Blessed Homecare 2 Roseville

Allegation investigated: Resident has injuries of unknown origin

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Licensee Baby Quintero to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unfounded Resident has injuries of unknown origin Interviews conducted with Licensee and staff indicated that Resident R1’s bruises are explainable due to R1’s activities within the home. Observations indicated that R1 is active within the home and occasionally with run in to furniture and dig in drawers and cabinets. These behaviors are R1’s baseline and the facility will redirect as needed. Records reviewed indicated that R1 has continued to be at baseline in the care home with no concerns. Licensee, staff, R1's family and physician are aware of R1’s behaviors and continue to support R1. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 59-AS-20260512163158

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Administrator Leriza Arambulo and Licensee Baby Quintero to conduct an annual inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed resident rooms, common area bathrooms, kitchen, common areas and perimeter of care home. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed six (6) resident files, one (1) staff file and resident medications. Facility has a current copy of certificate of liability insurance and LPA requested a copy. LPA and Administrator/Licensee discussed the importance of proper record keeping at the facility. As a result of this visit, no deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted with Administrator.the state’s words, verbatim · CDSS document, Oct 28, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassandra Mikkelson spoke with Licensee Baby Quintero regarding staff member S1's staff file that was requested on 10/10/2025. Licensee could not produce S1's staff file although staff worked on 10/09/2025. LPA discussed in length with Licensee the importance of what needs to be completed and on file for an employee to work. As a result of this visit, a deficiency was cited. Appeal rights given. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a) · Plan of correction due date: Oct 31, 2025

87412 Personnel Records (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: This was not met by evidenced by: Licensee allowed staff S1 to work 1 shift without proper paperwork on file.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Licensee will review regulation 87412 and submit a statement of understanding to LPA by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassandra Mikkelson conducted an unannounced case management visit on October 10, 2025. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPA met with Administrator Baby Quintero and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective October 10, 2025 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, Oct 10, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cassandra Mikkelson, conducted this unannounced case management visit in response to Case Management visits conducted on 05/28/2025 and 06/04/2025. The following observations were cited on 05/28/2025. Civil Penalties were assessed on 06/04/2025 for below citations. - 87465(h)(2) Incidental Medical and Dental Care- Facility did not meet regulations as medications were left unlocked in kitchen drawer. - 87309 Storage Space and Access - Facility did not meet regulations as knives and chemicals were unlocked and accessible to residents. During today's visit, LPA observed above deficiencies to be corrected and maintained. LPA and Licensee discussed the importance of maintaining the above regulations moving forward. LPA also reviewed five (5) resident records. No deficiencies were cited during today's visit. Exit interview conducted with Licensee.the state’s words, verbatim · CDSS document, Jul 16, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cassandra Mikkelson, conducted this unannounced case management visit in response to Case Management conducted on 05/28/2025. The following observations were cited on 05/28/2025. LPA assessed civil penalties for the following deficiencies. - 87465(h)(2) Incidental Medical and Dental Care- Facility did not meet regulations as medications were left unlocked in kitchen drawer. - 87309 Storage Space and Access - Facility did not meet regulations as knives and chemicals were unlocked and accessible to residents. LPA and Licensee discussed at length regarding plans of correction and failure to correct. Exit interview conducted. A copy of the report has been issued. Civil Penalties assessed. Appeal Rights provided.the state’s words, verbatim · CDSS document, Jun 4, 2025

Allegation investigated: Staff are not ensuring that resident is administered their medications according to physician's instructions. Staff are mismanaging resident's medications.

