Carries Care Villa

Allegation investigated: Staff yelled at a resident.

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 10:15 AM. LPA met with facility staff who contacted the Administrator Carrie Acosta via telephone call. The Administrator arrived to the facility at 10:30 AM entrance interview was conducted and the reason for the visit was explained. During today’s visit LPA conducted a brief physical plant tour and conducted interviews with the Administrator, two (2) staff, one (1) witness, and four (4) residents between 10:20 PM and 02:45 PM. Continued on LIC-9099C Substantiated The allegation of “Staff yelled at a resident.” Alleges that the facility Administrator raised their voice and spoke inappropriately towards facility residents. Two (2) residents interviewed stated that the facility Administrator had raised their voice to an inappropriate level when speaking with them in the past. Residents reported that the Administrator raised their voice and shouted things like “If you don’t like it, you can get out of here!” when informing the Administrator that they did not like something about the facility and “Can’t you just wait!” when asking the Administrator for something. LPA interviewed two (2) staff members. Both staff members stated that previous residents had informed them in the past that they were spoken to inappropriately by the facility Administrator. Both staff members denied ever personally witnessing the Administrator speaking inappropriately towards facility residents. LPA interviewed one (1) witness who stated that they had been informed by a facility resident that the Administrator had spoken to the resident inappropriately but denied personally witnessing the Administrator ever speaking inappropriately towards facility residents. LPA interviewed the Administrator who denied ever speaking inappropriately towards residents but stated that they understand that their voice may be interpreted as having a harsh tone. Based on the information obtained during interviews there is sufficient evidence to support the allegation of “Staff yelled at a resident.” Therefore, the allegation is deemed Substantiated at this time. 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 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Jun 24, 2026 · control 29-AS-20260617080900

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 8, 2026

87468.1 Personal Rights of Residents... (a) ... shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews the Licensee did not comply with the section cited above as two residents reported that the Administrator had spoken inappropriately towards them in the past which poses a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jun 24, 2026

Plan of correction: Administrator agreed to attend training which covers the personal rights of residents and the different forms of abuse conducted by an outside agency not associated to the facility. Administrator agreed to submit proof of the completed training to CCLD no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:33 AM. LPA met with Licensee Representative Carrie Acosta. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:35 AM the LPA, along with the Licensee Representative toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be relatively clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured under-sink cabinet which contained cleaning chemicals. LPA observed a secured drawer which contained knives and other sharp objects. LPA observed an unlocked cabinet which contained medication bottles. LPA notified the Licensee Representative who immediately secured the items. Located adjacent to the kitchen is the facility’s washer and dryer room. LPA observed this room to contain the facility’s washer/dryer, dry food storage, and a fire extinguisher that was last serviced on 06/29/2025. LPA observed six (6) cans of expired food stored in this room. LPA notified the Administrator who agreed to conduct an audit of all of the facility’s food supplies and to dispose of any additional expired food items. CONTINUED ON LIC 809C. COMMON AREAS: This includes the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained a television and activities for resident use. Additionally, the living room contained a fire extinguisher that was last serviced on 06/29/2025. The dining area was observed to be equipped with adequate seating for resident use. Additionally, the dining room contained a locked storage cabinet which contained resident medications. The facility’s fire and carbon monoxide alarms were tested at 01:45 PM and were functional at the time of the visit. LPA observed cameras located throughout the common areas of the facility and confirmed with the Licensee Representative that audio is not recorded. All exits to the outdoors of the facility were observed to have functioning auditory alarms. BEDROOMS: There are four (4) bedrooms in the facility; three (3) are dual occupancy resident rooms and one (1) is a staff room. LPA and the Licensee Representative toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA observed the staff bedroom to be unlocked. LPA observed the staff bedroom to contain unsecured grooming supplies. LPA observed the emergency exit in bedroom # 3 to be blocked from opening by a metal bar. LPA informed the Licensee Representative who removed the bar at the time of the visit. BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a shared/common resident bathroom and one (1) is a staff bathroom. The resident bathroom was observed to be relatively clean and was equipped with nonskid surfaces. Grab bars were observed in the resident shower and near the resident toilet and all were properly secured. The water temperature was measured to be 127.6 degrees Fahrenheit, which is outside of the range required by regulation. OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the garage and ADU on the property. The ADU was observed to be appropriately secured. LPA observed the garage to contain the facility’s emergency food and water supply. LPA observed expired food items located in the garage. Additionally, LPA observed chemicals to be stored in the same area as the emergency food supplies. LPA informed the Licensee Representative that toxic substances shall not be stored in food storerooms. The Licensee Representative expressed understanding and agreed to remove the chemicals from the food storage area. Continued on LIC 809C. RECORD REVIEW: Record review began at 10:39 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Three (3) staff files were reviewed. One (1) staff file was observed to be missing a health screening, proof of a negative Tuberculosis (TB) test, and a signed criminal record statement. LPA notified the Licensee Representative who agreed to obtain the missing files for the identified employee. LPA observed the training records for two (2) employees to be missing the dates that they received the trainings. LPA notified the Licensee Representative who agreed to submit a true and accurate training record for the identified employees to Community Care Licensing Division (CCLD). Five (5) resident files were reviewed. Two (2) resident files were observed to be missing proof of a negative TB test. Two (2) resident medical assessments were observed to be missing the ambulatory status of the residents. Four (4) resident files were observed to be missing a resident personal property inventory record. LPA notified the Licensee Representative who agreed to obtain the missing documentation. LPA informed the Licensee Representative that they were recently cited for a violation of Health and Safety Code (HSC) 1569.153(d) on 06/27/2025. LPA informed the Licensee Representative that because they violated the same licensing regulation within a twelve (12) month period a civil penalty in the amount of $250 is being assessed on today’s date (06/16/2026). MEDICATION REVIEW: Medication review began at 01:04 PM. Medications for three (3) of five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; and the last disaster drill was conducted on 06/15/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Licensee Representative. INTERVIEWS: LPA interviewed five (5) residents. Residents interviewed expressed concerns with the facility. LPA interviewed one (1) staff members . The staff members interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. CONTINUED ON LIC 809C. During today’s visit LPA obtained copies of the facility’s emergency disaster plan, LIC 500, resident roster, and current liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited and civil penalty 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, Jun 16, 2026

