Bernadette Home Care VI

Allegation investigated: Facility is not sufficiently staffed to meet the needs of residents in care

Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegation. LPA met with Michelle Racan, Administrator and explained the purpose of the visit. Entrance interview conducted. Throughout the course of the investigation, LPA conducted interviews and reviewed all documents obtained and the following was determined: Regarding allegation of “Facility is not sufficiently staffed to meet the needs of residents in care” it was the Reporting Party’s (RP) concern that residents’ needs were not being met due to short staffing. Interviews with the Licensee indicated that two (2) staff members are generally on duty, unless a resident requires one-to-one care. However, resident interviews indicated that staff are at times overwhelmed and that two (2) staff members may be insufficient to provide care and supervision to all residents. Continued on LIC 9099-C Substantiated Continued from LIC 9099 Interviews with staff indicated that the facility coordinates residents’ medical appointments and visits with family members and outside agencies and adjusts staff schedules as needed to accommodate them. Staff reported that no visitors or service providers are intentionally denied entry. Resident interviews confirmed that staff and the Licensee take scheduled appointments and visits seriously and assist residents in preparing in advance to ensure they are ready on time. Adding that staff may occasionally be assisting other residents with bathing, dressing, or changing and may not be able to respond to the door immediately. An interview with a third-party agency also indicated that the facility is consistent in accommodating scheduled appointments and that none of the agency’s nurses had been denied entry to the facility. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff did not ensure resident's scheduled appointments were met” is deemed unsubstantiated at this time. No citations issued. Copy of this report provided to the Licensee. Continued from LIC 9099 Residents reported extended wait times for assistance. One resident also reported that when a staff member assists Resident #1 (R1) with their daily walk for approximately one (1) hour in the afternoon, only one (1) staff remains available to assist the other residents. Record review further revealed that multiple residents require two-person assistance with transfers, including one resident who requires a Hoyer lift. Additionally, timesheet and schedule for the month of May 2026 were provided and reviewed. They were compared and revealed that, in some instances, only two (2) staff members were schedule from 7:00 A.M. to 7:00 P.M., with no staff listed as scheduled from 7:00 P.M. to 7:00 A.M. The Licensee was unable to provide documentation showing that a staff member was assigned to the NOC shift explaining that a live-in caregiver is available to assist residents in the event of an emergency and that staff verbally assigned to the NOC shift. The Licensee further stated that any additional hours worked by staff would be documented on a separate worksheet. LPA requested the worksheets reflecting staff coverage between 7:00 P.M. to 7:00 A.M., however, Licensee stated that no staff claimed addition hours in the month on May 2026. Based on observations, documentation, and interviews, the preponderance of evidence standard has been met, therefore the above allegations, “Facility is not sufficiently staffed to meet the needs of residents in care” is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited at this time (refer to LIC 9099-D) with civil penalty. Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report, civil penalties and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 14, 2026 · control 29-AS-20260518125025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Aug 28, 2026

87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not comply with regulations as some residents needs 2-person assistance and they required the usage of Hoyer lifts and schedule/timesheets shows gaps and no NOC staff available which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2026

Plan of correction: Licensee agreed to provide a plan of action explaining how staff will be properly scheduled throughout all shifts to assist with all residents needs. Licensee will submit action plan to LPA prior to POC due date.

Type of visit: Case Management - Deficiencies

This report was amended to reflect correct civil penalty amount. Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced case management – Other at the above-mentioned facility. At 10:13 A.M. LPA met with Administrator Michelle Racan. Entrance interview conducted. During a complaint investigation, LPA observed deficiencies unrelated to the complaint allegations. During today’s visit, LPA conducted a physical plant tour and interviews with residents. Several residents expressed concerns regarding the facility’s hot water supply, stating that the water does not consistently become hot during showers and that showers have occasionally been cancelled due to lack of hot water. Between 12:00 P.M. and 12:10 P.M., the LPA measured the hot water temperature in all three (3) bathrooms and the kitchen. Water temperature in the bathrooms measured 72.8, 77.4 and 78.4 degrees Fahrenheit. The kitchen hot water temperature measured 72.9 degrees Fahrenheit. These temperatures are below the allowable minimum hot water temperature of 105 degrees Fahrenheit. Administrator stated that facility has been experiencing ongoing issues with the hot water system. Administrator further stated that staff attempted to adjust the water heater; however, they were unable to raise the water temperature to the required range. During today’s visit, the Administrator contacted a professional/plumber and scheduled a service visit for the following day. An immediate civil penalty of $250 repeat violation is assessed today due to being cited for the same violation within 12 months. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, deficiencies cited, copy of report and appeal rights provided to the Administrator.the state’s words, verbatim · CDSS document, May 27, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: May 28, 2026

