Baron's Presidio University City

Type of visit: Case Management - Deficiencies

Licensing Program Manager sent this report to the licensee's last known address to cite a deficiency discovered during the course of an unrelated complaint investigation 08-AS-20251006104258, which was conducted by LPA Arian Golbaksh. While conducting file review for the above mentioned complaint investigation, it was noted that a resident with a Dementia diagnosis (identified as R1) required special observation/night supervision. Per staff interviews and notes on R1 by the facility, they were a known fall risk and had behaviors of wandering day and night. One staff interview indicated that while there were staff present during the night, they were not consistently awake. Another staff member interviewed revealed that R1 would call for help when they had a fall and staff would then go to assist R1. This interview also revealed that staff began leaving lights on at night to assist R1 with their nighttime wandering, hoping it would decrease R1's number of falls. Other staff member interviews shared accounts of R1 wandering out the front door at night and causing verbal disturbances to the neighborhood and other residents in the home. One outside source interviewed revealed concerns of there being no awake overnight staff, stating that administrative staff had initially informed them there would be but then shared that would be cut and only the live-in staff would be present. Another outside source interviewed shared that they made recommendations for 1:1 care for R1 but that the facility was unable to support that level of care with their staffing ratio. One (1) deficiency was cited and immediate civil penalty assessed for a violation that results in the absence of required supervision for a resident [ See attached LIC 809 (d) and LIC 421 IM]. A copy of this report, LIC 809(d), LIC 421 IM, along with Licensee/Appeal Rights (LIC 9058) were delivered via certified mail to the licensee's last known address.the state’s words, verbatim · CDSS document, Aug 31, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Aug 31, 2026

87705 Care of Persons with Dementia (b) Licensees shall be responsible for... (2) ...ensuring there is at least one night staff person awake and on duty... in addition to requirements specified in...Night Supervision. This requirement is not met as evidenced by: Based on LPA interviews and file review, the licensee did not ensure awake night staff were present and on duty to provide a Dementia resident with overnight supervision as required, which posed an immediate health and safety risk to 1 out of 4 persons in care (R1).the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Facility is closed; POC is deemed cleared.

Type of visit: POC

Licensing Program Analyst (LPA), Natasha Persaud conducted a Plan of Correction visit. LPA was greeted and allowed entry into the facility by Staff, Esther Villar and Administrator, Agnieszka Norton. The purpose of today's visit was to verify if deficiencies issued on 05/26/26 have been corrected. On 05/26/26, the licensee was issued deficiencies for the following: Personal Rights; Infection Control; Emergency Plans; Personal Accommodations and Services; and Plan of Operation. The deficiencies were due on 06/04/26. Today, LPA reviewed deficiencies mentioned above. All have been corrected and cleared. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Agnieszka Norton whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jun 11, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Deficiencies visit. LPA was greeted and allowed entry into the facility by Staff, Esther Villar and Administrator, Agnieszka Norton. LPA was at the facility for an unrelated issue. During the visit, deficiencies were observed. The required postings were not posted. Residents bedding did not contain the required elements to include mattress pads and flat sheets. The administrator was not aware of required PPE items, LPA explained the required items to obtain. Bathroom #2 did not have a non-skid shower mat or strips. There was a camera in use, located in the kitchen. The administrator didn't know if audio was involved and was not aware of the requirements for video surveillance. The camera was removed during the visit and the administrator stated they will no longer use the camera. The front gate had a metal latching device which was not locked at the time but has potential to be locked with a padlock. LPA explained the law and the metal latching device was removed. The disaster drill was reviewed. The drills are not be conducting according to law. The administrator is the assigned lead for their infection control plan. However, the administrator has not received the required training and was not familiar with the infection control plan. The administrator was not familiar with the Emergency Disaster plan and required training protocols. Also, the facility sketch does not match the layout of the facility. Deficiencies were observed and cited during the visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Agnieszka Norton whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, May 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 4, 2026

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not provide 4 out of 4 [R1-R4] residents with dignity by having a camera recording the residents without consent, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: The administrator was not aware if audio was being used. The camera was unplugged and removed. The administrator stated they will no longer use cameras. POC corrected.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468(c) · Plan of correction due date: Jun 4, 2026