Licensed Program Analyst (LPA) Cassandra Mikkelson and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced and met with Administrator Baby Quintero to deliver findings for the above complaint allegations. During the investigation, LPA and LPM conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Substantiated Staff are not ensuring that resident is administered their medications according to physician's instructions. LPA conducted a review of Resident R1’s medication against the Medication List that was provided by home health. LPA observed that R1’s medication list and Medication Administration Record (MAR) do not match and there are medications missing from the medication list that R1 is being given and medications that R1 is prescribed that the facility does not have for R1. During initial investigation on 05/15/2025, LPA requested a medication list for R1’s medications that were being given. Facility could not provide a medication list or Centrally Stored Medication Record (CSMR) to LPA. LPA received medication list from Home health nurse who arrived while LPA was conducting the visit on 05/15/2025. Interviews with home health nurses that are visiting R1 indicated that their first visit on 05/07/2025, the nurse attempted to review R1’s medications but there were no medications present at the facility for R1. Home health nurse came for a second visit and after their assessment, sent R1 to the hospital due to high blood pressure readings since no medication was being given for blood pressure even though R1 had a current prescription for blood pressure medication. The allegation staff are not ensuring that resident is administered their medications according to physician's instructions is substantiated. Staff are mismanaging resident's medications. LPA conducted a review of Resident R1’s medication record. The review of R1’s medications indicated that R1 has five medications on their medication list that are not being given or are not being given as prescribed. During investigation, LPA requested a Centrally Stored Medication Record (CSMR) for R1 but the facility did not have a CSMR for R1. Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted with Administrator and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, May 28, 2025 · control 59-AS-20250513102052

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(4) · Plan of correction due date: May 29, 2025

87465 Incidental Medical and Dental Care (4) The licensee shall assist residents with self-administered medications as needed. This poses an immediate health and safety risk to residents in care. This was not met as evidenced by: records reviewed indicated that medications for Resident R1 were not being dispensed correctly.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Licensee will conduct a medication audit of all resident medications and ensure that Centrally Stored Medication Record is accurate to physician's orders.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassandra Mikkelson and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced to conduct a case management visit. LPA and LPM met with Administrator Baby Quintero and explained the reason for the visit. LPA and LPM toured the facility and conducted a review of resident medications and resident file review. As a result of this visit, deficiencies were cited on 9099-D. Appeal rights given.the state’s words, verbatim · CDSS document, May 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 29, 2025

87465 Incidental Medical and Dental Care(h)The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This poses an immediate health and safety risk to residents in care. This was not met as evidenced by: LPA and LPM observed medications to be unlocked in kitchen drawer.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Licensee will conduct a training with staff regarding locking and storing medications. Licensee will send a copy of training to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: May 29, 2025

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This poses an immediate health and safety risk for residents in care. This was not met as evidenced by: LPA and LPM observed knives to be unlocked in kitchen, cleaning solutions unlocked outside and under sink in bathroom.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Licensee will conduct a training with staff regarding keeping knives and cleaning solutions locked and inaccessible to residents in care. Licensee will send a copy of training to LPA by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived at the facility to open a 10 day complaint. LPA met with Care staff, Joy Capili during today's visit. During visit, LPA conducted medication review, interviews and toured the facility. While touring the facility, LPA observed Resident R1 to have a cardboard box full of prescription medication bottles on the side table by their bed. LPA asked care staff why there are medications in R2's room. Care staff stated that medication was left there because it is old medication. Staff could not tell LPA when medication was left in R1's room or how long the box had been there. LPA requested staff lock medication immediately due to health and safety risk of residents in care. As a result of this visit, a deficiency was cited on 809-D. Appeal rights provided. Exit interview conducted. Copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(1)(C) · Plan of correction due date: May 16, 2025

87465(h)(1)(C) (h)The following requirements shall apply to medications which are centrally stored: (1)Medications shall be centrally stored under the following circumstances: (C)Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. This poses an immediate health and safety risk to residents in care. This regulation was not met as evidenced by: LPA observed R1's prescription medications to be left in an open box on R1's side table in their room exposed to residents in care.the state’s words, verbatim · CDSS document, May 15, 2025

Plan of correction: Licensee will submit a plan to LPA to ensure that all medications are locked and inaccessible to residents in care by POC date.

