Carewell Manor

Type of visit: Office

An Informal Conference was held on this date at the Orange County Adult and Senior Care Regional Office in Orange, California. The informal meeting process was explained to the Licensee. At this informal conference, present were: Licensing Program Manager (LPM) Kevin Saborit-Guasch, Licensing Program Analyst (LPA) Hanna Gough and Licensee Carol Wilson. The purpose of the meeting was to discuss the change of ownership of the facility. The following concerns were discussed during the meeting: § License is not transferable § Provide residents with 60 days’ notice regulations § Provide resident/responsible party that facility is undergoing a change of ownership § Provide resident/responsible party with letter of closure § Provide resident/responsible party that they have the right to stay or relocate to another licensed facility. An exit interview was conducted and a copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, May 20, 2026

Allegation investigated: Staff did not provide adequate meals to resident in care Staff did not provide toileting assistance to resident in care Staff attempted to terminate resident’s conservatorship

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a complaint investigation into the above mentioned allegations. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Carol Wilson and discussed the purpose of the visit. The investigation into the above allegations revealed the following: it was alleged that staff are providing meals to R1 that go against their diet restrictions, that R1 was not being assisted with their toileting needs and that staff at the facility attempted to terminate the resident’s conservatorship with R1s doctor. LPA observed an admission agreement for Resident #1 (R1) stating that they were admitted to the facility on October 11, 2024, and was signed by R1. LPA observed a physicians report for R1 dated August 11, 2025, stating that R1 does not have a special diet, does not have motor impairment and does not require assistance when transferring and repositioning. R1 was marked on their physicians report as being able to bathe, dress and care for their toileting needs. R1 is marked as ambulatory and the report was signed by a physician. Continue on LIC9099C Unfounded LPA observed a needs and services plan dated November 9, 2024, stating that R1 did not have any physical or functional issues and was signed and dated by facility staff only. LPA observed a preplacement appraisal for R1 dated November 4, 2024, stating that R1 had no physical disabilities, was able to walk without assistance, does not have a special diet and does not need assistance with toileting. This was signed by R1s Public Guardian at the time on November 4, 2024 only. LPA did not observe conservator paperwork for R1 in their facility file. Interviews with 2 of 2 staff revealed that R1 did not have a special diet that needed to be followed. 2 of 2 staff informed LPA that they make all residents in care fresh meals. 2 of 2 staff informed LPA that R1 uses the commode in their room only at night. 2 of 2 staff informed LPA that R1 wants to have the commode in their room for nighttime convenience. 2 of 2 staff informed LPA that R1 does not require assistance with their toileting needs. 1 of 2 staff informed LPA that R1 has a new conservator and their paperwork has not been provided to the facility. 1 of 2 staff informed LPA that they did not try to terminate R1s conservator, but R1 is trying to terminate the conservator themselves. LPA interviewed R1 and it was revealed that they can eat whatever they want and are not on a special diet. R1 informed LPA that facility staff will take them to the store so they can purchase things they like and this has included items such as ramen. R1 informed LPA that they do not need assistance with toileting, but they like having the commode in their room due to getting up to use the restroom multiple times during the night. R1 informed LPA that it is entirely their choice to have the commode in their room and staff will assist them if needed. R1 informed LPA that the staff at the facility has not tried to terminate their conservator, but R1 is trying to terminate their need for a conservator themselves. Based on the evidence gathered, the Department finds that the facility allegations of staff did not provide adequate meals to residents in care, staff did not provide toileting assistance to resident in care and staff attempted to terminate residents conservatorship has been deemed UNFOUNDED. This means that the allegations are false, could not have happened or is without a reasonable basis. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 22-AS-20260206123901

