Carrie's Board and Care

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 10:15 AM to conduct a case management - deficiencies visit at the facility. LPA met with facility staff who contacted the Administrator Carrie Acosta. The Administrator arrived to the facility at 10:37 AM. Entrance interview was conducted and the reason for the visit was explained. During today’s visit LPA conducted a brief physical plant tour, conducted a medication audit for two (2) residents and interviewed the Administrator between approximately 10:15 AM and 03:45 PM. During medication review LPA observed a total of Nine (9) medications and their respective Centrally Stored Medication and Destruction Record Sheets (CSMDRs). LPA observed inaccurate information for medications entered on the CSMDR including prescription numbers, dates started, expiration dates, and medication strength. LPA informed the Administrator that they shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year. The Administrator expressed understanding and agreed to submit updated CSMDRs for the identified residents which contain accurate information as required by Title 22 regulations. The Administrator had to leave the facility at the time of the visit but has designated facility staff to sign this report on their behalf. This report was read to the Administrator via telephone call. The following deficiency was cited (refer to LIC 809D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 16, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Sep 30, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for... a record of... medications for each resident...and includes: This requirement is not met as evidenced by: Based on record review the Licensee did not comply with the section cited above as inaccurate information for medications entered on the CSMDR included prescription numbers, dates started, expiration dates, and medication strength which poses a potential health risk to clients in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: The Administrator agreed to submit updated and accurate CSMDRs for the identified residents with all required information to CCLD no later than POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 02:22 PM to conduct a case management - deficiencies visit at the facility. LPA met with facility staff who contacted the Administrator Carrie Acosta. The Administrator arrived to the facility at 02:26 PM. Entrance interview was conducted and the reason for the visit was explained. During today’s visit, the LPA conducted a physical plant tour and interviewed one (1) resident between approximately 02:30 PM and 04:15 PM. During the physical plant tour LPA observed two (2) emergency exit doors attached to resident bedrooms #3&4 to be barricaded shut from the outdoors. LPA observed two (2) metal bedframes, a garden hose reel, and a rope positioned outside of the emergency exit doors which blocked the emergency exit. LPA observed the two metal bed frames to be positioned at an approximately 60 degree angle with the edge of the bedframe positioned under the door handle in such a way that the door appeared to be deliberately blockaded from the outdoors of the facility. LPA asked the Administrator why the doors appeared to be barricaded. The Administrator stated that they had a previous resident who exhibited exit seeking behaviors and often attempted to leave the facility. The Administrator stated that facility staff may have placed the items in that way to prevent the resident from utilizing the emergency exit doors as a way to leave the facility without staff knowing. The Administrator stated that that resident no longer resided at the facility. LPA notified the Administrator that under no circumstances should the exit doors to the resident bedrooms be barricaded to prevent resident egress and having done so constituted a violation of the facility’s fire clearance. The Administrator had the barricades removed from the doors at the time of the visit. LPA notified the Administrator that an immediate civil penalty in the amount of $500 is being assessed on today’s date (07/16/2026) for a violation of health and safety code (HSC) section 1569.149. CONTINUED ON LIC 809C. During the visit LPA observed the facility Administrator instructing facility staff to wake up Resident #1 (R1) from their sleep and to bring R1 to the dining table using their walker to prepare them for dinner. LPA observed facility staff informing the Administrator that R1 was sleepy but the Administrator insisted that R1 be woken up and brought to the table using their walker. LPA observed staff members walking R1 to the dining table using their walker. R1 was slumped over the walker and appeared unstable on their feet and tired. Upon observing the resident LPA notified the Administrator who immediately instructed staff to transfer R1 to their wheelchair for the safety of the resident. LPA asked the Administrator why facility staff would attempt to ambulate R1 through the facility in an unsafe manner when R1 appeared too tired to support their own weight. The Administrator stated that facility staff were just following their instructions but should have made a better judgement call for which device was appropriate to assist R1 in ambulation. LPA asked facility staff why they thought it was appropriate to assist R1 in the unsafe manner. Facility staff responded that this was because their boss told them to do it that way. LPA informed staff that they need to communicate their concerns with the Administrator if given instructions would place a resident into harms way. LPA reminded the Administrator and facility staff that the facility is responsible for providing care and supervision appropriate to the resident's needs. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited and civil penalty was assessed (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.149 · Plan of correction due date: Jul 17, 2026

§1569.149 Fire clearance... ... the facility shall secure and maintain a fire clearance... This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as two facility emergency exit doors attached to bedrooms #3&4 were deliberately blockaded from the outside of the facility which posed an immediate safety risk to clients in care.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Administrator had the barricades removed at the time of the visit. Administrator agreed to conduct an in-service training with all facility staff on the importance of ensuring all emergency exit ways remain clear and free from obstruction. Additionally, the Administrator agreed to conduct training on... ...appropriate staff responses to resident's with wandering behaviors, redirection techniques, and emergency notification procedures for resident elopement. Administrator agreed to submit proof of the completed trainings to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87464(f)(1) · Plan of correction due date: Jul 17, 2026

