Casa De Castro

Allegation investigated: Staff did not prevent resident from wandering from facility.

On 02/21/2026, LPA Janet Ngallo conducted a subsequesnt visit to deliver findings regarding the above-mentioned allegation. LPA spoke with Caregiver Fransisco Tullas and explained the purpose of the visit. Regarding the allegation of Staff did not prevent resident from wandering from facility, Resident (R1) was able to leave the facility unassisted During the investigation, staff members were interviewed, and records were reviewed. On 9/9/2024, R1 was able to leave the facility unassisted. Staff took a break and did not notice that R1 was missing from the facility. It was not clear how long R1 was missing. Based on records review, R1 is not able to leave the facility unassisted. (Cont. on LIC 9099-C) Substantiated (Cont. from LIC 9099) Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Caregiver Fransisco Tullas, whose signature below confirms receipt of these rights. (Cont. from LIC 9099) Regarding the allegation of Staff handles residents in a rough manner, all residents denied being mistreated by staff. For the allegation of staff are not providing a comfortable environment for residents, during the interviews, R1 stated that the facility is very comparable to home. All residents expressed that they liked living at the facility. Regarding the allegation of Staff did not prevent residents from engaging in inappropriate behaviors, during the visit, most of the residents were sitting in the living room watching TV. All residents looked calm and content. Based on interviews, observations and records review, the department has determined that 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 allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Caregiver Fransisco Tullas, whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Feb 21, 2026 · control 08-AS-20240910143605

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 22, 2026

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 was not met as evidenced by: Based on interviews and records review, R1 was able to leave the facility unassisted which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 21, 2026

Plan of correction: Staff will provide proof of scheduled care and supervision training with all staff within 24 hours to LPA via email. Training will be completed and submitted to LPA with sign-in sheet and training topic clearly noted via email by 03/06/2026.

Allegation investigated: Licensee financially abused a resident while in care.

Licensing Program Analyst (LPA) Liliana Silveira completed a complaint investigation and delivered findings via phone call with the Licensee Cheryl Castro. The Department’s investigation consisted of interviews and a records review. On April 6, 2022, it was alleged that the Licensee financially abused a resident while in care. Specifically, it was alleged that the Licensee was forging checks and taking Resident #1 (R1’s) money. The Department conducted a records review which revealed that R1 moved into the facility on February 16, 2018. A review of R1’s Physician’s Report, dated 02/12/2018, revealed that R1's physical health status was fair. R1’s was assessed as being able to follow instructions and able to communicate needs with occasional confusion. Regarding capacity for self-care, R1 was assessed as not being able to manage their own cash resources. Resident records indicated that R1’s money was managed by both R1 and their Responsible Relative (RR). (CONTINUED ON NEXT PAGE, LIC 9099C) Unsubstantiated (CONTINUED FROM PAGE 1, LIC 9099) Department interviews with an Outside Source (OS), the RR and the Licensee revealed that R1 had two sources of income. Source #1 was managed by the OS and source #2 was managed by R1 and their RR. The interviews revealed that part of the board & care fees were paid by the OS and the other part was paid by the resident’s RR. The interviews also revealed that there were communication issues between all parties, causing confusion and problems in paying the board & care fees timely. Interviews and the records review of facility invoices revealed that R1 was continuously behind on board & care payments due to these issues. The Department attempted to interview R1, however, the resident is deceased. Interviews with both the Licensee and the RR did reveal that the Licensee helped R1 with some banking issues involving overdraft fees related to loss of income deposits and over-spending. The Department also reviewed R1’s bank statements and checkbook receipts for random months spanning from 2020 to 2022, but was unable to determine if someone other than R1 was making financial decisions. Finally, interviews with the OS revealed that on more than one occasion, R1 expressed that they were "happy" and liked living at the facility. There was insufficient evidence to support this allegation. This report was discussed with Licensee Cheryl Castro via phone call. A copy of this report, along with Licensee/Appeal Rights, (LIC 9058 03/22) were mailed via certified mail to the Licensee. An email response verifies receipt of the documents.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 08-AS-20220406152357

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose De La Cruz made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Cherryl Castro. The facility's license shows a maximum capacity of six (6) elderly clients, 60 and above, all of whom might be non-ambulatory. An approved hospice waiver for one (1) resident. LPA arrived at 12:50 pm, facility looks clean and in good repair. LPA requested staff and residents files. LPA and Licensee toured the facility, the interior and exterior and inspected four residents’ rooms, and two bathrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings and were personalized by the clients. Doors, windows, screens, toilet, and shower were in working order. Extra linen and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days of non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Toxic chemicals were found and accessible to clients and two scissors were found on an unlocked drawer in the kitchen. Medications were labeled, as required, and stored in locked areas. No bodies of water or fireplaces on the premises. [CONTINUED ON LIC9099-C] [CONTINUED FROM LIC9099] Per Licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. Two deficiencies were cited by the California Code of Regulations, Title 22 (refer to the LIC809-D page). No Civil Penalty was assessed. Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Licensee Cherryl Castro, to whom a copy of this report, the LIC 809-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Feb 9, 2026