87303 (e) (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water....used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Based on observation, hot water was measured in 3 bathrooms and the kitchen and measured below to minimum required range. Due to lack of hot water resident's showere were occationally cancelled, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: Administrator agreed to contact a professional to come out to check and correct the water temp issue. Proof of water temp within regulatory range will be sent to LPA via photo/video before POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced case management – Other at the above-mentioned facility. At 10:13 A.M. LPA met with Administrator Michelle Racan. Entrance interview conducted. During a complaint investigation, LPA observed deficiencies unrelated to the complaint allegations. During today’s visit, LPA conducted a physical plant tour and interviews with residents. Several residents expressed concerns regarding the facility’s hot water supply, stating that the water does not consistently become hot during showers and that showers have occasionally been cancelled due to lack of hot water. Between 12:00 P.M. and 12:10 P.M., the LPA measured the hot water temperature in all three (3) bathrooms and the kitchen. Water temperature in the bathrooms measured 72.8, 77.4 and 78.4 degrees Fahrenheit. The kitchen hot water temperature measured 72.9 degrees Fahrenheit. These temperatures are below the allowable minimum hot water temperature of 105 degrees Fahrenheit. Administrator stated that facility has been experiencing ongoing issues with the hot water system. Administrator further stated that staff attempted to adjust the water heater; however, they were unable to raise the water temperature to the required range. During today’s visit, the Administrator contacted a professional/plumber and scheduled a service visit for the following day. An immediate civil penalty of $1,000 repeat violation is assessed today due to being cited for the same violation within 12 months. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, deficiencies cited, copy of report and appeal rights provided to the Administrator.the state’s words, verbatim · CDSS document, May 27, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: May 28, 2026

87303 (e) (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water....used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Based on observation, hot water was measured in 3 bathrooms and the kitchen and measured below to minimum required range. Due to lack of hot water resident's showere were occationally cancelled, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: Administrator agreed to contact a professional to come out to check and correct the water temp issue. Proof of water temp within regulatory range will be sent to LPA via photo/video before POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. LPA arrived at 09:30 A.M. and met with caregiver, Jester Tapia. Caregiver contacted the Administrators by phone. At 10:00 A.M. Administrator, Michelle Racan arrived at the facility. Entrance interview conducted. At 10:23 A.M. LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Fire extinguishers are fully charged and last serviced 2/15/2026. The smoke detectors and carbon monoxide detectors are combined units; at 10:28 A.M they were tested and functioned properly. The facility has a fire door in the hallway which also functioned properly. The following was noted: Bedrooms: There are 6 (six) total bedrooms in the facility; 4 (four) are designated for private resident use and 1 (one) is a shared room. All residents’ bedrooms were inspected and contained appropriate furnishings and linens. The facility also contains a staff room, which was observed to be inaccessible to residents in care. LPA observed that Resident #1’s (R1’s) bed was equipped with full bed rails, The administrator stated that R1 was recently discharged from hospice care and that the facility was awaiting removal of the hospital bed by the hospice agency. During today’s visit, care staff removed the full bed rails. Technical Violation (TV) was issued. Continued