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). This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as three staff members followed the Administrator's instructions and utilized an ambulatory aid inappropriate to the resident's current condition which posed an immediate safety concern to clients in care.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Administrator agreed to conduct an in-service training with staff members on appropriate assistance techniques and devices when assisting residents with ambulation through the facility. Additionally, Administrator agreed to train facility staff about voicing safety concerns and modifying instructions to... ...better care for the residents and to ensure no resident is placed in harm's way due to following instructions as given. Administrator agreed to submit proof of the completed trainings to CCLD no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with the Administrator Carrie Acosta and informed them of the visit. The Administrator arrived shortly thereafter. The LPA, along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is inaccessible. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The LPA observed the fire extinguisher to be fully charged and last serviced on 10. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications are located in a locked filing cabinet near the kitchen area. First aid kits are located inside a kitchen drawer. Cleaning solutions items were inaccessible and locked away inside a kitchen cabinet. Continues on LIC809C... BEDROOMS: The facility is a single-story residential home with four (4) bedrooms, three (3) for resident's use and one (1) for staff. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.The staff’s bedroom is located next to the living room. Inside temperature was maintained at a comfortable level. RESTROOMS: The facility has two (2) bathrooms, one (1) for resident use and one (1) for staff use. Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. The sinks had sufficient liquid soap. OUTDOOR SPACE: The back patio has a covered outdoor area for residents’ use. There is a gate on the side of the house designated for an emergency exit. There are no bodies of water on the premises. There is one (1) locked shed in the back patio that is used for storage. Laundry units are located inside the garage. The garage is attached to the house but remains inaccessible to residents. The kitchen sliding door needs the screen door to be replaced, the glass door needs to be fixed to make it easier to slide open, as right now the door is difficult to open. The sliding back door also requires a ramp for easy access to the back yard. The Administrator will have the corrections done by 11/07/2025. RECORDS: Records review began at 11:00 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 1:30 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area next to the refrigerator; medications are labeled and checked for expiration dates. The medications are documented properly on the centrally stored medications and destruction record. No errors observed during the medication review. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Certificate of Liability - Emergency Drills No citations were issued. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 21, 2025

Allegation investigated: Staff are not providing residents adequate food service. Staff do not provide linens for residents.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to deliver findings for the allegations listed above. The LPA met with the Administrator Carrie Acosta and explained the reason for the visit. On 06/10/2025, the Department received a complaint from a reporting party, and on 06/16/2025, Licensing Program Analyst (LPA) Sandra Urena conducted an initial unannounced visit to investigate the allegations listed above. The LPA met with the Administrator Carrie Acosta and explained the reason for the visit. LPA Urena interviewed the Administrator and staff and requested records pertinent to the investigation. On 07/23/2025, the LPA interviewed two current residents, reviewed additional records, and inspected the physical plant. Continues on LIC 9099C... Unsubstantiated Staff are not providing residents with adequate food service. On the allegation that the facility staff are not providing adequate food service, the concern of the reporting party (RP) is that R1 reported that they lost weight because the food was disgusting, and R1 was concerned about their protein intake. To investigate the allegation the LPA interviewed the staff and two current residents, and observed the refrigerator’s supply of perishable food, and the pantry for non-perishable food. The review of perishable and non-perishable food availability was observed to be adequate. Residents’ interviews revealed that they have sufficient food to eat, they get three meals a day, and snacks. The LPA interviewed R1, and the interview revealed that they did not care for the meals prepared by staff. Furthermore, R1 stated that they required a special diet, and staff did not provide R1 with the adequate fluids/beverages, that they lost . R1’s physician report and file review revealed that R1 did not have a special diet. The staff interviews revealed that they try to prepare eggs and toast in the mornings, oatmeal and cereals. For lunch they may prepare rice, fish, sausages, and vegetables. Although the allegation may have happened or is valid, based on the interviews, observation, and record review, there is not sufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed Unsubstantiated at this time. Staff do not provide linens for residents. On the allegation that facility staff are not providing residents with linens, it is alleged that R1 was not receiving towels as requested. To investigate the allegation the LPA conducted a physical plant tour to observe the linen supply of towels, sheets and blankets. The supply of linens and towels was observed to be adequate to serve six (6) residents at the time of the visit. LPA Urena interviewed R1, and R1 stated that staff would change the cloth hand towel hanging in the bathroom only once a week. Furthermore, R1 stated that staff would not provide the required paper towels in the bathroom. R1 stated that the staff refused to wash R1’s comforter, because it was not the one provided by the facility. Residents currently residing at the facility did not express concern about the linens. Staff denied changing cloth hands towels once a week or refusing to wash R1’s personal blanket. Staff stated that they change bed linens as often as necessary and/or once a week. Although the allegation may have happened or is valid, based on the interviews, observation, and record review, there is not sufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed Unsubstantiated at this time. Interview exit was conducted. A copy of the report was issued. Staff held retained resident at the facility against their will. On the allegation that staff held the resident at the facility against their will, it is the concern of the RP that the staff would not allow R1 to leave the facility. To investigate the allegation the LPA conducted interviews and reviewed records. The Administrator’s interview revealed that R1 would express that they wanted to go out on walks, but that staff was not able to accompany R1, so the Administrator would tell R1 that they could not leave the facility on their own, without staff going with them. Record review of R1’s physician’s report indicated that R1 was not able to leave the facility unassisted. The interview with R1 revealed that the door was not locked all the time, and they could possibly have been able to walk out the door, but the Administrator would threaten R1 not to allow them back into the facility if they left unassisted. Furthermore, R1 added that they saw a staff hammer a nail at the top of the front door. The nail was then bent to keep the front door from opening and was utilized to prevent another resident who consistently wanted to elope from the facility. The LPA conducted an inspection of the front door, and during the inspection observed that indeed, a bent nail was nailed to the frame of the front door, the nail could then be positioned against the door to prevent it from opening. Based on information obtained from interviews and observation, although the facility staff did not hold R1 from eloping by physically restraining them, language was used to threaten R1, and staff did not make accommodations for R1 to go on supervised walks. Furthermore, a nail was placed on the front door frame and used to keep the door from opening and preventing residents from going to the front yard of the house. Therefore, the allegation that staff held residents against their will, is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and appeal rights was issued.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 29-AS-20250610172856