Personal Rights. Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not post the required documentation for 4 out of 4 [R1-R4] residents, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: The administrator was not aware of the required postings. The administrator stated they will post all the required documentation by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87470(a) · Plan of correction due date: Jun 4, 2026

Infection Control Requirements. A licensee shall ensure that infection control practices are maintained as follows: This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not obtain required training on their infection control plan and do not have required PPE for staff to assist with 4 out of 4 residents [R1-R4], which poses a potential health and safety risk to residents on care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: The administrator was not aware of required PPE and training regarding infection control plan. The administrator stated they will obtain the required PPE and necessary training by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.695(c) · Plan of correction due date: Jun 4, 2026

Emergency Plans. A facility shall conduct a drill at least quarterly for each shift. The type of emergency...vary from quarter to quarter...scenarios. An actual evacuation of residents is not required during a drill. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not conduct or document quarterly drills with various topics and requirements for 4 out of 4 [S1-S4] staff, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: The administrator was not aware of various topics and documentation requirement. The administrator will conduct and document a disaster drill by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Jun 4, 2026

Personal Accommodations and Services. Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. Based on interviews and observations, the licensee did not have required bedding to include flat sheets and mattress pads on 4 out of 4 residents [R1-R4], which poses a potential health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: The administrator was not aware of bedding requirements for residents. The administrator will ensure all bedding is appropriate to law by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87208(a)(7) · Plan of correction due date: Jun 4, 2026

Plan of Operation. The licensee shall have... plan of operation for the facility. The licensee shall operate...1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. This requirement is not met as evidenced by: Based on interviews and observations, the licensee does not have a facility sketch that matches the actual floor plan of the facility for 4 out of 4 residents, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: The administrator was not aware the facility sketch didn't match the layout of the facility and will submit a current updated sketch by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to the facility. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to caregiver Ester Villar. The purpose of LPA's visit was to follow up on a hospice exception request from the facility as well as answering questions from Administrator Angie Norton regarding the facility's planned change of ownership. During the visit, LPA consulted with Administrator Norton via telephone on the remaining items needed for the exception request as well as answering questions pertaining to the change of ownership process with the Centralized Applications Bureau (CAB). LPA observed no health and safety concerns during the visit. No deficiencies were cited during the visit. An exit interview was conducted with caregiver Villar to whom a copy of this report was provided to. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, Dec 16, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregiver Ester Villar. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, one (1) of which may be bedridden. Additionally, the facility is approved for two (2) hospice waivers. During today’s inspection there were five (5) residents in care. Administrator Angie Norton arrived later during the visit. LPA and Caregiver Villar toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Bathroom sink in common bathroom 1 was 105F and common bathroom 2 read at 107F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked an kept inaccessible to residents in care. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Caregiver Villar, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors as well as emergency lighting were all in working order. Last staff fire drill conducted was on 2/25/25. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. When inspecting the facility's fire extinguishers, LPA noted that there was no service tags on the extinguishers and the receipt of purchase was dated 8/21/2022. Administrator Norton stated they purchase new extinguishers annually but did not retain the receipt. As date of purchase could not be verified, a deficiency is being cited per Title 22 regulations and noted on the attached LIC 809D. In addition, a Civil Penalty is being assessed for a Zero Tolerance Violation regarding Fire Safety and are noted on the attached LIC 421IM in the amount of $500. LPA interviewed two (2) staff and two (2) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. One deficiency was cited during the inspection. An exit interview was conducted with Administrator Norton to whom a copy of this report, the LIC 421IM, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 28, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Annual Continuation Inspection. The LPA identified himself and disclosed the purpose of the visit to Caregiver Ester Villar. The facility was licensed for a capacity of six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility also had a hospice care waiver approved for two (2) residents. The LPA reviewed the facility Infection Control Plan, Emergency Disaster Plan, and staff and resident records. There were not immediate concerns and the LPA provided technical advise. The facility was clean, sanitary, and in good condition. No deficiencies were observed, nor cited on today's date. An exit interview was conducted with Caregiver Ester Villar, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided.the state’s words, verbatim · CDSS document, Aug 8, 2024