from LIC 809-C Continued from LIC 809 Bathrooms: The facility contains 3 (three) full bathrooms; one (1) bathroom is located in the hallway and designated for shared use, one (1) is a private bathroom on suite in room #2, and one (1) bathroom is designated for staff and resident use. LPA observed all 3 (three) bathrooms were clean, properly supplied and had functional fixtures. LPA observed all bathrooms to have slip resistant mats and grab bars. Between 10:26 A.M. and 10:37 A.M. hot water temperatures were measured in all three (3) bathrooms and were found to be outside the required regulatory range. The hallway bathroom measured 132.1 F at 10:26 A.M. The private bathroom in room #2 measured 130.8 F at 10:31 A.M. and the shared bathroom located adjacent to the laundry room measured 133 F at 10:27 A.M. The administrator adjusted the water temperature during the visit. Additionally, LPA observed a spray bottle containing a purple cleaning solution inside an unlocked drawer inside Resident 2’s (R2's) private bathroom. Per R2’s physicians report they are at risk if access to disinfectants and cleaning solutions. Administrator immediately removed the spray bottle from the drawer and locked it away from residents in care. Common Areas: These included the dining area and living room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a designated telephone available for residents’ use. There are nightlights in all common hallways/rooms providing ample lighting to common bathrooms. A fireplace, which was properly screened, was observed in the living room. LPA observed all required postings on the wall in the main hallway/entryway. Additionally, LPA observed a complete first aid kit, PPE supplies such as gloves and mask and extra linens inside hallway cabinets. The facility maintained a temperature of 71 degrees. All facility exit doors contain functional audible alarms. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of non-perishable food at the facility; properly stored. Knives and sharp objects are stored locked inside a locked kitchen drawer. At 10:38 A.M. hot water measured 134.6 degrees Fahrenheit. LPA did not observe a hot water warning sign during the visit. The administrator adjusted the water temperature during the visit. Resident files and staff files were observed to be stored inside locked kitchen cabinet. The facility has a sufficient supply of perishable and non-perishable food and water. LPA conducted a review of expiration dates on product labels. Continue on LIC 809-C Continued from LIC 809-C Laundry Room: There is a locked laundry room; chemicals and cleaning supplies were observed in a locked cabinet inside the laundry room above the washer and dryer machine. Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises at the time of the visit. All passageways and exits were observed to be clear and free of hazards. Facility has two total side gates; both were observed to be self-closing and self-latching with clear passageways for emergency exit use. Facility provides sufficient space to accommodate both indoor and outdoor activities. Garage: The facility garage is attached to the home; however, it has a separate locked entry, and it remains locked and inaccessible to the residents in care. Garage was observed to contain emergency water and food supplies, an extra fridge, as well as ample storage areas. RECORD REVIEW: Between 11:35 A.M. and 12:54 P.M. LPA conducted a file review of resident and staff records. Six (6) resident and four (4) staff files were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. All records were complete and current. MEDICATION REVIEW: Medications are securely stored in a locked cabinet located in the kitchen. At 1:13 P.M. LPA reviewed medications for all six (6) residents. All medications observed were labeled, stored, and properly documented at the time of the visit. Continued on LIC 809-C Continued from LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill documented on 01/29/2026. During today’s visit LPA obtained a copy of the facility’s Personnel report (LIC 500), resident roster, and liability insurance. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 3, 2026

