Candleberry Care

Allegation investigated: Staff left resident unattended Staff offered resident drugs Staff made inappropriate comments towards resident Staff are not answering facility phone

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Licensee Rico Almiranez and explained the purpose of the inspection. Regarding allegation, Staff left resident unattended, the following was revealed: Complaint alleges Resident 1 (R1) was left in the shower unattended for an hour and a half. During the course of the investigation, interviews were conducted with three residents, including R1 and three facility staff. During their interview, R1 stated they were left in the shower unattended “for a long time”, however, was unable to indicate approximately how long, and stated they were unsure of where staff was during that time. R1 is no longer a facility resident and was discharged on October 17, 2022. Three of three staff employed during the time R1 was a resident have not been employed by the facility in over three years and contact information for three of three staff is no longer available. (Cont. LIC9099-C) Unsubstantiated During their interview, two of two current staff denied having any knowledge of any current or former staff leaving a resident unattended. During their interview, Licensee stated R1 was not left in the shower unattended and stated R1 was able to shower independently and would request that staff leave them in the shower in order to have some privacy. Per Licensee, R1 was never left in the shower alone for more than 10 minutes and staff would check on them periodically. One of two current facility residents interviewed denied ever being left unattended and stated staff is responsive to their needs. One of two residents was unable to confirm or deny the allegation. Regarding allegations, Staff offered resident drugs and Staff made inappropriate comments towards resident, the following was revealed: Complaint alleges Staff 2 (S2) offered R1 drugs and that Staff 1 (S1) made inappropriate comments to R1. During the course of the investigation, interviews were conducted with three residents, including R1 and three facility staff. During their interview, R1 denied staff ever made inappropriate comments towards them or offered them drugs. S1 and S2 could not be interviewed as they have not been employed by the facility for over three years and contact information for both staff is no longer available. During their interview, two of two current staff denied having any knowledge of any current or former staff offering resident drugs and denied witnessing or having any knowledge of S1 making derogatory towards any resident. During their interview, Licensee denied S2 or any other current or former staff offering R1 or any other resident drugs and denied S1 or any other current or former staff making inappropriate comments toward R1 or any other resident. During their interview, Resident 2 (R2) stated they were acquainted with S1, however, stated they were not acquainted with S2. R2 denied any current or former staff ever offering them drugs and denied S1 or any other current or former staff making inappropriate comments towards them. During their interview, Resident 3 (R3) was unable to confirm or deny the allegations. Regarding allegation, Staff are not answering facility phone, the following was revealed: Complaint alleges Staff do not answer the phone or they hang up. During the course of the investigation, interviews were conducted with three residents and three facility staff. During their interview, R1 stated they had a personal phone while residing at the facility and did not use the facility phone. R1 was unable to confirm or deny if staff would purposely ignore the facility phone or hang up. During their interview, two of two staff denied purposely ignoring the facility phone or hanging up. One of two staff, however, stated that S1 would purposely ignore the facility phone and one of two staff stated S1 would not ignore the phone but were simply busy tending to residents and could not answer the phone. (Cont. LIC9099-C) S1 could not be interviewed as they have not been employed by the facility for over three years and contact information for them is no longer available. During their interview, Licensee denied the facility phone being purposely ignored by any current or former staff and denied having any knowledge of any current or former staff hanging up the phone. One of two current facility residents interviewed denied staff not answering the facility phone and stated that in the event they receive a call on the facility phone, staff will bring the phone to them, and they are able to receive the call privately. One of two residents was unable to confirm or deny the allegation. Due to allegations being uncorroborated during interviews conducted, the Department is unable to determine if Staff left resident unattended, if Staff offered resident drugs, if Staff made inappropriate comments towards resident, or if Staff are not answering facility phone. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Apr 16, 2026 · control 22-AS-20221019153708