The state marks this report as 20 pages; the online copy we transcribed has 12. You can request the full file from the county licensing office.

Allegation investigated: Staff do not respond in a timely manner to assist resident.

This is an amended report that supersedes the report issued under this facility on 04/15/2026. LPA arrived at the facility unannounced at 01:31 PM to issue this amended report. LPA met with facility staff who contacted the Administrator Carrie Acosta. The Administrator arrived to the facility at 01:53 PM. Entrance interview was conducted and the reason for the visit was explained. On 04/15/2026 Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 01:29 PM to conduct a follow-up complaint investigation visit at the facility. LPA met with facility staff who contacted the Administrator Carrie Acosta. The Administrator arrived to the facility at approximately 01:51 PM. Entrance interview was conducted and the reason for the visit was explained. During the 04/15/2026 visit, the LPA conducted a brief physical plant tour, conducted a file review for one (1) resident, obtained copies of pertinent documentation, and delivered findings between 01:30 PM and 02:45 PM. CONTINUED ON LIC 9099C. Substantiated The allegation of “Staff do not respond in a timely manner to assist resident.” alleges that, facility staff do not respond to resident’s requests for assistance in a timely manner. LPA interviewed facility residents who expressed concerns in the amount of time it takes facility staff to respond to resident’s requests for assistance. Resident #1 (R1) stated that staff take anywhere between twenty (20) minutes to two (2) hours to respond to their requests for assistance. Resident #2 (R2) stated that they had been left in soiled diapers overnight on multiple occasions due to staff not assisting residents at night. Resident #3 (R3) was unable to provide an estimated time on how long it takes staff to assist them but reported that facility staff eventually assist them with their needs but R3 believed that staff could be faster about providing care to them. LPA interviewed two (2) facility caregivers. The caregivers interviewed stated that they respond to resident’s requests for assistance as soon as they are asked. Staff stated that their shifts end at 06:00 PM on the days they work and that the facility Administrator provides care to the residents during the night until shift start at 06:00 AM. The facility staff members stated that they do not remain at the facility after their shift ends. One (1) staff member interviewed confirmed that in the past at the start of their shift (06:00 AM) they had observed facility residents in diapers that were soiled during the night and not changed. LPA interviewed the Administrator who stated that they remain awake until 12:00 AM and that they perform checks on the residents during the night. The Administrator stated that staff are expected to check on the residents throughout the day. Based on the information obtained during interviews there is sufficient evidence to support the allegation of “Staff do not respond in a timely manner to assist resident” Therefore, the allegation is deemed Substantiated at this time. LPA reminded the Administrator that the facility is responsible for providing basic services including appropriate care and supervision to the residents in care. The Administrator expressed understanding and agreed to conduct training with all current staff members to discuss the importance of periodic checks on the residents to ask if they need assistance. Administrator agreed to send Community Care Licensing Division (CCLD) their plan on how they would ensure adequate night supervision for residents between 06:00 PM and 06:00 AM. LPA informed the Administrator that they were recently cited for a violation of California Code of Regulations (CCR) 87464(f)(1) on 03/30/2026. LPA informed the Administrator that because they violated the same licensing regulation within a twelve (12) month period a civil penalty in the amount of $250 is being assessed on today’s date (06/03/2026). The following deficiency was cited and civil penalty assessed (Refer to LIC 9099D). Exit interview was conducted, a copy of the report was printed, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 29-AS-20260323103529

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 3, 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, record review, and interviews the licensee did not comply with the section cited above as residents were left in soiled diapers and residents requests for assistance went unanswered for extended periods of time which posed a potential health or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2026

Plan of correction: Administrator conducted training with all current staff members discussing the importance of periodic checks on the residents to ask if they need assistance. Administrator sent CCLD their plan on how they will ensure adequate night supervision for residents between 06:00 PM to 06:00 AM. POC Cleared.