Allegation investigated: Staff is administering a non prescribed medication to a resident in care. Staff are not following physician's orders. Staff left resident in a wheel chair for a long period of time.

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above allegations. The purpose of this visit is to deliver findings for the above allegations. At 9:25 a.m., LPA was greeted by staff and explained the reason for the visit. Staff called the Administrator who arrived at 9:41 a.m., The LPA met with Michelle Racan, Administrator and explained the reason for the visit. On 07/23/2024 the Department received a complaint regarding the following allegations, Staff is administering a non-prescribed medication to a resident in care, Staff are not following physician's orders, Staff left resident in a wheelchair for a long period of time. On 07/31/2024 LPA Brian Balisi conducted an unannounced initial 10-day complaint visit. At approx. 10:05 a.m., LPA conducted physical plant tour, interviewed five (5) staff including the Administrator, reviewed and obtained copies of pertinent documentation relevant to the investigation. Report Continued on LIC 9099-C page 2... Unsubstantiated (Page 2) Report Continued from LIC 9099... During today’s visit, starting at 9:32 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations. Starting at 10:00 a.m., LPA conducted in person interviews with three (3) residents and the Administrator, a file review, medication audit and collected documents pertinent to the investigation. On the allegation Staff is administering a non-prescribed medication to a resident in care it is the concern of the reporting party (RP) that the facility staff administered Hydrocodone to Resident #1(R1) without a prescription. To investigate this complaint, LPA conducted in person interviews with five (5) staff including the Administrator, three (3) residents, a file review of documents pertinent to the investigation for R1 and medication audit on all current residents. R1 has passed away and all medications were properly destroyed and documented therefore no medication for R1 was available. File review of documents pertinent to the investigation for R1 revealed that that R1 was not prescribed hydrocodone nor was it listed on R1’s centrally stored medication record (CSMR) or on the medication administration record (MAR). Interview with staff revealed that R1 was not on Hydrocodone. Staff did not administer Hydrocodone to R1. Staff do not administer non-prescribed medications to their Residents. Interview with the Administrator revealed that R1 was not prescribed Hydrocodone. They did not administer Hydrocodone to R1. They do not administer non-prescribed medications to their Residents. Interviews with Residents revealed that they are familiar with the medications they take. They have not had any discrepancies or concerns with medication management at the facility. Medication audit revealed that medications are securely stored in a locked cabinet located in the kitchen. At 12:02 p.m., LPA reviewed medications for five (5) residents. All medications observed were labeled, stored, and properly documented at the time of the visit. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff is administering a non-prescribed medication to a resident in care is deemed unsubstantiated at this time. On the allegation Staff are not following physician's orders it is the concern of the reporting party (RP) that the facility staff did not follow physician orders for R1 to receive breathing treatment every day. To investigate this complaint, LPA conducted in person interviews with five (5) staff including the Administrator and a file review of documents pertinent to the investigation for R1. R1 has passed away and is no longer available to provide an interview.File review of documents pertinent to the investigation for R1 revealed that R1 was prescribed DUONEB (Iprat-Albut) on 06/24/2025 instructing the “use 1 vial via nebulizer 3 times daily routine”. Report Continued on LIC 9099-C Page 3... (Page 3) Report Continued from LIC 9099-C Page 2... R1’s MAR indicates that R1 received treatment as prescribed three (3) times daily. Interviews with the staff revealed that R1 received breathing treatment as prescribed three (3) times daily. Staff ensured that R1 received breathing treatment as prescribed. The staff followed physician orders and gave R1 breathing treatments as prescribed. Staff do not violate physician orders. The staff have never not followed physician orders. Interview with the Administrator revealed that R1 received breathing treatment as prescribed three (3) times daily. The staff would ensure R1 received breathing treatment as prescribed and document it on the MAR. They do not violate physician orders, and they have never not followed physician orders. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation Staff are not following physician's orders is deemed unsubstantiated at this time. On the allegation Staff left resident in a wheelchair for a long period of time it is the concern of the reporting party (RP) that the staff left R1 in a wheelchair for a long period of time because staff were unable to transfer R1. To investigate this complaint, LPA conducted in person interviews with five (5) staff including the Administrator and three (3) residents of which two (2) are wheelchair users. R1 has passed away and is no longer available to provide an interview. Interviews with staff revealed that R1 had expressed body weakness and unwillingness to ambulate and preferred to stay in a wheelchair. Staff would encourage and assist R1 at time with ambulating in a walker around the facility. Staff did not leave R1 in a wheelchair for a long period of time. Staff were always able to assist and transfer R1. When R1 had body strength they required one (1) staff assistance when transferring. When R1 expressed body weakness R1 required two (2) staff assistance when transferring. Interviews with the Administrator revealed that R1 had frequently expressed body weakness and unwillingness to ambulate. R1 preferred to stay in a wheelchair however Staff would often encourage and assist R1 with ambulating in a walker around the facility. They did not leave R1 in a wheelchair for a long period of time. They do not leave their residents in wheelchairs for a long period of time. They encourage residents to walk around the facility. Staff were always able to assist and transfer R1 when needed. Staff are always available to assist transferring residents. Interviews with residents revealed that they are not left in a wheelchair for a long period of time. Staff assist and encourage the residents to walk around the facility with their walkers if possible. Staff assist with transferring when needed and requested. Residents have no concerns with the care that is provided to them. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation Staff left resident in a wheelchair for a long period of time is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Apr 17, 2025 · control 29-AS-20240723170819