Allegation investigated: Staff are physically abusing residents in care Staff are financially abusing residents in care Staff do not allow residents access to phone Staff do not allow residents access to their doctors

On 04/02/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak and Cassandra Mikkelson arrived at the facility unannounced to deliver final findings to a complaint Community Care Licensing (CCL) received on 01/24/2025. LPA met with Licensee Baby Quintero and explained the purpose of the visit. During the course of the investigation, the Department conducted interviews and record review. Please continue to LIC9099-C Unfounded Staff are physically abusing residents in care- Unfounded Staff are financially abusing residents in care- Unfounded During the investigation it was learned that R1 has behaviors of alleging false claims. Based on information obtain and interviews conducted, there is no evidence that R1 was physically or financially abused by staff at this home. The department was unable to interview R1 due to cognitive decline. Staff do not allow residents access to phone-Unfounded During facility visit on 03/11/2025 LPA and Licensee tested the facility phone. Facility does have a working phone, and residents have access to it whenever they may need it. During an interview with Licensee, they stated that residents do not use the phone often due to their families being so involved and are at the facility often. LPA attempted interviews with residents but due to cognitive impairment of the residents, LPA was unable to interview residents. Staff do not allow residents access to their doctors-Unfounded During an interview with Licensee, it was revealed that most of the residents have family that are involved and do the communications with their doctors. Facility will let the family know if there is a change in resident’s condition. R1 is the only resident that does need assistances when it comes to the doctors. Licensee will assist with scheduling the appointments. Additionally, Licensee provide LPA with R1s upcoming appointments. LPA attempted interviews with residents but due to cognitive impairment of the residents LPA was unable to interview residents. Based on information obtained through interviews, the Department finds the allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Apr 2, 2025 · control 59-AS-20250124130413

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassandra Mikkelson and Cheyenne Ratajczak arrived to the facility to conduct a case management visit. LPAs met with Licensee and explained the purpose of the visit. LPAs conducted a file review of five (5) resident files, toured the facility and conducted interviews. As a result of this visit, deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D pages. Exit interview was conducted with Licensee. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Mar 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(c)(1)(a) · Plan of correction due date: Apr 1, 2025

87458 Medical Assessment (c) The medical assessment shall include...: (1) A physical examination...indicating the licensed medical professional's diagnosis... and results of an examination... (A) Communicable tuberculosis. This poses a potential health and safety risk to the residents in care. This was not met as evidenced by: Based on records reviewed and interviews conducted, R1 did not have a Tuberculosis test completed prior to moving into facility.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: Licensee will ensure that R1 receives Tuberculosis test by POC due date. Licensee will ensure that all new residents have a tuberculosis test prior to move in.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87456(a)(2)(4) · Plan of correction due date: Apr 1, 2025

87456 Evaluation of Suitability for Admission (a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall... (2)Perform a pre-admission appraisal. (4) Execute the admissions agreement. This poses a potential health and safety risk to residents in care. This was not met as evidenced by: Based on records reviewed and interviews conducted, R2 did not have an admission agreement or pre-admission appraisal completed prior to moving in.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: Licensee will ensure that R2 has signed admission agreement and apprasal completed by POC due date. Licensee will ensure that all new residents have an admission agreement and pre- placement appraisal completed prior to move in.

Type of visit: Office

On 11/18/2024 at 10:30 AM, a Non-Compliance Conference was held at the Sacramento North Regional Office located at 9835 Goethe Road Suite 100, Sacramento CA 95827. The purpose of this meeting is to discuss the high volume of citations and a substantiated complaint. The following facilities are involved because they are owned by Licensee: BLESSED HOMECARE #342700911; BLESSED HOMECARE 2 ROSEVILLE # 315002812; and BLESSED HOMECARE 3 # 345920062. Present in the meeting was Licensee, Baby Quintero, Facility Representative Leriza Arambulo, Regional Manager (RM) Alycia Rayner, Licensing Program Manager (LPM) Anthony Perez, LPM Troy Ordonez, Licensing Program Analyst (LPA) Cassandra Mikkelson, LPA Cassie Yang, LPA Cheyenne Ratajczak, and LPA Kerry Hiratsuka. Issues discussed during the meeting were: • High volume of Type A and Type B citations • Substantiated Complaint • Fire Safety issues • Supervision issues • Administrators lack oversight. • Reporting requirements • Communication breakdown • Criminal record clearance • Resident files are incomplete • Food Service • Licensee not completing Plan of Correction correctly and timely • Licensee/Administrator accountability The licensee was in agreement with the drafted non-compliance plan as outlined in LIC 9111. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 18, 2024