Allegation investigated: Staff hit resident

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Esther Villar. LPA spoke with Licensee Angie Norton via telephone during the visit. The Department’s investigation consisted of interviews with staff, residents, and outside sources, record review, and a tour of the facility. It was alleged that Staff 1 (S1) hit Resident 1 (R1). Review of R1’s physician’s report and assessment documents revealed that R1 had a diagnosis of major cognitive impairment and was receiving care from an outside care provider. Interviews with staff and outside sources revealed that R1 had a history of becoming aggressive and combative during personal care, however, R1’s assessment records did not indicate that R1 had any aggression or inappropriate behaviors. Continued on LIC9099-C page... Substantiated Interviews with staff and outside sources revealed that on 12/19/2023, an outside care provider was providing personal care services to R1 when R1 became aggressive. Statements made by outside sources and staff revealed that S1 entered R1’s room to assist the outside care provider. R1 remained agitated and attempted to hit S1 but did not make physical contact with S1. Outside sources revealed that S1 hit the right side of R1’s face with S1’s hand following R1’s attempt to hit S1. Interviews with S1 stated that S1 was attempting to grab R1’s hands to prevent R1 from punching or hitting when S1’s hand accidentally hit R1’s face. Interviews with S1 and outside sources made conflicting statements regarding the details of the incident, however both parties agreed that S1’s hand made physical contact with R1’s face during personal care on 12/19/2023. Interviews with staff and outside sources revealed that R1 did not sustain any injuries or physical marks following the incident on 12/19/2023. The Department has investigated the above-mentioned allegation and based on interviews, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with Licensee Angie Norton via telephone and Caregiver Esther Villar, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jul 29, 2024 · control 08-AS-20231221162314

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 26, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents… shall have all of the following personal rights: (1) to be accorded dignity with their personal relationships with staff… This requirement has not been met as evidenced by: Based on interviews, the Licensee did not ensure that Resident 1 was accorded with dignity when S1 hit R1 during personal care. This poses a potential personal rights risk to 6 of 6 residents in care.the state’s words, verbatim · CDSS document, Jul 29, 2024

Plan of correction: Norton stated that the staff member is no longer working at the facility. Staff will receive vendor training on personal rights and will submit certificates of completion to the Department by POC due date of 8/26/2024.

Allegation investigated: Staff did not address pests in the facility.

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced a follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Esther Villar. Administrator Angie Norton arrived during the visit and assisted the LPA. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources, including staff and residents. It was alleged staff did not address pests in the facility. On 5/8/2024, it was reported to the Department spiders, and cockroaches were observed in the facility, and that the facility had not addressed the pest. Interviews with multiple external sources, who confirmed conducting several visits to the facility, reported not witnessing any pest at the facility, and not having concerns with pest at the facility. Some internal interviews also reported not having any concerns, and not witnessing any pest at the facility. (See LIC 9099-C for continuation of report.) Unsubstantiated Other internal sources did witness cockroaches, but also mentioned a pest control company had been hired to address the concern. The sighting of cockroaches had decreased or stopped since then. An interview with the administrator confirmed someone had report cockroaches at the facility, that the administrator had witnessed at least one dead cockroach at the facility, and a pest control company was hired. The administrator initial sprayed the facility with store bough products, prior to obtaining professional services. Receipts showed the pest control started services on 5/2024, and conducted a subsequent visit on 6/19/24. Although the pest control services were hired after the allegation was reported the Department, there was not enough evidence to prove the facility staff did not address the pest concern. Therefore, the allegation was Unsubstantiated. An exit interview was conducted with Norton, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Jul 18, 2024 · control 08-AS-20240508163943

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabel Martinez conducted a case management visit to obtain signatures and deliver an amended report. LPA met with Administrator Angie Norton, introduced himself and disclosed the purpose of the visit. Today's visit is to collect report signatures and deliver an amended report. An exit interview was conducted with Norton, to whom a copy of the this report, and Appeal Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Jul 18, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA identified himself and disclosed the purpose of the visit to Administrator Angie Norton. The facility was licensed for a capacity of six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility also had a hospice care waiver approved for two (2) residents. The LPA, accompanied by the administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstructions and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, visitation, meetings, and client activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, and stored in a locked area. No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Due to time constraints, a follow up visit will need to be conducted to complete this required visit. No deficiencies were cited today. An exit interview was conducted with Administrator Norton, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided.the state’s words, verbatim · CDSS document, Jul 18, 2024