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. LPA arrived at 09:45 A.M. and met with caregiver, Leonilo Dela Cruz. Caregiver contacted the Administrators by phone. At 10:10 A.M. Administrator, Michelle Racan arrived at the facility with Licensee Representative Janette Villapando. Entrance interview conducted. At 10:17 A.M. LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Fire extinguishers are fully charged and last serviced 2/15/2025. The smoke detectors and carbon monoxide detectors are combined units; at 10:40 A.M they were tested and functioned properly. The facility has a fire door in the hallway which also functioned properly. No fire clearance concerns were observed. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted: Bedrooms: There are 6 (six) total bedrooms in the facility; 4 (four) are designated for private resident use and 1 (one) is a shared room. All resident bedrooms were inspected and contained appropriate furnishings and linens. The facility also contains a staff room, which was observed to be locked. Continued on LIC 809-C Continued from LIC 809 Bathrooms: The facility contains 3 (three) full bathrooms; 1 (one) is located in the hallway and is designated for shared use, 1 (one) is a private resident restroom, and 1 (one) is designated for staff and resident use. LPA observed all 3 (three) bathrooms were clean, properly supplied and had functional fixtures. LPA observed all bathrooms to have slip resistant mats and grab bars. Between 10:32 A.M. and 10:45 A.M. hot water was measured in all 3 (three) bathrooms and measured within the required range. Common Areas: These included the dining area and living room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a designated telephone available for resident use. There are nightlights in all common hallways/rooms providing ample lighting to common bathrooms. A fireplace, which was properly screened, was observed in the living room. LPA observed all required postings on the wall in the main hallway/entryway. Additionally, LPA observed a complete first aid kit, PPE supplies such as gloves and mask and extra linens inside hallway cabinets. The facility maintained a comfortable temperature of 73 degrees. All facility exit doors contain functional audible alarms. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of non-perishable food at the facility; properly stored. Knives and sharp objects are stored locked under the sink in a locked cabinet. At 10:53 A.M. hot water measured 111.8 degrees Fahrenheit. Resident files and staff files were observed to be stored inside locked kitchen cabinets. The facility has a sufficient supply of perishable and non-perishable food and water. LPA conducted a review of expiration dates on product labels. Laundry Room: There is a locked laundry room; chemicals and cleaning supplies were observed in a locked cabinet inside the laundry room above the washer and dryer. Continued on LIC 809-C Continued from LIC 809-C Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. All passageways and exits were observed to be clear and free of hazards. Facility has two total side gates; both were observed to be self-closing and self-latching with clear passageways for emergency exit use. Facility provides sufficient space to accommodate both indoor and outdoor activities. Garage: The facility garage is attached to the home; however, it has a separate locked entry, and it remains locked and inaccessible to the residents in care. Garage was observed to contain emergency water and food supply, an extra fridge, as well as ample storage areas. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill documented on 01/24/2025. RECORD REVIEW: Between 11:23 A.M. and 12:57 P.M. LPA conducted a file review of resident and staff records. All resident files were complete. During audit of staff files, LPA observed three (3) out of five (5) records reviewed to have incomplete Personnel Record (LIC501) form on file. Administrator was able to produce missing forms during today’s visit. Technical Violation issued (TV). MEDICATION REVIEW: Medications are securely stored in a locked cabinet located in the kitchen. At 2:20 P.M. LPA reviewed medications for five (5) residents. All medications observed were labeled, stored, and properly documented at the time of the visit. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance. No deficiencies cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 2, 2025

Allegation investigated: Staff are inappropriately restraining resident in care. Resident sustained an unexplained injury while in care.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 07/09/2024 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Administrator, Michelle Racam. Entrance interview. During the initial visit on 07/09/2024, LPA Arroyo conducted a plant tour at 1:31 p.m. to ensure there are no health and safety concerns, conducted interviews with the Administrator, two (2) staff members, and three (3) residents between 12:20 p.m. and 2:05 p.m., conducted a resident file review at 12:30 p.m., and obtained copies of pertinent documents Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff are inappropriately restraining resident in care. It was reported that Resident #1 (R1) was sitting in a wheelchair while being restrained by two (2) different devices. One (1) device being a bath robe that was tied around the wheelchair and shoelaces tied together around R1’s waistband and secured to the back of the wheelchair. Records reviewed revealed that R1 was admitted to the facility on 06/12/2024. Per Physician’s Report, dated 06/07/2024, it lists R1’s primary diagnosis of dementia and temporal lobe lacunar infarct and secondary diagnosis of anxiety, mood disorder, and a high fall risk. Additionally, it states under R1’s mental condition that R1 is confused/disoriented; however, is able to follow simple instructions and is able to communicate their needs. Interviews conducted with staff revealed that R1 was constantly being supervised as R1 had one (1) caregiver specifically watching over them at all times. During staff interviews, staff denied restraining R1 or any other resident while at the facility. Interviews conducted with residents revealed that facility staff is nice and reported having no concerns living at the facility. Furthermore, three (3) out of three (3) residents interviewed denied being restrained by facility or witnessed staff restraining another resident at any time while living at the facility. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “staff are inappropriately restraining resident in care", is deemed Unsubstantiated at this time. It was also alleged that resident sustained an unexplained injury while in care. It was reported that R1 had a large bruise on the right cheek which extended upwards toward the temple. Record review of incident report dated 06/13/2024, stated that R1 was agitated at night and was banging their head on the wall while yelling and screaming. The caregiver sat beside R1 for the rest of the night; however, the caregiver reported that R1 had sustained a bruise on their forehead as a result from R1 banging their head on the wall. Records reviewed and interviews conducted with staff revealed that after the self-injury incident with R1, R1 was placed on bleeding / bruising precautions due to R1 being on blood thinner. Additionally, staff stated that R1 was placed on constant supervision. The Administrator stated that they had hired a caregiver specifically to supervise R1 at all times to avoid R1 from harming themselves. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Furthermore, during resident interviews, residents stated that staff are nice, they feel safe living at the facility, and reported no concerns. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “resident sustained an unexplained injury while in care ", is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Aug 12, 2024 · control 29-AS-20240703104847