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3)(6) · Plan of correction due date: Jul 31, 2025

87468.1(a)(3)(6) 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: To be free from punishment,humiliation, intimidation… other actions of a punitive nature,... (6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from …such as locking doors at night to protect residents…with permission from the Department. This requirement is not met as evidenced by: Based on observation, the staff did not meet the requirement due to placing a nail to prevent residents from opening front door, and threatening residents. The Administrator removed the nail from front door frame during the inspection visit.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: POC: Licensee/Administrator agrees to review regulation for understanding and submit a self-certification of reviewing and understanding the regulations.

Allegation investigated: Staff did not ensure medical attention was provided to resident in a timely manner.

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent visit to deliver the findings for the allegation listed above. The LPA met with the Licensee Carrie Acosta and explained the reason for the visit. On 01/07/2025, LPA Urena conducted the initial 10-day visit, interviewed the staff and the administrator, and requested records pertinent to the investigation. Further investigation is needed at this time. Continues on LIC 9099C... Substantiated Staff did not ensure medical attention was provided to resident in a timely manner. On the allegation that the staff did not ensure medical attention was provided to resident in a timely manner; it is the concern of the reporting party (RP) that R1 sustained an un-witnessed fall, and after the staff (S1) discovered R1 on the floor, S1 failed to provide immediate assistance to R1 and did not call 911 until five (5) hours after R1 was discovered on the floor. The interview with S1 revealed that after S1 discovered R1 on the floor, S1 attempted to assist R1 to get up, but R1 did not want to be touched, and mumbled something. S1 did not notice any injuries, and R1 was not complaining of pain. Furthermore, S1 stated that they called R1’s POA before calling 911 and asked the POA if they wanted S1 to wait on calling 911 until the POA arrived at the facility, and the POA stated, “Yes”. The interview with the administrator revealed that after being informed by S1 that R1 had sustained a fall, they told S1 that they should have called 911 to provide medical assistance to R1 right away, then S1 should have called the POA and the administrator. The LPA interviewed the POA on 01/07/2025, and the interview revealed that on 12/27/2024, the POA received a call from the facility and was informed at approximately 10:00 a.m. of the fall sustained by R1. The POA stated that after S1 explained the incident, S1 asked the POA if S1 should wait until the POA arrived before calling 911, and the POA stated, “yes to wait”. The POA arrived at the facility and saw R1 laying on the floor. The POA noticed bruising on the left side of the forehead, shoulder and wrist. Emergency medical team (EMT) personnel arrived at the facility and found R1 lying face down on the ground. When asked what happened, R1 stated that they slid out of bed, onto the floor earlier in the morning, and R1 reported bilateral leg pain. EMT noticed that R1 had visible bruising to the left shoulder and mild swelling to the left side of the face. Based on the information received through interviews, the facility staff did not ensure medical attention was provided to R1 in a timely manner. S1 waited approximately four (4) hours, before calling 911, and getting medical assistance to R1. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency was cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 29-AS-20250102084848