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Carol Wilson and discussed the purpose of the visit. The facility has 5 residents in care of which all were observed relaxing and watching tv in their bedrooms. The facility is a one story home with 5 resident rooms, 3 bathrooms, kitchen, dining room, living room, den, staff room, backyard and 2 car garage. LPA observed the resident bedrooms to have all the required components and furnishings. LPA observed the staff room to be clean and free of medications or other supplies that should be inaccessible to residents in care. LPA observed the bathrooms to have paper towels, toilet paper and non slip mats in the shower. LPA tested the water to in the bathrooms to be between 106.7 and 112.4 degrees Fahrenheit. LPA observed a clean supply of linens for resident use in the hall cupboard located by the restrooms. LPA observed the kitchen to be clean and free of vermin. LPA observed the knives to be in a locked drawer by the kitchen sink and made inaccessible to residents in care. LPA observed the toxins and chemicals to be locked under the kitchen cabinet and made inaccessible to residents in care. LPA observed the centrally stored medication to be in a locked cabinet above the kitchen sink making them inaccessible to residents in care. LA observed a fire extinguisher in the kitchen charged and with a service date of January 11, 2026. LPA observed the garage to be used for extra storage. LPA observed the backyard to be free of debris and obstructions. LPA observed a shaded seating area for resident use. LPA and AD tested the fire alarms and smoke detectors and they were found to be operational. continue on LIC 809C LPA reviewed staff files and observed that Staff #1 did not have the required regulatory hours per topic for their 20 hours annual training. LPA reviewed resident files and observed that 2 of 5 residents do not have a tb test on file and 5 of 5 residents need updated needs and services plans. LPA reviewed resident medications and observed that medications are not being given and left in the bubble pack, but being signed off on the MAR with no explanation. LPA observed the last fire drill was conducted on January 8, 2026. All staff present are background cleared and associated to the facility. Based on observations during the inspection technical violations and citations were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC 858, 859, 809D, technical violations and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jan 23, 2026

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: . Staff do not have fingerprint clearance, 2. Staff insert suppositories to residents in care, 3. Staff did not maintain resident records, 4. Residents are not provided proper food service, 5. Staff did not inform resident's physician of resident's change of condition, 6. Staff did not ensure sufficient food items were available at the facility for residents in care, 7. Centrally stored medications are accessible to residents in care, 8. Staff do not have a fire evacuation plan at the facility, 9. Staff do not have an infection control plan at the facility, 10. Staff are not following reporting requirements, 11. Staff did not ensure resident's diapering needs were met 12. Staff consume liquor while on shift and 13. Staff left residents unattended

