requirement is not being met as evidenced by: LPA noted that annual fees have not been paid.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: The licensee has agreed to pay facilitiy fees by the POC date and provide proof that fees have been paid.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(a) · Plan of correction due date: Oct 7, 2024

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, resident... This requirement was not met as evidenced by: LPA observed two staff members who were not associated to the faciity.Rosalinda Antonio Penela and Carmelita Dadivas did not have clearance or associated to the facility.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: The licensee has agreed to prived proof of Criminal Record Clearance for Staff membersRosalinda Antonio Penela and Carmelita Dadivas

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(a)(5) · Plan of correction due date: Oct 7, 2024

(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: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement was not met as evidenced by: LPA observed Residents medications were transferred between containerswhich poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: The licensee has agreed to provide training to all staff members to ensure medications remain in it original packaging and provide a written statement of understanding of the cited regulation signed by all staff members.

Allegation investigated: Staff's behavior poses a risk to residents in care

Licensing Program Analysts (LPAs) Mary Rico and Raquel Hernandez conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with staff Carmelita Dadivas and explained the purpose of the visit. The investigation consisted of staff interviews, client interviews and facility tour. For allegation, Staff's behavior poses a risk to residents in care. LPA Rico conducted (4) staff interviews. 4 out of the 4 staff stated that they have not pose residents at risk by their behaviors. 4 out of the 4 staff also stated that they have not witness a staff member use the bathroom outside the facility. Unsubstantiated In addition, LPA conducted (3) resident interviews. 3 out of the 3 resident stated they have not witnessed a staff member used the bathroom outside and have not put them at risk. Based on the evidence found during the investigation, the one (1) allegation listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to staff Carmelita Belveder.the state’s words, verbatim · CDSS document, Sep 20, 2024 · control 56-AS-20240328103346

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Caroline Armstrong, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6) and a hospice waiver for (5). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor activity area is fenced and sufficient for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s showers, toilets, and hand washing areas were operating in a safe and sanitary condition. The hot water temperature in residents' bathrooms measured 118 degrees F. Resident’s bedrooms audited had sufficient lighting, beds, bed linen and dressers. Facility has operating carbon monoxide alarms and telephone service. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, Personal Rights, Theft and loss plan, and evacuation exit plan. Food Service: The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps were kept locked and inaccessible to residents in care. LPA observed uncovered perishable food items in kitchen refrigerator. Deficiency cited. Care & Supervision: Facility has 24-hour, 7 days a week direct care staff. Record Review: LPA review of resident files reveals, resident #1 (R1) did not have a preadmission appraisal on file for review. LPA requested record of an infection control plan, a quarterly emergency drill, and staff training and criminal record clearance files; however facility staff did not know where the documentation was kept. Medical Related Services: LPA review of resident medications reveals, medications for prescribed for resident(s) (R1), (R2), (R3), (R4), and (R5) were not all documented and did not have a record of dosages listed on file. LPA observed in R3's medication box, a medication that was missing the name of medication, dosage, and instructions. LPA also observed in R3's medication box,medication stored in a zip-lock bag with no prescription label. Based on observations and record review, deficiencies are being cited per Title 22, of The California Code of Regulations and Health and Safety Codes. An exit interview was conducted where the Licensing reports were reviewed. Copies of the reports were provided with Appeal Rights to the Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 22, 2024