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(b)(8) · Plan of correction due date: Jan 24, 2025

87468.1 (b)(8)-Deny or restrict medical or nonmedical care that is appropriate to a resident’s organs and bodily needs or provide medical or nonmedical care to the resident in a manner that, to a similarly situated reasonable person, unduly demeans the resident’s dignity or causes avoidable discomfort. This requirement was no met as evidenced by: Based on interviews the licensee did not comply with the above regulation as R1 sustained a fall, with visible bruises to the left side (forehead, wrist and knee) and pain in knee, and timely medical attention was not provided which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: Licensee or a qualified instructor will provide training to staff on providing immeadite care to residents in facility. Licensee will email a sign in sheet and copies of the materials used for the training by 01/24/2025.

Allegation investigated: Licensee did not provide a copy of admissions agreement to resident as required.

Licensing Program Analyst (LPA) Sandra Urena conducted an initial 10-day visit to investigate the allegation listed above. The LPA met with the Administrator Carrie Acosta and explained the reason for the visit. The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Continues on LIC 9099C... Substantiated Licensee did not provide a copy of admissions agreement to resident as required. It is the concern of the reporting party, that after requesting a copy of the Admission Agreement (LIC 604A) from the licensee, the licensee has failed to provide a copy to either the resident (R1) or the resident’s legal representative. To investigate the allegation, the LPA interviewed the resident (R1) and the licensee from 11:25 to 01:06 p.m. and requested records pertinent to the investigation. The interview with the R1 revealed that they had signed the LIC 604A and had requested several times from the licensee to provide them with copies of the signed agreement, however, the licensee failed to provide R1 with copies of the agreement. Furthermore, R1 stated that they asked their legal representative to request the copies from the licensee; the legal representative communicated with the licensee via email and text requesting a copy of the LIC 604A and the licensee failed to provide them with a copy as well. The interview with the Licensee revealed that they thought they had given a copy of the LIC 604A to R1. Furthermore, the licensee stated that they probably disregarded the emails from R1’s legal representative because they did not recognize the name. Upon arrival the LPA reviewed the R1’s file and found R1’s file to have a signed and completed LIC 604A. Based on the information obtained through interviews, the licensee did not provide a copy of admissions agreement to resident as required. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), and the Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 29-AS-20250113114708

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.887(a)(c) · Plan of correction due date: Jan 14, 2025

1569.887 (a)(c) Signature of resident on admission agreement; copy of agreement to go to resident or resident’s representative; review. (a) The admission agreement shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative. (c) The licensee shall provide a copy of the signed and dated admission agreement to the resident or the resident's representative, if any. (d) The admission agreement shall be reviewed at the time of the compliance visit and in response to a complaint involving the admission agreement. This requirement is not met as evidenced by: Based on information obtained, the Licensee did not comply with the above citation, as one (1) out of four (4) residents' records were not available at facility upon request for review, which poses a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: Licensee will provide copies of the LIC604A to the resident and resident's legal representative and to the LPA by the end of the day on 01/14/2025.

Allegation investigated: Staff could not provide medical paperwork to emergency personnel.

Licensing Program Analyst (LPA), Sandra Urena conducted an intimal unannounced visit to investigate the allegation listed above. The LPA arrived at the facility and was greeted by staff. The LPA explained the reason for the visit. The staff called the Licensee Carrie Acosta to inform them of the visit, however the staff could not get in touch with them. Furthermore, the LPA called the licensee, and texted them at their cell phone, but was unable to communicate with them. The LPA requested records pertinent to the allegation at 11:15 a.m. and interviewed the staff at 11:45 a.m. The Licensee arrived at 12:38 p.m. Staff could not provide medical paperwork to emergency personnel. On the allegation that staff could not provide medical paperwork to emergency personnel, it is the concern of the Reporting Party (RP) that when emergency personnel responded to a 911 call at the facility and asked facility staff (S1) about R1’s current mental status as well as medical history, S1 stated they did not know. Furthermore, when emergency personnel asked S1 for R1’s medical file or face sheets for personal information, S1 claimed that the residents’ records are not kept on site. Substantiated To investigate the allegation, the LPA reviewed the file for R1, and the file review revealed that the file for R1 was complete and contained medical information, Identification and Emergency Information form (LIC 601), and the Centrally Stored Medication and Destruction Record form (LIC 622). Additionally, the facility had a Register of Facility Residents (LIC 9020) available for review. The LPA interviewed S2 at approximately 11:45 a.m.; S2 stated that on 12/17/2024 they were at the other licensee’s facility, when S1 called them to inform them that EMT personnel were at the facility for a 911 call. R1 had called 911, although R1 was not in distress or had an emergency. S2 stated that they came back to the facility and arrived within 15 minutes of receiving the call from S1. Furthermore, S2 stated that S1 was probably nervous and that is the reason they said that R1’s records were not at the facility, because S1 is never in charge of the residents’ files. S2 added that they were able to show the medical records to the EMT personnel and spoke with the EMT staff’s captain and explained the situation. The LPA was unable to interview S1, as S1 was not available. Based on the information obtained through credible sources, interviews and record review, the investigation revealed that although the facility may have had a file for R1, S1 did not know how to access the file to provide it to emergency personnel at the time of their request. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 29-AS-20241217081608