Allegation investigated: Staff do not respond in a timely manner to assist resident.

This report has been amended. Please see report issued 06/03/2026. Substantiated This report has been amended. Please see report issued 06/03/2026. The allegation of “Staff using inappropriate forms of punishment.” alleges that facility staff left Resident #1 (R1) suspended in the Hoyer lift for forty-five (45) minutes to one (1) hour to discipline them. LPA interviewed R1 who stated that they had been suspended in the Hoyer lift for an extended period of time twice in the past. R1 stated that the last time this punishment occurred was approximately one (1) month ago. LPA interviewed other residents of the facility all of whom denied ever being placed into the Hoyer lift. No other residents interviewed observed R1 suspended in the Hoyer lift for an extended period of time. LPA interviewed facility staff #1 (S1) who stated that the last time the Hoyer lift was utilized to move R1 was approximately two (2) months ago. S1 stated that R1 was not left in the lift for more than five (5) minutes while the lift was utilized. Staff #2 (S2) stated that they do not utilize the lift without the Administrator present because they do not know how to use the lift and never received training on how to operate the lift. S2 confirmed that the lift was only utilized twice in the past. Both staff members denied R1 being left in the lift for an extended period of time and both staff denied the lift being utilized as a form of punishment. LPA interviewed the Administrator who stated that facility staff are not allowed to utilize the Hoyer lift without the Administrator present to ensure proper operation. The Administrator stated that the longest R1 had been left in the lift was approximately 10 minutes. The Administrator denied ever leaving R1 in the lift for an extended period of time. The Administrator denied ever utilizing the Hoyer lift as a form of punishment. LPA reviewed R1’s physician report and observed R1 to have a primary diagnosis of Dementia. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Staff using inappropriate forms of punishment.” Therefore, the allegation is deemed Unsubstantiated at this time. A copy of the report was printed and exit interview was conducted.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 29-AS-20260323103529

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 01:29 PM to conduct a case management - deficiencies visit at the facility today. LPA met with facility staff who contacted the Administrator Carrie Acosta. The Administrator arrived to the facility at approximately 01:51 PM. Entrance interview was conducted and the reason for the visit was explained. During today’s visit, the LPA conducted a brief physical plant tour, conducted a file review for one (1) resident, obtained copies of pertinent documentation, and delivered findings between 01:30 PM and 02:15 PM. During a visit to the facility on 03/30/2026 LPA interviewed Staff #1 (S1). S1 stated that they do not use the Hoyer lift to transfer Resident #1 (R1) as they do not know how to use the lift and never received training on how to operate the lift. S1 stated that only the Administrator uses the lift to transfer facility Residents. LPA informed the Administrator that all personnel shall be given on the job training appropriate for the job assigned and as evidenced by safe and effective job performance including the skill and knowledge required to provide necessary resident care and supervision. The Administrator expressed understanding and agreed to conduct a training with all facility staff on the safe operation of the Hoyer lift to transfer facility residents. Pursuant to Title 22 CA Code of Regulations the following deficiency was cited (Refer to LIC 809-D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Apr 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Apr 29, 2026

87411 Personnel Requirements - General (d) All personnel shall be given on the job training ,,,skill in the following... (3) Skill and knowledge required to provide necessary resident care... This requirement is not met as evidenced by: Based on interview the licensee did not comply with the section cited above as S1 was not trained on proper use of the facility's Hoyer lift which poses a potential safety risk to clients in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Administrator agreed to conduct a training with all facility staff on the proper use of the Hoyer lift. Administrator agreed to submit proof of the completed training to CCLD no later than POC due date.

Allegation investigated: Staff do not ensure resident toileting needs are met in a timely manner