Type of visit: POC

LPA Hiratsuka conducted this unannounced plan of correction visit. This is a follow-up to deficiencies issued on 10/24/2024, and not corrected until Sunday, November 3, 2024. Civil penalties were issued on 10/30/2024 and accrued at $100.00 per deficiency per day and the civil penalties will stop on November 3, 2024. The following deficiencies have now been cleared: Health and Safety Code 1569.312(3) Basic Services- Title 22 Regulations 87307(d)(6) 87465(e) The following deficiencies were due on October 31, 2024. LPA spoke to Caregiver Leriza Arambulo, on the phone today and Caregiver stated she didn't see the remaining deficiencies. She stated she thought there were only the ones above. LPA is leaving a copy of all reports that were issued on 10/24/2024. A reminder that annual fees are due on 11/12/2024. Licensee is to submit a staff schedule or LIC 500 to Community Care Licensing Division The person appointed by Licensee to be administrator Maria Clardy, is not associated to this facility. Licensee shall submit the transfer request to Community Care Licensing Division prior to Ms. Clardy working at this facility. No deficiencies citedthe state’s words, verbatim · CDSS document, Nov 6, 2024

Type of visit: Case Management - Deficiencies

Licensed Program Analysts (LPAs) Cassandra Mikkelson and Kerry Hiratsuka arrived unannounced to conduct a Case Management following deficiencies cited. During annual visit on 10/02/2024 conducted by LPA Bethany Mirlohi, the following deficiencies were cited. 87506 Resident Records (a)- facility did not meet regulations for resident files, ensuring that all resident files are complete and up to date. 87457(c)- Resident's needs and service plans were absent in resident files. 87458(a)- Residents physicians' report were absent in resident files. 1569.69(a)(2)- Administrator did not ensure that all employees, new and existing, meet the appropriate training requirements per Title 22 regulations. During complaint visit on 10/24/2024 conducted by LPA Mikkelson and Hiratsuka, the following deficiencies were cited. 87203- Fire safety- facility had chairs blocking the front door and a wooden dowel blocking the glass sliding door. 1569.312(e)- Licensee not ensure the safety of the resident by a resident leaving the facility through the side gate unnoticed by staff. This is an immedate health and safety risk to residents 87465(g)- Licensee did not ensure the safety of the resident because a resident left the facility unassisted and the Licensee did not call for emergency services for at least 30 minutes. *Continued on LIC 809-C During Case Management visit on 10/24/2024 conducted by LPA Mikkelson and Hiratsuka, the following deficiencies were cited. 87705(j)- LPAs observed the audio alerts were not working and Licensee stated the batteries die quickly so she put chairs to block the entrance so staff can hear the chairs move. 87463(a)- The appraisal has not been updated to address the resident wandering and leaving the facility unoticed by staff. 87211(a)(2)- Facility did not meeting reporting requirements according to Title 22 regulations when incidents occur. It was learned today that Licensee did not report to Licensing when a resident left the facility unnoticed. There is also not a current administrator for facility. The Department was not notified with a change of administrator. Based on deficiencies during 10/02/2024 annual visit and complaint visit on 10/24/2024 and case management visit conducted on 10/24/2024, it shows that there is no qualified administrator operating the facility. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. Exit interview conducted. A copy of the report has been issued. Failure to correct the deficiencies may result in Civil penalties being assessed. Appeal Rights provided.the state’s words, verbatim · CDSS document, Oct 30, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Nov 6, 2024

87405 Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person... This was not met as evidenced by: Based on interview, it was learned that there is no current administrator for this facility. This poses a possible risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: By 11/06/2024, the Licensee shall appoint a qualified administrator and submit a written plan on how she shall show that there will always be a qualified administrator working.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(g)(1) · Plan of correction due date: Nov 6, 2024

The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: Name and residence and mailing addresses of the new administrator. This was not met as evidenced by: Based on interview, it was learned that there is no current administrator for this facility and the Department was not notified. This poses a possible risk to the residents in carethe state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: By 11/06/2024, the Licensee shall appoint a qualified administrator and submit a written plan on how she shall show that there will always be a qualified administrator working. Licensee will also submit written notification to the Department of change in administrator.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 6, 2024

87211: Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence This was not met as evidenced by: Based on interview, it was learned that facility did not report resident leaving facility unnoticed. This poses a possible risk to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: By 11/06/2024, Licensee will submit a written plan of how facility will ensure that all incidents are reported to the Department and all relavant parties.