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a)(8-10) · Plan of correction due date: Dec 31, 2024

The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff, and emergency personnel…This requirement is not met as evidenced by: Licensee did not comply with the above citation, as one (1) out of four (4) residents' records were not available at facility upon request for review, which poses a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: Licensee to submit proof by 12/31/2024 of residents' Emergency Information readily available for review upon request by EMT and CCL personnel, and training for staff to be informed of the facility's procedures and documentation of residents' files.

Allegation investigated: Staff member sexually abused resident in care.

Licensing Program Analyst (LPA) Trevor Byrne conducted a subsequent complaint visit to deliver findings for the above allegation at 09:03 AM. LPA met with facility staff and explained the reason for the visit. The facility Administrator Carrie Acosta was contacted via telephone call and arrived to the facility at 09:27 AM entrance interview conducted. On 03/11/2024, the Department received a complaint regarding an allegation that a staff member sexually abused resident in care. It was alleged that facility Staff #1 (S1) sexually abused Resident #1 (R1) while changing their briefs and had asked R1 for a semen sample. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Olivia Spindola. Continued on LIC 9099C. Unsubstantiated On 03/13/2024, from 10:26 AM to 11:32 AM, Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced 10-day initial complaint visit to the facility. At 10:26 AM, LPA Peraldi met with facility staff and explained the reason for the visit. At 10:50 AM, Administrator Carrie Acosta arrived at the facility. The LPA informed the Administrator that the Department received a complaint on 03/11/2024 and a referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). At 10:42 AM, the LPA, along with staff conducted a physical plant tour. At 11:00 AM, the LPA requested copies of pertinent documents. At 10:55 AM, the LPA conducted an interview with the Administrator. On 04/11/2024 and 04/12/2024, Investigator Spindola conducted interviews with the Administrator and the Reporting Party (RP). The investigator was informed by the facility Administrator that R1 had passed away on 03/24/2024 due to complications with kidney failure and prior to R1’s death, they required dialysis treatments three (3) times per week. The facility Administrator informed the Investigator that they had conducted an investigation into S1’s sexual abuse of R1 but did not find any evidence to support the allegation. The Administrator added that R1 did not like to be cleaned up prior to being taken to dialysis. The interview with the Reporting Party (RP) revealed they reported the possible sexual abuse of R1 after R1 complained about it. The RP also stated they were aware that R1 did not liked to be cleaned or changed by staff. During today’s visit on 10/31/2024 LPA Byrne interviewed residents, facility staff, the facility Administrator, and S1 between 09:27 AM and 11:55 AM. Additionally the LPA conducted a physical plant tour and obtained copies of documents pertinent to the investigation. LPA Byrne interviewed three (3) Residents. Resident #2 (R2) is newer to the facility and had not had any interactions with R1 or S1. Resident #3 (R3) and Resident #4 (R4) have been at the facility for almost four (4) years. Both R3 and R4 knew R1 and S1. Both R3 and R4 stated that S1 was nice. R3 stated that S1 had helped them change and shower and never had any issues with S1 previously. LPA Byrne interviewed two (2) staff members. Staff #2 (S2) has worked at the facility for 4 years. S2 stated that S1 stopped working at the facility 4-5 months ago. S2 stated that S1 was a good worker and had good interactions with the facility’s residents. S2 stated that R1 did not like to be changed by facility staff. S2 confirmed that they were aware of R1’s complaint that S1 has touched them inappropriately but stated that R1 would often say things to staff that were not true. Staff #3 (S3) was newer to the facility and had not had any interactions with R1 or S1. Continued on LIC 9099C. LPA interviewed the facility Administrator. The facility Administrator confirmed that S1 no longer works for the facility. The Administrator stated that the reason S1 was no longer working at the facility was due to an altercation between S1 and S2 and not related to their job performance. The Administrator confirmed that they were aware of R1’s allegation against S1. The Administrator confirmed that R1 did not like being changed by staff but stated that it was necessary prior to R1 attending dialysis due to R1’s incontinence. The Administrator denied S1 ever acting inappropriately towards the facility’s residents. LPA interviewed S1 via telephone call. S1 confirmed that they are no longer working at the facility. S1 confirmed that they knew R1 and had assisted them with changing, using the bathroom, and showering in the past. S1 denied having ever touched R1 inappropriately. S1 denied ever having asked R1 to produce a semen sample. S1 denied abusing R1. LPA Byrne reviewed R1’s file which revealed that R1 had multiple diagnoses that required dialysis visits three (3) times per week. Based on interviews and record review there is insufficient evidence to support the allegation that a staff member sexually abused a resident in care. Although the allegation may have happened or is valid there is not sufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was providedthe state’s words, verbatim · CDSS document, Oct 31, 2024 · control 29-AS-20240311142503