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 10:14 AM to conduct a follow-up complaint investigation visit at the facility today. LPA met with facility staff who contacted the Administrator Carrie Acosta. The Administrator arrived to the facility at approximately 12:00 PM. Entrance interview was conducted and the reason for the visit was explained. During today’s visit, the LPA conducted a physical plant tour, conducted a file review for two (2) residents, interviewed four (4) residents, two (2) staff members and the Administrator between 10:15 AM and 02:30 PM. Continued on LIC 9099C. Substantiated The allegation of “Staff do not ensure resident toileting needs are met in a timely manner” alleges that, facility staff leave residents in soiled diapers for extended periods of time. LPA interviewed facility residents who expressed concerns in the amount of time it takes facility staff to respond to resident’s requests for assistance. Resident #1 (R1) stated that they have been left in a soiled diaper overnight on multiple occasions due to staff not assisting residents at night. LPA interviewed two (2) facility caregivers. The caregivers interviewed stated that their shift ends at 06:00 PM on the days they work and that the facility Administrator provides care to the residents during the night until shift start at 06:00 AM. The facility staff members stated that they do not remain at the facility after their shift ends. One (1) staff member interviewed confirmed that in the past at the start of their shift (06:00 AM) they had observed facility residents in diapers that were soiled during the night and not changed. LPA interviewed the Administrator who stated that they remain awake until 12:00 AM and will perform checks on the residents during the night. Based on the information obtained during interviews there is sufficient evidence to support the allegation of “Staff do not ensure resident toileting needs are met in a timely manner” Therefore, the allegation is deemed Substantiated at this time. The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted. The allegation of “Resident sustained multiple pressure injuries while in care due to lack of care from staff or neglect” alleges that Resident #1 (R1) sustained multiple pressure injuries while under the care of the facility. LPA interviewed R1 who stated that they have one (1) pressure injury on their body that is being cared for, R1 denied the presence of any additional pressure injuries. R1 confirmed that the care for this injury is being provided by a hospice company. Additionally, R1 stated that the injury occurred prior to their arrival at the facility. R1 had no concerns with the care they were receiving for this injury. LPA reviewed R1’s file and observed R1’s hospice care plan to contain wound care orders for the nurse providing care to R1’s pressure injury. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Resident sustained multiple pressure injuries while in care due to lack of care from staff or neglect.” Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Staff retained a resident that requires a higher level of care” alleges that the facility retained R1 despite R1 requiring a higher level of care than the facility is licensed to provide. LPA reviewed R1’s physician’s report and did not observe R1 to have any prohibited health conditions listed in their file. R1 informed LPA that they had a pressure injury on their body but care was being provided by a hospice agency. LPA reviewed R1’s file and observed hospice paperwork which confirmed that a hospice nurse was visiting to provide care to R1’s pressure injury. LPA interviewed R1 who expressed that they would like to transfer to a skilled nursing facility (SNF). R1 stated that they would like to receive physical therapy but they were unable to obtain physical therapy at the facility due to hospice interfering with their ability to obtain a physical therapist through their insurance. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of "Staff retained a resident that requires a higher level of care.” Therefore, the allegation is deemed Unsubstantiated at this time. Continued on LIC 9099C. The allegation of “Staff did not adequately address a change in resident's health condition” alleges that the facility did not implement an appropriate change in R1’s care plan following R1’s development of a pressure injury. LPA interviewed R1 who confirmed that the pressure injury was obtained prior to their arrival to the facility. R1 stated that the wound has been getting better while under the care of their hospice nurse. Additionally, R1 denied the development of new pressure sores. LPA reviewed R1’s file and confirmed that wound care was being provided through a hospice agency. LPA interviewed the facility staff and the Administrator who denied R1 experiencing any changes in condition throughout their stay at the facility. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Staff did not adequately address a change in resident's health condition.” Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Staff do not provide resident with adequate food service” alleges that the facility was not providing R1 with adequate meals and was only serving oatmeal for each meal. LPA interviewed R1 who stated that they have a dietary restriction that staff and the facility adhere to. R1 stated that the food served is okay and consists of a variety of meals that conform with their restrictions. R1 had no concerns about the food that was being served to them at the facility. LPA observed sufficient perishable and non-perishable food supplies at the facility. LPA interviewed staff who stated that R1 is on a soft mechanical diet and requires foods to be ground. Staff members interviewed were aware of R1’s dietary restrictions and stated that they adhered to these restrictions when preparing meals for R1. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Staff do not provide resident with adequate food service.” Therefore, the allegation is deemed Unsubstantiated at this time. A copy of the report was printed and exit interview was conducted.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 29-AS-20260303165713

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 13, 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, record review, and interviews the licensee did not comply with the section cited above as residents were left in soiled diapers and residents requests for assistance went unanswered for extended periods of time which posed a potential health or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 30, 2026

Plan of correction: Administrator agreed to conduct training with all current staff members to discuss the importance of periodic checks on the residents to ask if they need assistance. Administrator agreed to send CCLD their plan on how they will ensure adequate night supervision for residents between 06:00 PM to 06:00 AM. Administrator agreed to send CCLD proof of the completed training, their plan on how often staff will conduct resident checks, and their plan for adequate night supervision no later than POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne and Long-Term Care Ombudsman Diane Torres arrived to the facility at 09:57 AM to conduct an unannounced Case Management - Deficiencies visit at the facility today. LPA met with facility staff who contacted the Administrator Carrie Acosta. The Administrator arrived to the facility at approximately 10:50 AM. Entrance interview was conducted and the reason for the visit was explained. The purpose of today’s visit was to follow-up on a self-reported incident that occurred on 02/18/2026. During today’s visit, the LPA and LTCO conducted a physical plant tour, conducted a file review for one (1) resident, interviewed three (3) residents, and interviewed the Administrator between 10:02 AM and 12:00 PM. On 03/12/2026 Community Care Licensing Division (CCLD) received a self-reported incident report regarding an incident that occurred on 02/18/2026. LPA interviewed the Administrator and asked why the reports were not submitted to CCLD in a timely manner. Administrator explained that they waited to submit the incident report because they were waiting to see if the resident would be returning to the facility. LPA informed Administrator that a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence any incident which threatens the welfare, safety or health of any resident. Administrator confirmed that they are aware of the reporting requirement and agreed to submit a written statement confirming that they will submit all future incident reports to CCLD within the required timeframe. CONTINUED ON LIC 809C. During the physical plant tour LPA and LTCO observed the staff bedroom of the facility to be unlocked. LPA and LTCO observed unsecured cleaning supplies in the staff bedroom including a bottle of floor cleaning chemicals. LPA informed the Administrator that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. The Administrator expressed understanding and secured the chemicals at the time off the visit. Pursuant to Title 22, California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D.) Exit interview conducted and copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Mar 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 18, 2026