Type of visit: POC

Licensing Program Analysts (LPAs) Hiratsuka and Mikkelson conducted this unannounced plan of correction visit in response to deficiencies cited for Complaint 59-AS-20241022104408 and a Case Management visit on 10/24/2024. LPA Mirlohi arrived later to conduct her own Plan of Correction visit. On 10/24/2024, the following deficiencies were issued and they are not corrected as of today: -Health and Safety Code 1569.312(e) Basic Services- this was cited because a resident made it out of the facility unnoticed by staff and was found about four blocks away. The Licensee was to submit a written plan of correction on how she shall ensure how staff monitor residents based on needs. Licensee did not submit this plan. Civil penalties of $500.00, is issued today and shall accrue at $100.00 until Licensee submits contacts LPA Hiratsuka. -Title 22 Regulation 87465(e) Incidental Medical and Dental Care. this was cited because per Title 22 the facility shall telephone 9-1-1 if there is an imminent threat to the health and safety to residents. A resident left the facility unnoticed and Licensee took approximately 30 minutes before calling 9-1-1. Licensee was to submit a written plan that addresses what staff are going to do when a resident is missing. Civil penalties of $500.00, is issued today and shall accrue at $100.00 until Licensee submits contacts LPA Hiratsuka. -87307(d)(6) Personal Accommodations and Services. This was cited because the front door was blocked by two chairs and the sliding glass door had a wood rod put on the track to keep the door from sliding open. The chairs and wood rod were removed, but the licensee did not submit a written plan of correction on how she is going to ensure the exits are not blocked. Civil penalties of $500.00, is issued today and shall accrue at $100.00 until Licensee submits contacts LPA Hiratsuka. -87463(a) Reappraisals. This was cited because the appraisal and needs and services plan for the residents did not meet what the residents needs were. One did not mention the resident was a wanderer and there was a second one that had a resident's name written over White-Out, and had another person's name in the body of it. Licensee was to submit a written plan how she was going to ensure the appraisals and needs and services plan address the resident abilities and needs and how she was going to have the staff meet those needs. Civil penalties of $500.00, is issued today and shall accrue at $100.00 until Licensee submits contacts LPA Hiratsuka. The following was not corrected but no civil penalties issued because the licensee did part of the plan of correction: -87705(j) Care of Persons with Dementia. Title 22 regulations requires audio alerts on exits when exiting poses a risk to residents. Licensee blocked the front door with two chairs and put a wood rod on the track of the sliding glass door. The licensee has removed the chairs and the wood rod. Licensee installed audio alerts on the exits. Licensee was to submit a written plan of correction of how she shall ensure the exits are not blocked and the audio alerts working. LPA is not issuing civil penalties and Licensee is to submit a written plan about the audio alerts and not blocking exits. A total of $2000.00 civil penalties were issued. The four uncorrected deficiencies shall accrue at $100.00 per day until Licensee submits a written plan of correction. No additional deficiencies issued during this visit. Appeal rights left for the civil penalties. A copy of the report has been issuedthe state’s words, verbatim · CDSS document, Oct 30, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to complete a POC visit in concerns to the annual inspection on 10/02/24. LPA met with licensee Baby Quintero during today's inspection. During today's inspection LPA reviewed POC's that were due by 10/18/24. LPA assessed civil penalties for the following deficiencies: Post the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475). Although licensee posted the poster, it was not the correct size 20” x 26”. Complete a needs and service plan for R1 and R2. Licensee submitted an incomplete needs and service plan, and only completed and sent 1 page. Complete a statement of understanding and send the plan into LPA. Licensee did not send a statement of understanding for regulation 87506. Licensee sent in a infection control plan on 10/17/24, however licensee did not complete the plan properly. Licensee agrees to complete the infection control plan on form LIC9282 and send a copy into LPA by 11/4/24. Licensee agrees to complete POC's by 11/4/24 and send into LPA. Civil penalties assessed. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 30, 2024

Allegation investigated: Resident able to leave the facility unnoticed by staff. Facility did not contact 9-1-1 timely regarding resident leaving the facility unnoticed Facility is obstructing fire exits.