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:03 AM to conduct an unannounced Case Management visit at the facility today. LPA met with facility staff and contacted the facility Administrator. The facility Administrator Carrie Acosta arrived at 09:27 AM. The LPA advised the Administrator of the reason for the visit. During an interview the LPA conducted with Resident #2 (R2), R2 informed the LPA that there is not a working telephone for resident use at the facility. During the physical plant tour LPA observed a phone in the kitchen. LPA and R2 attempted to use the phone to call the LPAs cell phone. LPA observed the facility phone to fail to make a call to the LPAs cell phone. LPA asked the facility Administrator Carrie Acosta to use the facility phone to make a phone call. The facility Administrator attempted to make a call but was unsuccessful. The facility Administrator stated that they were unaware that the phone was out of order and agreed to have it fixed. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 31, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87311 · Plan of correction due date: Nov 14, 2024

87311 Telephones All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. This requirement is not met as evidenced by: Based on interviews and observation the licensee failed to comply with the section cited above as the facility's telephone was observed to fail to make telephone calls which poses a potential personal rights and safety risk to clients in care.the state’s words, verbatim · CDSS document, Oct 31, 2024

Plan of correction: Licensee will submit proof of a functioning facility telephone to CCLD no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with staff and explained the reason for the visit. Staff contacted the Administrator Carrie Acosta and inform them of the visit. The Administrator arrived shortly thereafter. The LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is inaccessible. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The LPA observed the fire extinguisher to be fully charged and last serviced on 10/29/2023. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications are located in a locked filing cabinet near the kitchen area. First aid kits are located inside a kitchen drawer. Cleaning solutions items were inaccessible and locked away inside a kitchen cabinet. Continues on LIC809C... BEDROOMS: The facility is a single-story residential home with four (4) bedrooms, three (3) for resident's use and one (1) for staff. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Five out of six beds were observed to have half bedrails. The administrator was advised to remove the bedrails. The fire EXIT door signal in bedroom #2 and bedroom #4, is barely audible. The Administrator was advised to change the signal system or change the batteries. The staff’s bedroom is located next to the living room. At the time of the visit the staff’s bedroom door was observed to not have a lock mechanism. The Administrator was advised that the staff’s bedroom door must be locked at all times during the day. Inside temperature was maintained at a comfortable level. RESTROOMS: The facility has two (2) bathrooms, one (1) for resident use and one (1) for staff use. Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. The sinks had sufficient liquid soap. No paper towels were available at the time of the visit. The administrator immediately placed a roll of paper towels in the bathroom. OUTDOOR SPACE: The back patio has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. There are no bodies of water on the premises. There is one (1) locked shed in the back patio that is used for storage. Laundry units are located inside the garage. The garage is attached to the house but remains inaccessible to residents. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster Due to time constraints, the LPA will return for a continuation inspection. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 4, 2024

Allegation investigated: Staff failed to complete pre-admission appraisals prior to move in.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 1:18 p.m., the LPA met with the Licensee and explained the reason for the visit. During the initial visit on 5/02/2022, between 10:30 a.m. and 2:00 p.m., LPA Peraldi conducted a facility tour and reviewed records and obtained copies of pertinent documents. The LPA also conducted interviews with the Licensee, three (3) residents and two (2) staff. Continued on LIC 9099-C. Substantiated Regarding the allegation: Staff failed to complete pre-admission appraisals prior to move in. On 04/26/2022, the Department received a complaint alleging that the Licensee did not complete a pre-admission appraisal for Resident #1 (R1) prior to move in. During the initial visit, the LPA reviewed R1’s file and received a copy of R1’s records and documents. R1’s records did not include a pre-admission appraisal. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights was provided. Regarding the allegation: Staff not giving resident personal belongings. On 04/26/2022, the Department received a complaint alleging that the Licensee withheld Resident #1 (R1) personal belongings while R1 was moving out. The complainant stated that the Licensee went through R1’s belongings and refused to give it back. During the initial visit, the Licensee stated that R1 took all of R1’s belongings during move out. The Licensee said that R1 was residing at the facility for one (1) month and had a small inventory of personal belongings. The Licensee provided the LPA with a document dated on 03/11/2022 that had a list of R1’s personal belongings signed by the Licensee and R1. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the 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 the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff not providing adequate food service. On 04/26/2022, the Department received a complaint alleging facility food being horrible. During the initial visit, majority of resident interviews did not have issues with quality of food or food service. During the visit, the LPA observed sufficient amount of vegetables, meat, and fruit. The LPA had a conversation with the Licensee about grocery shopping and updating the facility menu. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the 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 the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 30, 2024 · control 29-AS-20220426135424