87309 Storage Space and Access (a) ... the licensee shall ensure that disinfectants, cleaning solutions...are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as the staff room was observed to be unlocked and contained unsecured cleaning supplies which posed an immediate safety risk to clients in care.the state’s words, verbatim · CDSS document, Mar 17, 2026

Plan of correction: Licensee locked the staff room and secured the cleaning supplies at the time of the visit. Licensee agreed to conduct a training with staff on the importance of securing cleaning chemicals. Licensee agreed to submit proof of completed training to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Mar 31, 2026

87211 Reporting Requirements (a) Each licensee shall furnish...: (1) A written report shall be submitted to... licensing...within seven days of... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on record review and interview the licensee did not comply with the section cited above as an incident report was not submitted to licensing within the required timeframe which posed a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Mar 17, 2026

Plan of correction: Administrator agreed to submit a statement of understanding confirming that they will adhere to the required timeframe when reporting incidents to CCLD. Administrator agreed to submit the document to CCLD no later than POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management visit in conjunction with Complaint # 29-AS-20260303165713. The LPA arrived at 9:17AM and met with Administrator Carrie Acosta. Entrance interview conducted. Between 9:20AM and 10:45AM, the LPA conducted a physical plant tour and reviewed resident and staff files. Four (4) out of four (4) residents were receiving hospice services and the facility did not have hospice care plans on file. Additionally, a review of the facility’s staff roster revealed two (2) staff were not associated to the facility and had prior criminal record clearance. Staff #1 (S1) was hired in March 2023 and Staff #2 (S2) hired on 02/15/2026. An immediate civil penalty in the amount of $1,000, $100 per day for a maximum of 5 days per staff, was assessed on a violation of criminal record clearance (Refer to LIC 421BG). The Administrator was advised that failure to correct may result in additional civil penalties. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and issued.the state’s words, verbatim · CDSS document, Mar 5, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Mar 6, 2026

(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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) ... This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the above cited section as 2 staff were not associated to the facility which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2026

Plan of correction: The Licensee will request a criminal record transfer and associate the 2 staff and send CCLD proof by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(b) · Plan of correction due date: Mar 13, 2026

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section as 4 residents did not have a hospice care plan on file whihc poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2026

Plan of correction: The Licensee will obtain hospice care plans for 4 residents and provide them to CCLD by POC due date.

Allegation investigated: Staff is mismanaging resident's medication.

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 12:31 PM. LPA met with facility staff who contacted the Administrator Carrie Acosta via telephone call. The Administrator arrived to the facility at 12:35 PM entrance interview was conducted and the reason for the visit was explained. During today’s visit LPA conducted a brief physical plant tour, reviewed one (1) staff file, conducted a medication audit for one (1) resident and conducted interviews with the Administrator, one (1) staff, and two (2) residents between 12:31 PM and 02:54 PM. Continued on LIC-9099C Substantiated The allegation of “Staff is mismanaging resident's medication.” Alleges that the facility is not giving resident #1’s (R1) medication as prescribed by their physician. LPA reviewed R1’s medications and observed R1’s prescription bottle of Medication #1 (M1). LPA observed M1 to be filled on 08/31/2025 with the administration instructions of “Take one (1) tablet by mouth two (2) times a day as needed for…” LPA observed M1’s dispensed quantity to be sixty (60) pills. LPA observed the M1 bottle to contain three (3) remaining pills. LPA reviewed R1’s Centrally Stored Medication and Destruction Record Sheet (CSMDR) and did not observe M1 to be logged accurately on the CSMDR. This deficiency is addressed in a separate Case Management-Deficiencies report. All of R1’s other medications were logged appropriately on the CSMDR. LPA interviewed the Administrator who stated that R1 consistently asks the facility for more M1 but stated that the facility is following the doctors’ orders on dispensing the medication to R1. LPA was unable to determine the exact start date of the medication due to the incomplete CSMDR but LPA informed the Administrator that there are a minimum of seven (7) M1 pills missing from the bottle. The Administrator confirmed that they are the only staff member trained to handle resident medications. The Administrator denied administering extra medication to R1 despite R1’s requests. The Administrator informed LPA that Staff #1 (S1) witnessed Staff #2 (S2) administering extra an extra M1 pill to R1 on two (2) separate occasions. LPA interviewed S1 with the assistance of telephonic interpretation services and S1 corroborated this statement. S1 informed LPA that S2 had given R1 extra M1 pills on two separate occasions but did not recall the dates this happened. S1 also confirmed that they had given R1 an extra M1 pill on one (1) occasion earlier this morning (09/24/2025). S1’s file was observed, the Administrator was unable to provide LPA with S2’s file. This deficiency is addressed in a separate Case Management-Deficiencies report. LPA observed that S1 did not have the required trainings to handle resident medications. This deficiency is addressed in a separate Case Management-Deficiencies report. LPA informed the Administrator that the three (3) instances of S1 and S2 administering an extra pill still do not explain the discrepancy in the medication count. The Administrator again denied giving R1 extra medication but could not account for the extra missing medication. Two (2) residents interviewed denied missing medications or being given extra medications by facility staff. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Staff is mismanaging resident's medication.” Therefore, the allegation is deemed Substantiated at this time. The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 24, 2025 · control 29-AS-20250918201939