This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned bove. LPA arrived at the facility and was greeted by facility staff. LPA met with Administrator Rafael Torres and explained the nature of the inspection. The department received a complaint on 11/20/2024 alleging the following: 1. Staff do not have fingerprint clearance, 2. Staff insert suppositories to residents in care, 3. Staff did not maintain resident records, 4. Residents are not provided proper food service, 5. Staff did not inform resident's physician of resident's change of condition, 6. Staff did not ensure sufficient food items were available at the facility for residents in care, 7. Centrally stored medications are accessible to residents in care, 8. Staff do not have a fire evacuation plan at the facility, 9. Staff do not have an infection control plan at the facility, 10. Staff are not following reporting requirements, 11. Staff did not ensure resident's diapering needs were met, 12. Staff consume liquor while on shift and 13. Staff left residents unattended. (continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) On 11/26/2024 LPA conducted a visit to the facility to initiate investigation into the above allegations. LPA obtained copies of resident roster, staff roster, infection control plan, disaster plan, training records, personnel records, CPR certification, admission agreements and facility sketch. On 1/16/2025, LPA returned to the facility to continue the investigation. LPA obtained photos of the following documents: criminal record clearances, physician's reports and health screenings. Regarding the allegation of "Staff do not have fingerprint clearance," LPA reviewed staff files and observed Criminal Record Clearances in all staff files. LPA also reviewed the facility's personnel records through Guardian and observed 6 out of 6 staff have been cleared to work at the facility. Regarding the allegation of "Staff insert suppositories to residents in care," LPA interviewed the 5 residents in care and all of them stated the facility does not insert suppositories or other medication into them rectally. Regarding the allegation of "Staff did not maintain resident records," the allegation indication LIC602s are missing or outdated in resident files. LPA observed LIC602s all resident files. 4 out of 5 LIC602s were created in 2024. 1 out of 5 LIC602s was created in December 2023. Regarding the allegation of "Residents are not provided proper food service," LPA interviewed 5 residents in care. Of the residents interviewed all stated they are provided proper food service and have no complaints. Regarding the allegation of "Staff did not inform resident's physician of resident's change of condition," LPA reviewed resident files and noted one resident with dementia. LPA observed an admission agreement for this resident stating they moved into facility on 7/24/2024. LPA observed a completed physician's report indicating the resident has dementia. This report was signed by the resident's physician and dated 8/23/2024. Regarding the allegation of "Staff did not ensure sufficient food items were available at the facility for residents in care," LPA observed the food supply in the facility. LPA noted the facility has 7 day supply of non-perishable foods and a 2-day supply of perishable foods. LPA conducted interviews with 5 residents in care. Of the residents interviewed, all stated there is enough food in the facility and that they receive enough. Regarding the allegation of "Centrally stored medications are accessible to residents in care," LPA observed medications to be locked in a kitchen cabinet behind a lock that requires a key to open. Of the residents and staff interviewed, all stated medication remains locked in the kitchen. (Continued on 2nd LIC9099-C) (Continued from 1st LIC9099-C) Regarding the allegation of "Staff do not have a fire evacuation plan at the facility," LPA observed a completed LIC610E posted in the facility. Regarding the allegation of "Staff do not have an infection control plan at the facility," LPA observed a completed LIC9282 posted in the facility. Regarding the allegation of "Staff are not following reporting requirements," LPA reviewed documents and interviewed residents in care. Based on LPA's review and interviews, LPA could not determine if any incidents occurred that went unreported. Regarding the allegation of "Staff did not ensure resident's diapering needs were met," LPA conducted interviews with 5 residents in care. Of the residents interviewed, 3 stated they wear diapers. Of these residents, all of them stated they are changed appropriately and when they need to be. Regarding the allegation of "Staff consume liquor while on shift," LPA observed no liquor or consumable alcoholic products in the facility. LPA conducted interviews with 5 residents and two staff. Of the 7 individuals interviewed, all of them denied this allegation. Regarding the allegation of "Staff left residents unattended," LPA conducted interviews with 5 residents in care. Of the the residents interviewed, all of them stated the staff do not leave them unattended and that there is always a staff member present at the facility. LPA conducted interviews with 3 staff. 3 said the staff do not leave residents unattended. Based on observations made, interviews conducted and records reviewed there is insufficient evidence to support the allegations of "Staff do not have fingerprint clearance," "Staff insert suppositories to residents in care," "Staff did not maintain resident records," "Residents are not provided proper food service," "Staff did not inform resident's physician of resident's change of condition," "Staff did not ensure sufficient food items were available at the facility for residents in care," "Centrally stored medications are accessible to residents in care," "Staff do not have a fire evacuation plan at the facility," "Staff do not have an infection control plan at the facility," "Staff are not following reporting requirements," "Staff did not ensure resident's diapering needs were met," and "Staff consume liquor while on shift." Although the allegations may have happened or are valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation are UNSUBSTANTIATED. LPA reviewed this report with staff and provided a copy. (Continued from LIC9099) On 11/26/2024 LPA conducted a visit to the facility to initiate investigation into the above allegations. LPA obtained copies of resident roster, staff roster, infection control plan, disaster plan, training records, personnel records, CPR certification, admission agreements and facility sketch. On 1/16/2025, LPA returned to the facility to continue the investigation. LPA obtained photos of the following documents: criminal record clearances, physician's reports and health screenings. Regarding the allegation of "Staff lock facility doors to prevent residents from leaving," LPA observed facility staff unlock and lock the front door to the facility from inside the facility with a key. Of the 5 Residents interviewed, 4 of them stated the facility door locks from the inside with a key. Regarding the allegation of "Staff did not complete required trainings," LPA interviewed Staff 1. S1 stated they were hired at the facility in April of 2024. LPA reviewed S1's file and observed a completed in-service training for PRN medication administration. LPA observed no other completed trainings. LPA conducted interview with S1 and AD. Both stated S1 had not completed their required training. LPA interviewed S1 about their previous work experience. S1 stated they did not do food preparation or medication administration at their previous job. LPA determined S1 has not received training and does not have previous work experience in multiple areas related to their current role as caregiver Regarding the allegation of "Staff facility records are falsified," LPA observed a CPR card for Staff 1. LPA contacted the company named on the CPR card. The company had no record of the reference number on S1's CPR card. The company representative stated anyone who completed their course will have valid login credentials to their website. S1 stated they have valid login credentials to the website but was unable to login. S1 stated the CPR card was falsified and that they did not complete CPR certification through the company named on the CPR card. Regarding the allegation of "Staff did not provide adequate medication assistance to residents in care," LPA conducted interview with 5 residents in care. Of the residents interviewed, all of them stated they receive adequate medication assistance. Based on record review, the staff present at the facility at the time of the inspection has not received full medication administration training. Although the LPA observed record of this staff member attending an in-service training for PRN medication, the facility could not produce proof of any other medication training. S1 also stated they did not administer medication at their previous job. LPA determined staff are not providing adequate medication assistance to residents. (Continued on LIC9099-C) (Continued from LIC9099-C) The preponderance of evidence standard has been met. The allegations of "Staff lock facility doors to prevent residents from leaving," "Staff did not complete required trainings," "Staff facility records are falsified," and "Staff did not provide adequate medication assistance to residents in care" is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that violations have occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 22-AS-20241120085349