Licensing Program Analysts (LPAs) Hiratsuka and Mikkelson, conducted this unannounced complaint visit. LPAs interviewed Caregivers and Licensee Baby Quintero via the phone. LPAs toured the facility and reviewed resident files. On 10/21/2024, a resident was able to leave the facility without staff noticing. The resident is a known wander risk. The facility staff were assisting other residents when the one left out the side gate. The facility has audio alerts on the doors as required by Title 22 Regulations if exiting poses a risk to residents and in this case exiting does pose a risk to residents but the audio alerts were turned off due to the batteries not working. The facility also does not have a staffing plan to address the issue of two residents who make attempts to leave the facility. The two residents were determined by their doctors to not be able to leave the facility unassisted. This is a $500.00 immediatel civil penalty because the resident was able to leave the facility unnoticed by staff. Substantiated Licensee Baby Quintero, stated she did not wait one hour to call 911 to report the resident missing. Licensee stated it was probably 30 minutes because she and her staff went around the neighborhood looking for the resident first. Title 22 Regulations does not have time limits to call for emergency services; however, this resident has a diagnosis of dementia and per the physician, this resident was unable to leave the facility unattended and was found about four blocks away unharmed. Because the Licensee waited before calling emergency services the allegation is substantiated. When LPAs arrived at the facility and was waiting for someone to answer the front door, LPAs observed a sound like something was being moved from in front of the front door. Upon entering the front door LPAs observed two chairs placed directly to the left of the front door which put them behind the open door. LPAs asked the caregiver who answered the front door what the chairs were for and the caregiver admitted to blocking the front door with the chairs to prevent the residents from leaving through the front door. Licensee Baby Quintero, also stated she had the chairs placed in front of the door along with a can so the staff can hear the chairs and can being moved so they can get to the residents before the residents are able to open the front door. LPAs also observed a wood rod placed in the sliding glass door to prevent it from opening. This is a fiire safety violation. This is a $500.00 immediate civil penalty for blocking exits. As a result of this investigation, the Department finds the allegations above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. A total of $1000.00 Immediate Civil Penalties Assessed during today's visit. Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Failure to correct the deficiencies may result in Civil penalties being assessed.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 59-AS-20241022104408

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Oct 25, 2024

Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. Licensee failed this by a resident leaving the facility through the side gate unnoticed by staff. This is an immedate health and safety risk to residentsthe state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: By 10/25/2024, the licensee shall come up with a written plan of correction that specifies how the residents shall be monitored, how staff are going to be trained to monitor the residents, and how she is going to ensure the staff are monitoring the residents. Licensee shall submit this plan to Community Care Division. $500.00 Immediate civil penalty assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Oct 25, 2024

Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... Licensee failed this because a resident left the facility unassisted and the Licensee did not call for emergency services for at least 30 minutes. This poses an immediate risk to residents.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: By 10/25/2024, Licensee shall come up with a plan addressing residents who leave the facility without assistance and unoticed. This plan shall address what steps shall be taken to find the missing resident. Licensee shall submit this plan to Community Care Licensing Division.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Oct 25, 2024

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Licensee failed to meet this because the front door was blocked by two chairs and the sliding glass door had a wood rod placed at the bottom in the track to prevent the door from being opened. This is an immediate risk to residents.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: By 10/25/2024, Licensee shall come up with a written plan for staf to address monitoring of residents who are wander risks. This plans shall also address staffing needs because if the staff on duty are assisting other residents and that leaves no staff to monitor the rest of the residents the licensee shall have another staff on duty. Licensee shall include staff training and how often she is going to train staff. $500.00 immediate civil penalty

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(6) · Plan of correction due date: Oct 25, 2024

Personal Accommodations and Services. The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction. Licensee failed to meet this because the front door was blocked by two chairs and the sliding glass door had a wood rod placed at the bottom in the track to prevent the door from being opened. This is an immediate risk to residents.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: By 10/25/2024, the licensee shall ensure no walkways, doorways, etc., are blocked by anything. The licensee shall submit a written statement stating she understands she cannot do this and how she shall ensure no walkways, doors, etc., are blocked.