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c) · Plan of correction due date: Jun 30, 2024

87457 (c) Pre-Admission Appraisal - General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as R1 did not have pre-admission appraisals, which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 30, 2024

Plan of correction: The Licensee stated that she will submit a statement of understanding about the regulation by due date.

Allegation investigated: Resident sustained pressure injuries due to neglect

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 1:18 p.m., the LPA met with the Licensee and explained the reason for the visit. During the initial visit on 4/12/2022, between 9:30 a.m. and 2:20 p.m., LPA Peraldi conducted a facility tour and reviewed records and obtained copies of pertinent documents. The LPA also conducted interviews with the Licensee, three (3) residents and two (2) staff. On 04/17/2022, the LPA conducted a file review of Resident #1 (R1’s) documents such as but not limited to, admission agreement, and medical records. Continued on LIC 9099-C. Substantiated Regarding the allegation: Resident sustained pressure injuries due to neglect. On 04/04/2022, the Department received a complaint alleging neglect as it was alleged that Resident #1 (R1) sustained pressure injuries while in care. During the initial visit, the Licensee did not mention R1 having pressure injuries. The Licensee stated that staff conduct body checks on all the residents to ensure there are no injuries or wounds. Per record review, R1 was admitted to the facility on 12/28/2021. R1 was admitted to Hospice of St. Clare on 12/28/2021. Per Hospice documents, R1’s primary diagnosis was listed as Cerebral infarction, unspecified and secondary Dx- Parkinson’s disease. Prior to R1 residing at the facility, R1 was hospitalized due to anocix injury to brain, fall, hx of stroke. At the time of being admitted to the facility, R1’s Hospital and hospice records do not indicate that R1 entered the facility with pressure injuries. R1’s hospice prognosis summary described R1 as bed bound with gastrostomy tube (g-tube) non-ambulatory, incontinent and increased needs in assistance with activities of daily living (ADLs). R1’s hospice prognosis summary also describes that hospice registered nurse (RN) educated facility staff on patient safety to avoid fails with safe transfers and on preventing skin break down. R1’s pressure injuries were first noted in a hospice communication log dated 03/01/2022 and noted the following: “Visiting LVN called and informing patient’s pressure ulcer on sacrococcyx area is not healing and is getting worst. MD notified and patient referred to Wound Masters for wound consult and treatment. Visiting LVN informed and to notify patient’s PCG. IDT made aware.” On 03/08/2022, Wound Master’s conducted an initial assessment for R1 and two (2) wounds were listed: Wound 1 location as Left Posterior Heel, Arterial Ulcer with fat layer exposed. Wound 2 location as Sacrococcygeal and listed as Pressure Ulcer Stage 3. On 04/04/2022, Wound Master’s summary of R1 noted three (3) new wounds, Left Upper Back (New Wound) Pressure Ulcer Stage 4. Right Hip (New Wound) Pressure Ulcer Stage 4. Left Heel Foot (Current Wound) Ulcer of skin with fat layer exposed. Right, Buttock (New Wound) Pressure Ulcer Stage 3. Sacrococcygeal, Sacral Region (Current Wound) Pressure Ulcer Stage 3. On 04/11/2022, Wound Master’s summary of R1 noted, a total of five wounds; Left Upper Back (New Wound) Pressure Ulcer Stage 4. Right Hip (New Wound) Pressure Ulcer Stage 4. Left Heel Foot (Current Wound) Ulcer of skin with fat layer exposed. Right, Buttock (New Wound) Pressure Ulcer Stage 4. Sacrococcygeal, Sacral Region (Current Wound) Pressure Ulcer Stage 4. R1 was soon hospitalized on 04/14/2024 and did not return to the facility. From the date of admission to the day that R1 was hospitalized, R1 sustained a total of five (5) wounds and Four (4) out of five (5) wounds listed were Stage 4. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D). The Licensee/Administrator was informed that civil penalties might be assessed. Exit interview conducted. A copy of the report and appeal rights was provided. Regarding the allegation: Resident sustained unexplained injury to arm. On 04/04/2022, the Department received a complaint alleging Resident #1 (R1) sustained unexplained injury while in care. During the initial visit, the Licensee did not mention R1 having an arm injury. The Licensee stated that staff conduct body checks on all the residents to ensure there are no injuries. Per record review, R1 was admitted to the facility on 12/28/2021. R1 was admitted to Hospice of St. Clare on 12/28/2021. Per Hospice documents, R1’s primary diagnosis was listed as Cerebral infarction, unspecified and secondary Dx- Parkinson’s disease. Prior to R1 residing at the facility, R1 was hospitalized due to anocix injury to brain, fall, hx of stroke. R1’s hospital records dated 12/26/2021 from R1’s hospitalization prior to being admitted to the facility list but not limited to “Fracture of fifth metacarpal bone of right hand and Closed fracture of left elbow, initial encounter” as R1’s medical problems. R1’s hospice prognosis summary, plan of care, updated assessments and communication logs dated 12/28/2021 to 03/13/2022, did not indicate or document injuries to R1’s arm. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegations: Facility is not allowing indoor visitation. Facility retaliating against resident. On 04/04/2022, the Department received a complaint alleging that the facility was restricting family visits for Resident #1 (R1) due to facility retaliating against R1 from missed payments. During the initial visit, the Licensee stated that visitors are allowed inside the facility. The Licensee stated that the only time she limited visitation was during the COVID-19 pandemic or when the facility had COVID-19 outbreaks. The Licensee said that when there were COVID-19 outbreaks, visitors were able to visit the residents through windows. The Licensee confirmed that she has not received payments for R1 since January 2022 but stated that it did not matter if R1 was paying; the Licensee said that the facility still provides care and supervision. Interviews conducted with residents stated that they are allowed indoor visitation and no concerns were brought up about visitation. Interview with R1’s friend did not bring up concerns regarding indoor visitation. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the 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 the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 30, 2024 · control 29-AS-20220404161032