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(f) · Plan of correction due date: Jan 30, 2025

87705 Care of Persons with Dementia (f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: The Licensee did not comply with the section cited above due to the presence of a locked front door that requires a key to open from inside the facility. LPA determined the facility has not fulfilled the requirements to maintain a locked exterior door. The requirements are found in Title 22 Regulations 87705(f)(1)-(f)(4). This presents a potential personal rights and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 16, 2025

Plan of correction: The facility staff stated they will remove the lock from the exterior door by the assigned POC due date of 1/30/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d) · Plan of correction due date: Jan 30, 2025

87411 Personnel Requirements-General (d)All personnel shall be given on the job training or have related experience in the job assigned to them. The Licensee did not comply with the section cited above due to the presence of a staff member who is providing food preparation and medication administration without prior experience or training to do so. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2025

Plan of correction: The Administrator stated they will ensure all staff complete their required training. Administrator will document training with the following: staff participating, topics covered and date/time of training. Facility staff will submit this documentation to the Department by the assigned POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Jan 30, 2025

87207 False Claims; No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. The Licensee did not comply with the section cited above due to the presence of a falsified CPR certification. This poses a potential health, safety or personal righs risk to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2025

Plan of correction: The Administrator stated they will remove the falsified CPR document from all files. The Administrator stated they will ensure there are no falsified documents in any of the facility records.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(3)(D) · Plan of correction due date: Jan 30, 2025

87411 Personnel Requirements-General(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training (3)(D) Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4). The Licensee did not comply with the section cited above due to being unable to show proof that all staff who provide medication assistance have adequate medication administration training and/or experience. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2025

Plan of correction: The Administrator stated they will conduct an in-service training regarding medication administration and ensure all care staff attend. AD stated they will document the training with: staff in attendance, topics covered and date/time of training. AD stated they will submit proof of training to the Department by the assigned POC due date.

Type of visit: Case Management - Other

On 12/3/2024 LPAs Dwayne Mason Jr and Fred Arias arrived at the facility for the purpose of conducting a case management visit to return files taken from the facility. On 11/26/2024, LPA Mason conducted a 10-day complaint visit and borrowed the following files from the facility: resident roster, staff roster, infection control plan, disaster plan, training records, personnel records, CPR certification, admission agreements and facility sketch Administrator received the original files. LPAs reviewed the report with the Administrator and provided a copy.the state’s words, verbatim · CDSS document, Dec 3, 2024

