Carnelian Villas

Type of visit: Required - 1 Year

On October 14, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Administrator Cherie Wood (AD) was notified via telephone but was not able to assist with today's inspection. LPA observed that Cherie Wood has a valid Administrator certificate which expires on August 19, 2027. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, of which four may be bedridden, and has a hospice waiver for four. The facility is a single story home with six private resident bedrooms, one staff bedroom, eight bathrooms, a living room, a dining room, a family room, a kitchen, and an attached two car garage. LPA, accompanied by a care giving staff, conducted a tour of the interior portions of the facility. On today's visit, LPA observed six resident in care and two care giving staff present. LPA observed residents watching TV in the family room. LPA observed the See Something, Say Something poster, (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected all six resident bedrooms and observed them to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed additional linens to be stored in a hallway closet. LPA inspected the resident bathrooms and observed them to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 111.2 to 111.9 degrees Fahrenheit. LPA observed the staff bedroom to be kept locked and inaccessible to residents in care. LPA observed the kitchen has a two day perishable and a seven day non-perishable food supply on hand. LPA observed kitchen appliances to be clean and operational. CONTINUED ON LIC809-C LPA observed the four burner gas stove lights unassisted. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed fire extinguishers to be mounted on the wall in the kitchen and it was observed to be charged and purchased on May 12, 2025. LPA tested the individual smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on July 25, 2025. LPA observed the centrally stored medication to be kept in a locked kitchen cabinet. LPA observed the facility has a First Aid Kit stored in the kitchen and it had all the required components. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed the door leading to the attached two car garage to be kept locked and inaccessible to residents in care. LPA observed the two car garage to be used for storage and laundry. LPA observed chemicals and toxins to be stored in a locked cabinet in the garage. LPA, accompanied by a care giving staff, conducted a tour of the exterior portion of the facility. The exterior portion was observed to be free of hazards and obstructions. LPA observed a shaded outdoor seating area with furniture for resident use. LPA observed the perimeter gates of the facility to be self latching and can be opened in an evacuation. There are no bodies of water on the premises. LPA reviewed all six resident files. LPA observed that the Reappraisals on file for Resident #4 (R4) and Resident #5 (R5) were outdated. LPA reviewed the residents' medication and medication administration records. LPA reviewed four staff files. All staff are background cleared and associated to the facility. Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D. An exit interview was conducted with an authorized facility representative. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Oct 14, 2025

Type of visit: Case Management - Health Checks

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Case Management – Health Checks Inspection. LPA met with Staff #1 (S1) Richard Robles and discussed the purpose of the inspection. Administrator (AD) Cherie Wood arrived at the facility at around 9:45AM, about two hours after AD was called to the facility. AD stated they live about one to two hours away, depending on traffic, and Licensee (LE) Jing Struve lives about an hour away. Per AD, S1 is in charge when AD is not present at the facility, AD comes to the facility three or four times a week, and LE comes to the facility once or twice a month. AD stated they are the administrator for only one other facility in Los Angeles County Per S1, AD comes to the facility twice or three times a week, LE comes to the facility once or twice a month, and S1 is in charge when AD and LE are not here. LPA found S1 to be knowledgeable and competent to oversee the facility and assist LPA during the inspection before AD arrived and S1 was also highly knowledgeable about the conditions and needs of the residents. LPA reviewed the facility’s infection control policies, emergency disaster plan, and fire drills, and noted the facility does not have an infection control plan. LPA reviewed and obtained a copy of the resident roster, staff roster, staff schedule, and liability insurance. LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 8-bedroom, 10-bathroom, one-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA observed 2 staff and 6 residents present at the facility in addition to AD. Resident Bedrooms: the 6 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the 2 staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 110 and 116 degrees F in the 7 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are not yet due. LPA reviewed 6 resident files and 5 staff files, interviewed 6 residents and 3 staff, and inspected medications for 6 residents. Facility does not handle resident money. During the inspection, LPA hand-delivered the Noncompliance Conference letter dated July 15, 2025, to AD scheduling a Noncompliance Conference to be held in-person at the Orange County Regional Office on Tuesday, July 29, 2025, at 10:00 AM. During the inspection, LPA and AD observed the following: based on observation, the licensee is not following its fire clearance by placing a latch on the very top of the front door which LPA observed Staff #2 (S2) was unable to unlatch for almost 2 minutes while trying to open the door to allow LPA entry and which AD stated was installed to address Resident #1’s (R1) wandering; based on documents and admission, the facility does not have an infection control plan; based on documents and admission, the licensee has not been conducting quarterly emergency disaster drills as there is only one partially completed disaster drill log for 2025; based on documents and observations, the licensee did not ensure Resident #3 (R3) received assistance with medications when they did not receive their evening Donepezil 10MG once this month; and based on documents and admission, the licensee does not have Staff #4’s (S4) personnel file present at the facility or otherwise accessible during the inspection Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Jul 25, 2025

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department... This requirement was not met as evidenced by: Based on observation, the licensee is not following its fire clearance by placing a latch on the very top of the front door which LPA observed S2 was unable to unlatch for almost 2 minutes while trying to open the door to allow LPA entry and which AD stated was installed to address R1’s wandering, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: CIVIL PENALTY ASSESSED. During the inspection, the licensee relocated this latch to the center of the door and LPA confirmed. Licensee stated they will retrain staff on emergency disaster exiting procedures and personal rights and will submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87208(a)(12) · Plan of correction due date: Aug 21, 2025