Type of visit: POC

Licensing Program Analyst (LPA) Cassandra Mikkelson conducted a follow up visit regarding deficiencies cited during the annual inspection on 10/02/2024. LPA requested a copy of the updated certificate of liability insurance. LPA was provided with a copy of a proposed liability insurance which is in process. Facility will send a copy of certificate of liability insurance to LPA once renewed. LPA observed the RCFE poster had not been displayed in a common area in facility. LPA requested that regulation sized (20' by 26') RCFE poster be displayed at facility. LPA reviewed six (6) resident files. LPA observed that physician reports for R1 and R2 had been filed in the appropriate resident files. LPA observed that needs and services plan for R1 and R2 were partially completed and not signed in files. LPA requested that needs and services plans for R1 and R2 be completed and signed. Deficiency 87458(a), is has been cleared. LPA requested a copy of the emergency drill log and disaster plan. LPA observed emergency drill log and disaster plan were current. LPA also asked for the infection control plan. Facility will email infection control plan to LPA. Deficiencies 1569.695(c) and 1569.695(d) have been cleared. The following was observed but not cited during this visit: there was an easy chair blocking one of the doors between the hallway to the resident rooms and the common area preventing it from closing. The doors are there per the fire department. The chair was moved during the visit and staff were advised to not block the door. It was not cited because the easy chair was easily moved out of the way. No deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 24, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Hiratsuka and Mikkelson, conducted this unannounced case management visit in response to investigating Complaint 59-AS-20241022104408. The following observations were cited: -There are no audio alerts on the exits to the outside. Title 22 Regulations require audio alerts on all exit doors when exiting poses a hazard to residents. There are two residents who attempt to leave or have left the facility unnoticed and the audio alerts were turned off. Licensee stated the audio alert batteries die quickly so she put two chairs in front of the door and a wood rod in the sliding glass door (cited on complaint visit) -A review of Resident (R1) needs and services plan it does not state the resident wanders outside and has left the facility a couple of times unnoticed by staff. There is no plan to address the resident attempting to leave the facility. -A Review of Resident (R2) file, the needs and services plan has White-Out on it with R2's name handwritten on it but the plan itself mentions another person. -A review of R2's file shows R2 does not have a pre-placement appraisal. Title 22 requires a pre-placement appraisal and annual appraisal. -Licensee did not report R1 leaving the facility unnoticed by staff within 24 hours or by next business day by fax or phone call as required by Title 22 regulations. The resident leaving the facility unassisted meets the 24 hour notice because it threatened the health and welfare of the resident. The resident was found unharmed. LPA Hiratsuka informed License Baby Quintero during a phone call that a meeting between Community Care Licensing Division and her shall be scheduled to address all the issues cited on the complaint and issues cited on this report. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. Exit interview conducted. A copy of the report has been issued.Failure to correct the deficiencies may result in Civil penalties being assessed. Appeal Rights provided.the state’s words, verbatim · CDSS document, Oct 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: Oct 25, 2024

Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This was not met as evidenced by: LPAs observed the audio alerts were not working and Licensee stated the batteries die quickly so she put chairs to block the entrance so staff can hear the chairs move.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: By 10/25/2024, Licensee shall come up with a written plan to address the audio alerts on the doors since there are two residents who attempt to leave out of the front door and one made it out the back door and side gate unnoticed by staff.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87463(a) · Plan of correction due date: Oct 25, 2024

Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition... This was not met as evidenced by the appraisal has not been updated to address the resident wandering and leaving the facility unoticed by staffthe state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: By 10/25/2024, the licensee shall update the appraisals to address the current needs of the residents. Licensee shall come up with a written plan on how she shall ensure the appraisals done on each resident is complete and addresses any and all needs of the residents and submit that plan to Community Care Licensing Division.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(a) · Plan of correction due date: Oct 31, 2024