Type of visit: Required - 1 Year

On January 30, 2026, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley introduced self and was granted entry into the facility by staff, after stating the purpose of the visit. Administrators Uldarico Almiranez and Shellad Yturralde. The facility is licensed to operate for six (6) non-ambulatory residents age 60 and over, with a Hospice waiver for six. The building is a one-story home located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, living room area, kitchen, outdoor covered seating, and an attached two car garage. During the visit, LPA toured the inside and outside of the physical plant with Yturralde. There were no bodies of water or obstructions on the premises. All rooms were inspected, beds and bedding supplies were in good condition, and storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. A comfortable temperature of 72 degrees F was maintained throughout the facility. Bathrooms were found to be clean and operational, with water temperatures in bathrooms measured between 118.2 degrees F and 119.5 degrees F. The smoke detectors and carbon monoxide detectors were operable. First aid kit is maintained and contains all the necessary elements. Continues on LIC 809-C… Emergency safety drills were last conducted on January 2, 2026. The facility has one (1) fire extinguisher that was charged, mounted, and last serviced March 20, 2025. Current Liability Insurance was provided during the visit with a policy start date of October 15, 2025, through October 15, 2026. A working telephone (562)296-5035 remains available and the facility has a device that can be used for video teleconference purposes. LPA conducted an audit of five (5) resident files (R1-R5), three (3) staff files (S1-S4), and medication and medication administration review. Resident and staff interviews were conducted. Based on record review, the licensee did not comply with the section cited above in five out of five resident bedrooms, which poses an immediate health and safety risk to persons in care. LPA observed non operational fire alarms in five resident bedrooms. Licensee contacted vendor and scheduled replacements during visit. The facility currently has one bedridden Resident #1 (R1) with a fire clearance for six (6) non-ambulatory only residents. Deficiencies were cited during this visit, as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrators Uldarico Almiranez and Shellad Yturralde, and a copy of this report, LIC809-D, LIC421 and appeals right were provided at exit.the state’s words, verbatim · CDSS document, Jan 30, 2026

Allegation investigated: -Staff leave resident in wheelchair for extended period of time -Staff leave resident in shower for extended period of time -Staff do not respond to resident cry for help -Staff barricaded resident's door

Licensing Program Analyst (LPA) William Vanegas made an unannounced inspection for the purposes of delivering findings regarding the above-mentioned allegations. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Care Giver (CG) Shellad Yturralde. LPA Vanegas explained the nature of the inspection. During the course of the inspection, LPA Vanegas obtained and reviewed copies of records pertinent to Resident 1(R1). Interviews were conducted with three residents, and three staff on duty. Interviews conducted revealed the following. LPA Vanegas attempted to contact R1two times and was unsuccessful. Regarding the allegation stating facility staff leave R1 in wheelchair for extended period, interviews with R2, R3, and R4 informed LPA Vanegas that they have never witnessed staff members leaving residents in a wheelchair for an extended period. CONTINUED ON LIC9099C Unsubstantiated Regarding the allegation stating facility staff leave resident in the shower for extended period, interviews conducted with residents in care revealed that all residents have never been left in the shower for an extended period; additionally, if they do need help, they get assistance right away. R2, R3, and R4 confirmed this information. Regarding the allegation that R1 cries out for help, but the staff do not respond to the cries for help; resident interviews revealed the following. R2, R3, and R4 stated that if they need help, they get assistance in a timely manner. They get help at all hours through the day if they require it, and at all hours throughout the night if needed. Additionally, LPA Vanegas tested the call button system for assistance, and staff responded immediately. Regarding the allegation stating that resident doors are barricaded interviews with staff and residents in care reveled the following: R4 stated that they have never seen any barricaded doors. R2, R3, and R4 all stated that they have never seen any barricaded doors. S1, S2, and S3 stated that they have never barricaded any doors in the facility. Based on the observations made and interviews, conducted during today’s inspection. The above allegations are deemed to be unsubstantiated. No deficiencies are being cited today per Tittle 22- Chapter 8 division 6 of the California Code of Regulations. An exit interview was conducted with CG Socrates Yturralde and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 21, 2025 · control 22-AS-20220928111256

Allegation investigated: -Facility staff stole resident's laptop from them.