Type of visit: POC

On 12/3/2024 LPAs Dwayne Mason Jr. and Fred Arias arrived at the facility for the purpose of conducting a Plan of Corrections visit. LPAs were greeted and granted entry by facility staff. LPAs met with Administrator Carol Wilson. On 11/26/2024, the facility received two Type A deficiencies. One deficiency was for toxins that were accessible to residents in two places. The other deficiency was issued due to the absence a medication administration record for PRN medications. While at the facility, LPAs observed bleach had been moved from two locations accessible residents to the locked garage. While at the facility, AD provided LPAs with a document for PRN Medication Administration Record In-Service training. The provided document indicated the staff in attendance, topics covered and date and time of the training. The training was conducted on 11/27/2024 at 3:00pm Based on today's visit, LPAs determined the facility fulfilled the plans of corrections. LPAs cleared the two deficiencies and provided the facility with a copy of this report and one clear letter.the state’s words, verbatim · CDSS document, Dec 3, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Nancy Guillen arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs were greeted at the facility by facility staff. LPAs met with Carol Wilson, Administrator and explained the purpose of the inspection. The facility is one-story building with 5 resident rooms, 3 bathrooms, kitchen, dining room, living room, den, staff room, backyard and 2-car garage. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. LPAs observed nails on the backyard table, an inoperable shower, oven is missing an igniter knob, light in the refrigerator in inoperable, broken drawer in the kitchen and two sinks not draining. A deficiency is being issued. LPAs observed 3 trash cans without lids, a deficiency is being issued. LPAs observed bleach in two accessible areas. A deficiency is being issued. Hot water measured between 105 and 120 degrees F. LPAs observed facility has emergency food and water supply. LPAs reviewed facility files. Base on file review, LPAs determined the facility does not have a dementia care plan. A deficiency is being issued. LPAs reviewed five staff files and six resident files. LPAs conducted interviews with five residents and two staff. LPAs reviewed medication. Based on medication review, LPAs determined the facility does not have a current record of dosages for prescribed medication or prescribed PRNs. Two deficiencies are being issued. LPAs also observed multiple residents' medication in pill containers up to one week in advance. One deficiency is being issued. Based on today's inspection, seven deficiencies are being issued. An exit interview was conducted and a copy of this report and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Nov 26, 2024

Allegation investigated: Administrator did not treat residents with dignity and respect.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above. LPA was greeted and granted entry by facility staff after explaining the reason for the visit. Administrator Carol Wilson was notified of the visit and read the findings via telephone before giving permission to staff to sin on her behalf The initial complaint investigation took place on April 22, 2024. During the visit, LPA conducted a tour of the physical plant. LPA then requested and reviewed the records and hospice file for one specific facility resident. Three staff interviews, one witness interview and one resident interview were additionally conducted or attempted during the facility visit. The contact information for additional witnesses was provided for use at a later date. Two additional witness interviews were conducted via telephone on June 14, 2024. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 On April 10, 2024, a verbal argument occurred between the facility's administrator and a visitor to the facility after the visitor requested access to one of the resident's hospice file and was denied access to the documents. Two additional visitors were present at the time of the incident and were later interviewed by LPA. A witness interview confirmed that the facility's administrator had received clear instructions to limit access to certain documents, as it was stated to have occurred on the day of the verbal confrontation. Both witnesses present described the administrator as experiencing visible frustration at the repeated requests to disregard the instructions in question, however both witnesses also denied having heard any insults or inappropriate language being used at the time, either directed at facility visitors or in the presence of facility residents. Two video files timestamped on the same day and reviewed by LPA also failed to provide any evidence of inappropriate or injurious language being used on that day. As a result, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 22-AS-20240416145901