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 25, 2025

87465 Incidental Medical and Dental... (a) A plan for incidental medical and dental care shall be developed...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed... This requirement is not met as evidenced by: Based on observation, interview, and record review the licensee did not comply with the section cited above as R1's M1 medication was not administered as prescribed by their physician on at least 3 separate occasions with at minimum 7 pills missing which poses an immediate health risk to clients in care.the state’s words, verbatim · CDSS document, Sep 24, 2025

Plan of correction: Administrator agreed to submit a statement of understanding confirming that they will adhere to physician's orders for medication administration. Additionally, Administrator agreed to submit signed statements from each current employee confirming that they will not handle resident medications without... ...Appropriate medication training. Administrator agreed to submit the required documents to CCLD no later than POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced Case Management-Deficiencies visit at the facility at 12:31 AM. LPA met with facility staff who contacted the Administrator Carrie Acosta via telephone call. The Administrator arrived to the facility at 12:35 PM entrance interview was conducted and the reason for the visit was explained. During today’s visit LPA conducted a brief physical plant tour, reviewed one (1) staff file, conducted a medication audit for one (1) resident and conducted interviews with the Administrator, one (1) staff, and two (2) residents between 12:31 PM and 02:54 PM. During the visit LPA reviewed Staff #1’s (S1) file. LPA did not observe S1 to have appropriate training pertaining to handling resident medications. LPA conducted an interview with S1 where they admitted to administering medication to Resident #1 (R1) on the morning of 09/24/2025. S1 also stated that they observed Staff #2 (S2) administering medication to R1 on two (2) separate occasions. LPA attempted to review S2’s file but the Administrator was unable to provide S2’s file to LPA for review during the visit. LPA reviewed R1’s Centrally Stored Medication and Destruction Record Sheet (CSMDR). LPA did not observe R1’s CSMDR to have Medication #1 (M1) appropriately logged. The following deficiencies were cited (refer to LIC 809Ds). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 24, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(4) · Plan of correction due date: Oct 8, 2025

87411 Personnel Requirements - General (d) All personnel shall be given on the job training... (4) Knowledge required to safely assist with prescribed medications... This requirement is not met as evidenced by: Based on record review and interview the licensee did not comply with the section cited above as S1 admitted to dispensing medication to R1 without appropriate medication training which poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Sep 24, 2025

Plan of correction: Administrator agreed to submit signed statements from each current staff member confirming they will not handle resident medications without proper documented training. Administrator may conduct medication training with S1 and send proof of completed training to... ...CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(6) · Plan of correction due date: Oct 8, 2025

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 assuring that a record...is maintained... This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as R1's CSMDR was missing an accurate log of M1 which poses a potential health risk to clients in care.the state’s words, verbatim · CDSS document, Sep 24, 2025

Plan of correction: Administrator completed M1's entry on R1's CSMDR at the time of the visit. Administrator agreed to submit a statement of understanding confirming that they understand the importance of accurately logging resident medications on their CSMDR no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(g) · Plan of correction due date: Oct 8, 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 is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as S2's file was missing from the facility which poses a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Sep 24, 2025

Plan of correction: Administrator agreed to submit a statement of understanding confirming that they will maintain accurate files on staff and residents of the facility for a minimum of 3 years, Administrator agreed to submit this statement no later than POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a Case Management - Deficiencies visit at 10:23 AM. LPA met with Licensee Representative Carrie Acosta. Entrance interview conducted and the reason for the visit was explained. The purpose of today’s visit was to follow up on a self-reported incident that occurred on 09/06/2025. During today’s visit between 10:23 AM and 10:35 AM LPA conducted a brief physical plant tour to ensure there are no health and safety hazards and interviewed the licensee representative. LPA interviewed the Licensee Representative about the event that occurred on 09/06/2025. The Licensee Representative stated that resident #1 (R1) eloped from the facility at approximately 03:00 PM. The Licensee Representative was present at the facility at the time of the incident and attempted to locate R1 in the surrounding areas. R1 was found by law enforcement approximately thirty (30) minutes later and paramedics were contacted to assess R1. R1 was transported to hospital after refusing to return to the facility. R1 has since been moved out of the facility by R1’s family. The Licensee Representative stated that R1 was able to elope from the facility after a staff member turned off the auditory alarms while doing laundry. LPA conducted a physical plant tour and observed three (3) auditory alarms located on the front door, bedroom #1, and the kitchen back door to be turned off/non-operational. LPA informed the Licensee Representative that auditory alarms must be functional on all exterior doors. The Licensee Representative expressed understanding and agreed to replace/repair the auditory alarms on the identified exits. Additionally, LPA had a conversation with the Licensee Representative about the care and supervision of residents with special health needs. The Licensee Representative expressed understanding and agreed to submit their plan on how they will ensure adequate monitoring of facility exits to prevent future elopements. Continued on LIC 809C. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were 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, Sep 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(d) · Plan of correction due date: Sep 29, 2025