Licensing Program Analyst (LPA) William Vanegas made an unannounced inspection for the purposes of delivering findings regarding the above-mentioned allegations. Upon arrival LPA Vanegas was greeted and granted entry by Care Giver (CG) Shellad Yturralde. LPA Vanegas explained the nature of the inspection. During the course of the inspection, LPA Vanegas obtained and reviewed copies of records pertinent to resident 1 (R1). Interviews were conducted with three staff members, and three residents in care; interviews, and record review revealed the following. Regarding the allegation stating that facility staff stole resident’s laptop from them; Interviews conducted with three out of three staff stated that R1 did not enter the facility with a laptop. Per LPA Vanegas review of R1’s personal property, and valuables record. There is no documentation of a laptop that belonged to R1 at the time of admission to the facility. Interviews with four out of four residents revealed that residents in care did not observe R1 with a laptop. LPA attempted to contact R1 twice to conduct an interview regarding allegations being investigated, however LPA was unable to contact R1. CONTINUED ON LIC9099C. Unsubstantiated Based on interviews conducted with staff and residents in care, the preponderance of evidence has not been met, and this allegation is deemed to be unsubstantiated. An exit interview was conducted with CG Socrates Yturralde, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 21, 2025 · control 22-AS-20230224131142

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 30, 2025

87468.1 Personal Rights of Residents in all Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. Regulation was not met by licensee as evedenced by interviews conducted with staff and residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2025

Plan of correction: Administrator will conduct an all staff in service training in regards to personal rights, harrasement, and job functions of all staff. Licensee will send proof of correction to LPA Vanegas via email by P.O.C due date.

Type of visit: Required - 1 Year

On this day Licensing Program Analysts (LPAs) William Vanegas and Fred Arias and Licensing Program Manager (LPM) Alisa Ortiz made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 6 residents and the home currently has 5 residents, with 2 residents on hospice. Administrator (AD) Ulderico Almiranez arrived shortly to help with the visit. AD Almiranez has a valid certificate that expires on April 10, 2026. LPA along with Lead Staff Shellad Yturralde toured the facility at 9:00 AM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 4 resident bedrooms, living room, dining room, and kitchen as well as 2 restrooms and 1 staff room. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 113.7 degrees F and 114 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the emergency disaster plans and plans are complete and thorough. Facility conducts emergency drills with the last drill conducted on 8/9/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise and outings. There is shaded outdoor seating for residents. Exit gates are unlocked and operational. LPA observed the emergency food and water supply. CONTINUED ON LIC 809C DATED 1/14/2025. LPAs reviewed five resident files and three staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. LPA observed some medications stored outside the designated medication locked cabinet. LPA reviewed medication for 3 of 5 residents. Medications for 1 resident were stored outside the original container. One medication for 1 resident was not being administered per physician's order. Based on the observations made during today’s visit, 4 deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy of this report and appeal rights was provided at the time of exit.the state’s words, verbatim · CDSS document, Jan 14, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 1:00 PM. During today’s visit, LPA met with Shellad Yturralde, Administrator Designee and Uldarico Almiranez (AD) via telephone. The facility is a single story building with an approved fire clearance of six non-ambulatory residents of which six may be on hospice. The facility currently has a census of three residents in care. At 1:05 PM LPA toured the facility and inspected the physical plant, including but not limited to testing hot water temperature in two of two resident bathrooms. The hot water temperature measured between 112.6 and 113.1 degrees Fahrenheit. At 1:11 PM LPA observed when necessary, PRN, medications in non-ambulatory bathroom #2 in which a deficiency is cited, Staff immediately placed meds in locked centrally stored medication cabinet. At 3:30 PM testing of smoke detectors, carbon monoxide and auditory devices on all exits were operational. The fire extinguisher is charged and was serviced on March 19, 2024. The facility’s last fire drill was conducted in 2023 and a Technical Violation will be given. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. LPA reviewed three of three staff training and fingerprint records and reviewed three of three resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on April 10, 2026. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Shellad Yturralde, AD Designee, and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D, LIC 9102-TV and Appeal Rights.the state’s words, verbatim · CDSS document, Jul 29, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.