Type of visit: POC

On this day, Licensing Program Analyst (LPA) conducted a review of the plan of corrections for a deficiency cited on April 29, 2024 regarding the presence of a bedridden resident in a facility for which the current fire clearance did not include a provision for the admission of bedridden individuals. The bedridden resident R1 has since passed away. However no death reports have been submitted to the Department at this time. However, the facility is no longer in violation of Section 87606(c) of the California Code of Regulations regarding the Care of Bedridden Residents, therefore the type A deficiency issued on April 29, 2024 is cleared at this time. A Technical Violation Advisory Note on reporting requirements is however issued to the licensee, as well as a consultation provided in order to ensure the timely reporting of Unusual Incidents directly to the Regional Office. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jun 20, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Dwayne Mason Jr. and Faith La arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs were greeted and granted entry into facility by Karen Moralde and John Moralde, Caregivers. Facility Administrator Carol Wilson joined the inspection after the tour. The facility is a one-story home with six client bedrooms, one staff room, three bathrooms, kitchen, dining room, living room, TV room, backyard and attached 2-car garage. LPAs noted there are two vacancies at the facility. All four residing residents were present. All client rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens for residents in the hallway closet. Restrooms are stocked with soap and paper towels. LPAs measured water all three bathrooms. LPAs measured hot water to be 109.8, 114.2 and 110.5 degrees Fahrenheit in the three bathrooms. LPAs noted Fire Extinguisher was last serviced on 04/22/2024. LPAs observed hazardous items such as knives, chemicals and cleaners to be locked up in cabinets in the kitchen. Knives are locked up separate from toxic chemicals. Medication for each client is kept locked in a kitchen cabinet. The backyard has a shaded sitting/lounging area. Exit gate is unlocked. LPAs observed exit gate to be unobstructed. LPAs reviewed two of the four resident files and three staff files. LPAs also reviewed medication for two out of four clients. LPAs interviewed two residents and two staff. LPAs issued Technical Assistances (TA) to advise the facility to maintain a plan of operation including a dementia care plan and bedridden care plan. Based on record review, LPAs determined that only one disaster drill was conducted and documented at the facility in the last year. Two deficiencies are being issued based on today's inspection. An exit interview was conducted and a copy of this report and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, May 10, 2024

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of issuing a citation for a deficiency. LPA was greeted and granted entry by facility administrator Carol Wilson after stating the purpose of the visit. On April 22, 2024, an initial investigation visit was conducted for complaint reference #22-AS-20240416145901. LPA reviewed records maintained at the facility for resident R1. Per a physician report dated November 29, 2021, R1 is diagnosed with Parkinson's disease and was assessed to be bedridden. According to the facility's administrator, this is the most recent medical assessment on file with the exception of R1's hospice plan of care. Per the terms of its current license printed on April 20, 2018, the facility is licensed for 6 non-ambulatory residents and has a hospice waiver in place for a total capacity of 2 residents receiving hospice care. The facility is however not in possession of a fire clearance for a bedridden resident at this time. A Type A citation for failure to meet the requirements of the California Code of Regulations Section 87606(c) was issued. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.the state’s words, verbatim · CDSS document, Apr 29, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87606(c) · Plan of correction due date: Apr 30, 2024

Per CCR 87606(c) on the Care of Bedridden Residents: "To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance(...). This requirement is not met as evidenced by: Based on interview conducted, facility observation and a review of records, resident R1 has been assessed to be bedridden while the facility is not in possession of an adequate fire clearance. This constitutes an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2024

Plan of correction: Licensee will provide increased two-person supervision to the resident as well as provide the Department with a written statement of its intent to obtain a bedridden fire clearance from the competent fire authority or seek alternative placement for R1.