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 31, 2024

87468.2(a) (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on medical records, licensee did not comply with the section cited as staff did not provide the necessary care and supervision resulting in R1 sustaining pressure injuries while in care, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 30, 2024

Plan of correction: Licensee agreed to submit a plan on how they will ensure that residents are provided with proper care and supervision to meet their individual health care needs. Submit to CCL by POC due date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 10/20/2023. At 9:50 a.m., the LPA met with staff and explained the reason for the visit. At 10:20 a.m., the Licensee arrived at the facility. At 10:10 a.m., the LPA conducted a brief physical plant tour to ensure there are no health and safety hazards. Starting at 10:11 a.m., the LPA conducted interviews with two (2) out of four (4) residents and two (2) staff. RECORD REVIEWS: Between 10:35 a.m. and 11:47 a.m., the LPA conducted a file review for all residents and staff regularly scheduled. Staff records were reviewed for documents including, but not limited to health screening, TB test, staff training records, and fingerprint clearance. The LPA was unable to identify the completed twenty (20) hours of annual training for staff. The LPA had several conversations with the Licensee with the goal of providing education in regard to staff training. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. The following was noted: Two (2) out of four (4) residents require updated appraisals/needs and service plan. Additionally, the LPA requested updated copy of valid liability insurance and Facility Emergency Plan. Between 1:20 p.m. and 1:50 p.m., the LPA conducted a review of medication and medication documentation with staff for four (4) out of four (4) residents and observed that all medications were properly documented. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiency was cited (refer to LIC 809-D). The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Nov 2, 2023

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 1:00 p.m., the LPA met with staff and explained the reason for the visit. At 1:20 p.m., the Licensee arrived at the facility, but shortly left. At 1:13 p.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:14 p.m., hot water measured at 106.1-degree Fahrenheit. Medications are located in a locked filing cabinet near the kitchen area. First aid kits are located inside a kitchen cabinet. Cleaning solutions items were inaccessible and locked away inside a kitchen cabinet. BEDROOMS: The facility is a single-story residential home with four (4) bedrooms, three (3) for resident's use and one (1) for staff. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: The facility has two (2) bathrooms, one (1) for resident use and one (1) for staff use. Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 1:18 p.m., hot water measured at 110.0-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. OUTDOOR SPACE: At 1:19 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. There are no bodies of water on the premises. There is one (1) locked shed in the back patio that is used for storage. Laundry units are located inside the garage. The garage is attached to the house but remains inaccessible to residents. Continued on LIC 809-C. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 10/29/2022. At 1:25 p.m., fire alarms/ carbon monoxide detectors were tested and functioned properly. Night lights were present in the hallway. Due to time constraints the LPA will return to complete the annual at a later date. No deficiencies were observed at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 20, 2023