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement... This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above as three auditory alarms were non-functional during the visit and one alarm was reported to be turned off when R1 eloped from the facility which poses a potential safety risk to clients in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Licensee agreed to replace/repair the auditory alarms on the bedroom, front door, and back kitchen exits no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.312(a) · Plan of correction due date: Sep 29, 2025

§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interview the licensee did not comply with the section cited above as R1 eloped from the facility while under the care of staff and was found by law enforcement away from the facility approximately 30 minutes later which poses a potential safety risk to clients in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Licecnsee agreed to submit their plan on how they will ensure adequate monitoring of facility exits to prevent future elopements. Licensee will submit this plan no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:45 AM. LPA met with facility staff who contacted the Licensee Representative Carrie Acosta. The Licensee Representative arrived to the facility at 10:13 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:15 AM the LPA, along with the Licensee Representative toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: This includes the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains a television and activities for resident use. Additionally, the living room contained a fire extinguisher that contained a tag stating the last service was conducted on 06/29/2025. LPA interviewed the Licensee Representative and asked why the tag was stamped for two (2) days from the date of today’s inspection (06/27/2025). The Licensee Representative stated that the fire extinguishers were serviced yesterday (06/26/2025) and were unsure why the person servicing them stamped the incorrect date. The dining area was observed to be equipped with adequate seating for resident use. Additionally, the dining room contained an extra refrigerator and a storage cabinet which contained resident medication. LPA observed a closet in the hallway to contain extra linens. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 01:13 PM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. LPA observed cameras located throughout the common areas of the facility and confirmed with the Licensee Representative that audio is not recorded. Continued on LIC 809C. KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured under-sink cabinet to contain cleaning chemicals and a secured drawer to contain knives and other sharp objects. Adjacent to the kitchen was the facility’s washer and dryer closet. LPA observed secured storage containing laundry chemicals. BEDROOMS: There are four (4) bedrooms in the facility; three (3) are dual occupancy resident rooms and one (1) is a staff room. LPA and the Licensee Representative toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #3 and 4 were observed to have narrow passageways due to furniture/clutter which would make it difficult for residents using a wheelchair or walker to traverse the room. Licensee Representative agreed to rearrange the rooms and remove clutter to allow for easy passage by residents. BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a shared/common resident bathroom and one (1) is a staff bathroom. The resident bathroom was observed to be relatively clean and was equipped with nonskid surfaces. The resident bathroom contained a toilet that was observed to contain a large piece of the ceramic broken off and missing on the water tank. Additionally, LPA observed an unsecured under-sink storage to contain cleaning chemicals. LPA informed the Licensee Representative of the deficiencies, the Licensee Representative agreed to replace the broken toilet and secured the chemicals at the time of the visit. Grab bars were observed in the resident shower and near the resident toilet. The water temperature was measured to be 115 degrees Fahrenheit, which is within the range required by regulation. OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed a secured storage shed that contained miscellaneous care supplies and household items. LPA observed the garage and ADU on the property. The ADU was observed to be appropriately secured. LPA observed the garage to contain an additional refrigerator and the facility’s emergency food and water supply. LPA observed expired food items located in the garage. LPA informed the Licensee Representative who agreed to conduct an audit of the food items and remove any expired items from the storage. Continued on LIC 809C. RECORD REVIEW: Record review began at 11:35 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Two (2) staff files were reviewed. All staff files contained all required documentation. LPA did not observe staff training records located in the staff files. LPA interviewed the Licensee Representative who stated that the staff had started recently and had received approximately eight (8) hours of training. LPA informed Licensee Representative that staff are required to have a minimum of twenty (20) hours of training before providing assistance to residents. Licensee Representative agreed to conduct the additional training with staff. six (6) resident files were reviewed. One (1) resident file was observed to contain a physician’s report that did not contain accurate information on the resident’s current condition. LPA informed the Licensee Representative who confirmed that this is the most recent physician’s report they had on file. LPA informed the Licensee Representative that an updated Physicians report must be obtained following a change in condition of a resident. Licensee Representative agreed to obtain an updated physicians report for the identified resident. Additionally, LPA observed six (6) resident files to have incomplete and unsigned personal property inventory records. LPA informed Licensee Representative who agreed to complete the forms with each resident. LPA observed three (3) resident files to be missing signed copies of the personal rights of residents. LPA informed the licensee representative who agreed to obtain signed copies of the form for the identified residents. MEDICATION REVIEW: Medication review began at 01:04 PM. Medications for two (2) of six (6) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the Licensee Representative was unable to provide LPA with the last date of the facility’s completed emergency disaster drill. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Licensee Representative. Continued on LIC 809C. INTERVIEWS: LPA interviewed three (3) residents. Two (2) residents interviewed stated that the staff treat them well and are attentive to their needs. LPA interviewed two (2) staff members with the assistance of telephonic translation services. The staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit the Licensee Representative agreed to email LPA a copy of the facility’s LIC 500, resident roster, and current liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were 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, Jun 27, 2025