Allegation investigated: Staff is not providing adequate care and supervision to individuals in care. Residents are left in their soiled clothing.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit to continue the complaint investigation and deliver the findings into the above allegations. LPA was allowed entry by Caregiver Karen Mae Moralde and stated the purpose of the visit. Administrator (Admin) Carol Wilson arrived at 10:37am. On October 10, 2022, LPA Claudia Gutierrez initiated the complaint and delivered the findings for three out of the five allegations. LPA Cho made an unannounced subsequent visit on February 14, 2024, to continue the investigation for the remaining two allegations. During the course of the investigation, LPA Cho conducted interviews with two out of the six residents and three staff. LPA was unable to conduct interviews with three residents due to their refusal and/or medical conditions. LPA also obtained copies of pertinent documentations such as the resident/staff rosters, face sheets, and physician’s reports. Additional records such as the Preplacements and Reappraisals were also obtained on today’s date. The investigation revealed the following: Continued on LIC9099-C... Substantiated It is alleged that the staff is not providing adequate care and supervision to the individuals in care. During the visit conducted on February 14, 2024, from 3:15pm to 5:30pm, LPA Cho observed six residents and two caregivers on duty. The Administrator was also on premises upon LPA’s arrival. Per LPA’s observations, caregivers were actively assisting the residents during the visit today and on February 14, 2024. Per review of the appraisals, it was documented that two out of the six residents need special observation/night supervision. Based on the interviews conducted, one out of the two residents indicated that care and supervision is not provided after 7:00pm. Two out of the three staff interviewed indicated that care is only provided upon request when their shift ends at 7:00pm. Both staff also indicated breaks are taken at staggered times to ensure residents’ needs are met throughout the day, however routine checks are not conducted after 7:00pm. It is alleged that the residents are left in their soiled clothing. Based on the observations made on February 14th during the diaper inspection requested by LPA, LPA along with the staff observed that the diaper for one out of six residents was visibly wet at 3:34pm evidenced by the yellow and heavy appearance. The stool was also observed to be impacted in the rectum. During today’s inspection with the staff approximately 9:40am, all diapers were dry. Per interviews conducted on February 14, 2024, one out of the two residents indicated that requests for diaper changes would go unanswered after 7:00pm until the next morning. Three out of the three staff interviewed indicated that routine checks are conducted every two hour interval during the day while checks during the nocturnal hours are not conducted unless requested. Based on LPA’s investigation, although residents are routinely checked every two hours during the day and upon request during the day and after 7:00pm, residents who are non-verbal, confused, and disoriented are unable to verbalize their needs. Documentation also noted that the two out of the six residents need special observation/night supervision to ensure that their needs are being met at all times. Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Staff is not providing adequate care and supervision to individuals in care and Residents are left in their soiled clothing are deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Carol Wilson, and a copy of this report including the LIC9099C, LIC9099D, and the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Feb 27, 2024 · control 22-AS-20221004145131

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1)(c) · Plan of correction due date: Apr 3, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c)… (c) “…means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living…” which “includes assistance with taking medications, money management, or personal care.” This requirement was not met as evidenced by: Based on record review and interviews, one out of the two residents and two out of the three staff confirmed that care and supervision is not provided at all times which poses a potential Health, Safety, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 27, 2024

Plan of correction: Administrator stated that they will submit the schedule for the nocturnal shift to LPA via email by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 3, 2024

87468.2 Additional Personal Rights of Residents in a Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs …” This requirement was not met as evidenced by: Based on observations and interviews, LPA and staff observed that diaper for one out of the six residents were soiled during the inspection which poses a potential Health, Safety, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 27, 2024

Plan of correction: Administrator stated that they will create and submit a copy of the toileting log to LPA via email by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jessica Cho continued the visit after observing a deficiency while conducting an investigation in connection to Complaint Control Number: 22-AS-20221004145131. LPA explained the purpose of this Case Management-Deficiencies visit to Administrator Carol Wilson. While investigating the complaint investigation mentioned above, LPA verified that Staff #1 (S1) was not associated per the Department's Licensing Information System (LIS) Facility Personnel Report Summary and the Guardian Employee Roster printed on today's date. S1 was employed on January 7, 2024. Therefore, the preponderance of evidence standard has been met as the facility did not ensure that S1 was associated as required by the Title 22 Regulations, 87355 Criminal Record Clearance. A deficiency is being cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC809-D. An immediate civil penalty is being assessed. See the attached LIC421BG. An exit interview was conducted with Administrator Carol Wilson, and a copy of this report including the LIC809D, LIC421BG, LIC811, and the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Feb 14, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Feb 15, 2024

87355 Criminal Record Clearance "(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance..." This requirement was not met as evidenced by: Based on LPA's observations, interviews, and review of records, S1 was not associated at the time of the visit which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 14, 2024

Plan of correction: Administrator to provide proof of association for S1, and to submit an Acknowlegement of Understanding regarding the said deficiency to LPA via emaill by POC due date.