Pre-Admission Appraisal - General. Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions This was not met as evidenced by, a review of R2's file there was not a pre-admission appraisal completed. There was one that had White-Out on it with R2's name written on top but someone else's name on the form.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: By 10/31/2024, Licensee shall come up with a written plan of correction on how she shall ensure pre-admission appraisals are completed and with the correct resident name is on it.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(2) · Plan of correction due date: Oct 31, 2024

Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency. Licensee did not report the resident who left the facility unassisted to Community Care Licensing Division as of today's visit.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: By 10/31/2024, the licensee shall come up with a written plan on how she shall ensure she shall meet the reporting requirements of Title 22 Regulations.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Caregiver Leriza Arambulo during today's inspection. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 4 resident rooms, 2 bathrooms, kitchen, common living spaces, backyard and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. LPA reviewed 3 of 6 resident files and 2 staff files. LPA reviewed medications of two residents comparing with physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Deficiencies cited on 809-D. Appeal rights provided. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 2, 2024

Allegation investigated: . Staff are restricting resident visits 2. Staff do not ensure that resident is appropriately dressed 3. Staff isolate resident in his room 4. Staff do not prevent visitors from posting resident confidential information in the facility 5. Staff mask medication in resident's food 6. Staff did not provide a bed that met the resident's needs 7. Furniture in the resident's room violates the facility fire clearance 8. Staff prohibit resident from eating without assistance from staff

LPA Hiratsuka, conducted this unannounced complaint visit to deliver the results into the allegations above. LPA reviewed resident files and conducted interviews with responsible party, Licensee, one staff, and two witnesses. 1. The resident has a conservator who has paperwork that states they may restrict vistations. Staff stated they do not restrict visitors. 2. LPA interviewed resident in question. Resident stated they do not want to wear certain clothing items at all times. LPA interviewed responsible party and two witnesses and all stated the resident does not want to wear certain clothing items and they have the right to refuse and to wear what they want. Unfounded 3. LPA interviewed resident in question. Resident stated they do not want to socialize with anyone and is content in their room. LPA interviewed responsible party and the two witnesses and all stated the resident has told them the resident does not wish to visit with the other people living in the facility and is content in their room. 4. LPA interviewed the witnesses. The note was not on the door when LPA visited on 09/14/2023. LPA was informed by one witness that it did not have any confidential information. It just stated to not wake up the resident if the resident was sleeping when visitors showed up because the resident does not want to be woken up and instructions for what to do if someone insisted on visiting against the resident's wishes. Responsible party stated the resident has always slept at random times and has never liked to have their sleep interrupted for a long as they have known each other. 5. LPA reviewed medication orders and conducted interviews. There are orders to crush the medications and to put it on food. Caregiver stated the medications are put on foods the resident likes to eat to try to ensure the resident will take it, but the resident refuses to take medications a lot. LPA confirmed that with the responsible party. Resident stated they do not get tricked into taking medications. Witness stated the resident refuses to take medications at times. The responsible party told LPA the resident has take naps at random times for as long as they have known each other and the resident is not over-medicated. 6. LPA interviewed Licensee. Licensee stated when the resident was admitted to hospice the hospice agency ordered a bed that did not originally fit the resident and so the agency had to order a new one. The resident was in the original hospice bed until a new one arrived that better fit the resident. This was confirmed by the responsible party. 7. All witnesses interviewed stated nothing blocked the bed the resident is in. They stated there were two beds in the room for a short time but the second bed was pushed up against the far wall and there was a lot of space between the beds. The witnesses stated they have not seen anything blocking any exits to the outside or anything blocking beds. LPA toured the facility on 09/14/2023, and did not see any fire hazards. 8. LPA interviewed two residents and both stated they get enough to eat. One was the resident in question and that resident stated they get more than enough food when they want it. Both stated the food is good. A witness stated they ask the resident when visiting if the resident is hungry and if the resident states they are the caregivers bring a meal to the resident and assist if need. The responsible party stated the resident gets enough to eat when the resident wants it. Based on information above, the department concluded that the allegations are Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. no deficiencies citedthe state’s words, verbatim · CDSS document, Oct 5, 2023 · control 59-AS-20230912152259