87208 Plan of Operation (a) …The plan and related materials shall contain the following: … (12) The Infection Control Plan pursuant to Section 87470.. This requirement was not met as evidenced by: Based on documents and admission, the facility does not have an infection control plan, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: Licensee stated they will review Provider Information Notice (PIN) 22-18-ASC, as well as related PINs, and submit the Infection Control Plan to LPA by POC due date and ensure a copy is always available at the facility.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Aug 21, 2025

1569.695(c) … (c) A facility shall conduct a drill at least quarterly for each shift... This requirement was not met as evidenced by: Based on documents and admission, the licensee has not been conducting quarterly emergency disaster drills as there is only one partially completed disaster drill log for 2025, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: Licensee stated they will conduct an emergency disaster drill and submit proof to LPA by POC due date and will conduct emergency disaster drills quarterly moving forward.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(a)(1) · Plan of correction due date: Aug 21, 2025

87465 Incidental Medical and Dental Care (a) … (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on documents and observations, the licensee did not ensure R3 received assistance with medications when they did not receive their evening Donepezil 10MG once this month, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: During the inspection, the licensee notified R3’s doctor who stated the missed dose is not a major concern. Licensee stated they will conduct medication refresher training and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(g) · Plan of correction due date: Aug 21, 2025

87412 Personnel Records … (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement was not met as evidenced by: Based on documents and admission, the licensee does not have S4’s personnel file present at the facility or otherwise accessible during the inspection, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: Licensee stated they will ensure S4 has a complete personnel file at the facility and submit proof to LPA by POC due date.

Type of visit: Case Management - Incident

On February 4th, 2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit due to an incident report that was received by the Orange regional office. Special Incident Report (SIR) was submitted stating that an elopement had occurred. Upon arrival LPA Vanegas was greeted and granted entry by caregiver Richard Robles. LPA Vanegas explained the nature of the visit and began to review staff files and file of resident that eloped. LPA Vanegas reviewed all staff files, and observed the following all staff on duty have updated training on elopement procedures and have completed required annual training. LPA Vanegas observed resident's file and reviewed physicians report. Per LPA Vanegas review of physicians report resident is diagnosed with blindness, anxiety, and depression. Resident is able to leave facility unassisted however, they need their walking cane if leaving the facility. LPA Vanegas interviewed staff member Richard Robles and was given the following information. Per staff member resident left the facility at some point in the middle of the night. They were unaware of what time it was, but it was after they have all gone to bed for the evening. Resident left pillows under their blankets to make it appear as if there was an individual under the blankets. Resident climbed out of the window and left their walking stick behind. At 7:00AM staff member Richard attempted to wake resident up for breakfast and realized resident was gone. Later that day they received a call from a concerned citizen stating that resident was at the Dana Point post office. An uber was ordered for resident and he was returned the facility safely and unharmed. LPA Vanegas interviewed resident and resident stated that they left on their own with out a walking stick because they wanted to prove to themselves that they can still do things on their own without any help. Resident stated that it was not any negligence or lack of supervision that caused him to leave, but that he did it on his own will and broke his screen to get out of his room. CONTINUED ON LIC809C Resident is high functioning and is now able to leave facility with out being assisted. Based on today's observations no health or safety concerns were noted and no deficiencies were cited on today's date. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst LPA Samer Haddadin conducted an announced visit for the purpose of completing an annual inspection. LPA was greeted and granted entry by staff member, Richard Robles. Administrator (AD) Cherrie Wood arrived shortly after. The facility is a single level home and licensed for six non-ambulatory of which 4 may be bedridden with a hospice waiver for 4. At the time of visit, resident had 5 residents in care. This facility is a Residential Care Facility for the Elderly. The facility had 7 bedrooms and 8 restrooms in which 6 are used for resident and 1 bedroom and bathroom for staff members. LPA toured the interior and exterior portions of the facility. Resident rooms were provided with furniture, chair, clean linen, adequate storage space, and kept free of tripping hazards. LPA observed over-the-counter medication in resident’s bedroom located in top drawer of nightstand. Hard wired smoke detectors, carbon monoxide and audible exit alarms were tested to be operational. LPA observed six screwdrivers, plier and a pair of scissors in the kitchen drawer and were not secured. LPA observed knifes and sharp were not locked nor secured due to a broken locked. Also, chemicals were found under the kitchen cabinet sink unlocked accessible to residents in care. LPA toured the outside exterior and observed shaded area for residents. LPA noticed both emergency exits doors were obstructed by a trash can and a brick from the opposite side. LPA tried to exit from one and could not. Bathrooms were observed not to be in good repair as three out of the 8-bathroom sinks were clogged and one bathroom did not have access to hot water due to thick rust on handle. Hot water was measured at 116.6 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. LPA checked fire extinguisher and it was in the green and was last purchased in December of 20204. (..CONTINUE 809C....) LPAs reviewed two clients’ files and no medication discrepancies were observed. LPAs reviewed two staff files with no discrepancies. All files of staff and residents contained all required documentation. LPA did not observe that the emergency drill was last conducted on April 11, 2024 and not current Based on this on this visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of appeal rights and this report was provided to AD.the state’s words, verbatim · CDSS document, Dec 23, 2024

Allegation investigated: Facility staff are not background cleared

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Cherie Wood arrived during the visit. During the visit, LPA toured the facility and interviewed staff as well as reviewed staff files. Regarding the allegation that facility staff are not background cleared, the investigation revealed the following: There are two staff present during today's visit. LPA reviewed staff files, criminal record clearances and LIC 500. All staff working at the facility are documented to be fingerprint cleared and associated to the facility. Based on record review, the allegation is deemed unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Mar 1, 2024 · control 22-AS-20240228122029