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20240703104847). The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation. During the complaint investigation of complaint # 29-AS-20240703104847, the following deficiency was observed: On 06/13/2024, Resident #1 (R1) had an unusual incident while at the facility where it states that around 8:50 a.m., caregiver on duty reported that R1 was agitated and banging their head on the wall while yelling and screaming. The caregiver reported that R1 sustained a bruise on their right forehead. On 07/09/2024, Incident report pertaining to R1 was provided to LPA; however, incident report was not reported to the Department prior to the visit as there was no documentation to show proof indicating that they submitted within the seven (7) days of occurrence as required by the California Code of Regulations. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 12, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 19, 2024

A written report shall be submitted to the licensing agency within seven days of the occurrence which threatens the welfare, safety or health of any resident… This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as R1’s unusual incident report from 06/13/2024 was not submitted to the Department within the seven (7) days of occurrence, which posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Aug 12, 2024

Plan of correction: The Administrator will review Regulation 87211 – Reporting Requirements and submit a statement of understanding to CCL on or before POC due date.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing inspection for this proposed facility. LPA arrived at 09:43AM and met with Licensee Representatives Janette Villapando, Bernadette Abiera, and Michelle Racan. Entrance interview conducted. Fire clearance was approved on 01/18/2024 for 6 (six) total residents, all of which may be non-ambulatory. The facility has an approved hospice waiver for 6 (six) and a pending dementia care plan. A tour of the facility was initiated at 09:54AM with the licensee representatives. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted: Fire extinguishers were purchased on 12/01/2023. Hardwired combination smoke/carbon monoxide detectors, as well as fire door were tested during today’s visit at 10:03AM and were functional at the time of the visit. LPA observed all required postings on the wall in the main hallway/entryway. Bedrooms: There are 5 (five) total bedrooms in the facility; 4 (four) are designated for private resident use and 1 (one) is a shared room. All resident bedrooms were inspected and contained appropriate furnishings and linens. The facility also contains a staff room, which was observed to be locked. Bathrooms: The facility contains 3 (three) full bathrooms; 1 (one) is located in the hallway and is designated for shared use, 1 (one) is a private resident restroom, and 1 (one) is designated for staff and resident use. LPA observed all 3 (three) bathrooms were clean, properly supplied and had functional fixtures. LPA observed all bathrooms to have non-skid mats and grab bars. Hot water was measured in 2 (two) of the 3 (three) bathrooms and measured within the required range. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of non-perishable food at the facility; properly stored. Cleaning supplies are Report Continued on LIC 809-C stored under the sink in a locked cabinet. Knives and sharp objects are stored locked. Medication: Medications, resident files and staff files will be stored in separate locked kitchen cabinets. First aid supplies are available, and were observed to be complete. Common Areas: These included the dining area and living room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a designated telephone available for resident use. There are nightlights in all common hallways/rooms providing ample lighting to common bathrooms. A fireplace, which was properly screened, was observed in the living room. There is a locked laundry room; chemicals were observed in a locked cabinet inside the locked laundry room. Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. All passageways and exits were observed to be clear and free of hazards. All facility exit doors contain functional audible alarms. Garage: The facility garage has a separate locked entry. Garage was observed to contain emergency water and food supply as well as ample storage areas. In addition, during today’s visit, LPA conducted the Component III Orientation with the licensee representatives. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under the new license until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. A copy of report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): none COMP II Participants: Janette Villapando, admin/corp member Interview Method: Telephone interview On March 13, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 3. Staffing requirements & Training 4. General Provisions/pre licensing readinessthe state’s words, verbatim · CDSS document, Mar 13, 2024