The state marks this report as 13 pages; the online copy we transcribed has 11. 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 10:30 a.m., the LPA met with staff and explained the reason for the visit. At 11:14 a.m., the Licensee, Carrie Acosta arrived at the facility. At 11:11 a.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards. KITCHEN: The LPA observed the kitchen/dining area. Knives and cleaning supplies are stored inaccessible. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:13 a.m., hot water measured at 105.2-degree Fahrenheit. Laundry units are located next to the kitchen in the laundry room. 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. During the tour, the LPA observed Resident #1 (R1), who is bedridden not residing in the bedridden room. The LPA held a conversation with the Licensee regarding the importance of following the facilities fire clearance. 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 11:24 a.m., hot water measured at 105.1-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Continued on LIC 809-C. OUTDOOR SPACE: At 11:30 a.m., the LPA observed the back patio which has a covered outdoor area for resident use. The property is gated. There are no bodies of water on the premises. There are two (2) locked sheds in the back patio that is used for storage. The garage is detached to the house and remains inaccessible to residents. The garage contains additional food and cleaning supplies. 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 10/30/2023. At 12:00 p.m., fire alarms/ carbon monoxide detectors were tested and functioned properly. Medications are centrally stored and locked in a cabinet in the dining room area. RECORD REVIEWS: Between 11:41 a.m. and 12:56 p.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, and fingerprint clearance. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. The following was noted: Four (4) out of five (5) residents require updated appraisals/needs and service plan, technical violation issued. Two (2) out of three (3) residents diagnosed with dementia need annual medical assessments, citation issued. Due to time constraints the LPA will return to complete the annual at a later date. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were cited (refer to LIC 809-D). Civil penalty in the amount of $500 was assessed. Exit interview conducted. A copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jun 13, 2024

Allegation investigated: Facility is refusing resident after hospitalization.

Licensing program Analyst (LPA) Sandra Urena conducted an initial unannounced visit to investigate the allegation listed above. The LPA arrived at 10:40 a.m. met with Administrator Carrie Acosta and explained the reason for the visit. On 11/29/2023, the department received a complaint about the allegation listed above. The Reporting Party (RP) alleged that the facility refused to take a resident (R1) after being discharged from the hospital. The hospital called the facility to inform them that the R1 was being discharged from the hospital, and the facility needed to be aware that R1 was going back via private ambulance, however, staff refused to take R1 back in the facility. Continues on LIC 9099C... Substantiated To investigate the allegation the LPA interviewed the RP on 12/06/2023 at approximately 10:05 a.m. The LPA interviewed the Administrator at approximately 10:40 a.m. and the R1 at approximately 11:12 a.m. The RP stated that when they called the facility, they spoke to the administrator to let them know that R1 was being discharged from the hospital, and to inform staff about admitting R1 back to the facility. However, the RP reports that the administrator told them that they did not want R1 back at the facility, and to send R1 somewhere else. The RP explained to the administrator that per State regulations, the facility must take the resident back. The RP added that the administrator hanged up on the call, and when the RP attempted to call the administrator back the calls went to voice mail. The RP left several messages for the Administrator and after three (3) hours of phone calls, the administrator called back, and said that it was ok to send the R1 back to the facility. The administrator’s interview revealed that they had indeed said to the RP that they did not want back R1 due to R1’s physical needs, however there was no updated appraisal in R1’s file to substantiate a change in condition that required additional care at another facility. The interview with the R1 revealed that they had heard the administrator telling the RP over the phone that they did not want them back at the facility. Based on the information obtained through interviews, the allegation that Facility is refusing resident after hospitalization, is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Citations were issued. Exit interview conducted. A copy of the report and Appeal Rights were issued via email.the state’s words, verbatim · CDSS document, Dec 6, 2023 · control 29-AS-20231129131316

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(20)(a) · Plan of correction due date: Dec 11, 2023

87468.2 (a)(20)(a) Personal Rights of Residents ... residents in privately operated residential care facilities for ... shall have all of the following personal rights:(20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for ...regulations and shall comply... For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee...and which poses an immediate health and safety or personal rights risk. This requirement was not met as evidenced by: Based on the investigation and information obtained. The administrator refused resident back to facility at the time resident was discharged, which poses an immediate risk to persons in care.the state’s words, verbatim · CDSS document, Dec 6, 2023

Plan of correction: Administrator admitted R1 same day, but three hours later after R1 was discharged from hospital. The Licensee/Administrator will submit a written explanation to the Regional Office for their actions pertaining to Resident 1 (R1).