Allegation investigated: Resident sustained unstageable pressure injury due to staff neglect

On 11/10/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Administrator Celeste Castro and explained the purpose of the call. Regarding the allegation resident (R1) sustained unstageable pressure injury due to staff neglect, R1 was brought to the hospital and had unstageable pressure injury. During the investigation, staff members were interviewed, and records were reviewed. R1 was under hospice upon admission to the facility under hospice. Per records, the facility submitted an incident report to the department regarding R1s hospitalization on 2/22/2025. R1 had started to develop pressure sores and the administrator recommended to the hospice nurse for a wound specialist. Hospice nurse (HN) mentioned that he/she is the wound specialist. HN also said that there is no issue with the facility as every time HN visits, R1 is changed properly, diapers are always dry. Based on interviews and records review, the department has determined that 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 UNSUBSTANTIATED. Report is reviewed and a copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 10, 2025 · control 08-AS-20250224165747

Allegation investigated: Staff took resident's phone away.

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced visit to continue a complaint investigation visit and to deliver findings. LPA Silveira introduced themselves, disclosed the purpose of the visit and was granted entry into the facility by caregiver Josefina “Josie” Wilkins. Licensee Cheryl Castro arrived a short time after. The Department’s investigation consisted of interviews and a records review. On June 23, 2025, it was alleged that staff took Resident #2’s (R2’s) phone away. A Department interview with Resident #2 (R2) revealed that Staff #1 (S1) had taken R2’s cell phone away. R2 stated that they would ask staff to charge the cell phone often. R2 also admitted that the phone would go “missing” because R2 was confused and would misplace it. An interview with S1 revealed that due to health issues, R2 was continuously dropping their cell phone and losing it. S1 stated that they held the phone for R2 to keep it safe and there were no intentions to take the phone away from R2. (CONTINUED ON NEXT PAGE, LIC 809C) Unsubstantiated (CONTINUED FROM PAGE 1, LIC 9099) A Department interview with Staff #2 (S2) revealed that they were unaware of R2’s phone being taken away. Department interviews with three other residents and a resident’s Responsible Relative revealed that there were no concerns regarding staff taking personal items from residents. There was not enough evidence to support this allegation. Due to a lack of corroborating evidence, the allegation that staff took R2’s phone away is unsubstantiated. Although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore, the allegation is unsubstantiated. This report was discussed with Cheryl Castro. A copy of this report, along with Licensee/Appeal Rights, (LIC 9058 03/22) were provided. Signature below acknowledges receipt of the documents. *NOTE: LPA left for a 1 hour lunch break and to type all reports related to this complaint. (CONTINUED FROM FIRST PAGE, LIC 9099A) RR also stated that R1’s Primary Care Physician (PCP) had approved the use of restraints on R1 to avoid falls. A records review of R1’s Physician’s Report, dated 11/21/2023, revealed that the PCP approved a “soft tie” for R1 while R1 was seated in a wheelchair to prevent falls. There was no other indication regarding the approval of restraints for a bed. An interview with the Licensee/Administrator confirmed that RR had requested the restrain from the facility and the Administrator believed that the restraint allowed on the Physician’s Report extended to use on the bed. Interviews with two care staff also revealed that they were restraining the resident to the bed and demonstrated the item used to restrain R1. Finally, an interview with R1 revealed that R1 recognized the items used to restrain them and was clearly able to demonstrate the procedure used by staff to restrain them to the bed. There was enough evidence to determine that this allegation is substantiated. Based on the evidence obtained from interviews, observations and a records review, the complaint allegation is substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is cited per Title 22 California Code of Regulation. LPA Silveira conducted an exit interview with Cheryl Castro to whom a copy of this report, the LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Signature below confirms receipt of the reports.the state’s words, verbatim · CDSS document, Oct 15, 2025 · control 08-AS-20250623154810

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Oct 15, 2025

87608 Postural Supports (a)(3): A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement was not met, as evidenced by: Based on a records review and interviews, the Licensee restrained Resident #1 to their bed without a physician's order, which posed a potential safety risk to 1 out of 4 residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: The Administrators and Caregivers will complete training on postural supports and resident personal rights by 10/29/25.

Allegation investigated: Staff do not ensure that resident's incontinence needs are met. Staff do not assist resident with ambulation. Staff do not answer facility phone when resident's responsible party calls. Licensee accepted resident #1 into facility even though resident required higher level of care. Administrator is not present at facility a sufficient amount of hours to manage facility.

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced complaint investigation visit to deliver findings for a complaint investigation. LPA Silveira introduced themselves, disclosed the purpose of the visit and was granted entry into the facility by caregiver Josefina “Josie” Wilkins. Licensee Cheryl Castro arrived shortly after. The Department’s investigation consisted of observations, interviews and a records review. On August 29, 2025, it was alleged that staff do not ensure that Resident #1 (R1’s) incontinence needs are being met. Specifically, it was alleged that R1’s incontinence briefs were not being changed in the evenings. The Department conducted an unannounced visit to the facility on October 8, 2025 and observed that R1’s incontinence briefs and bedding were clean. A Department interview with R1 revealed that R1 stated that the facility caregivers were “really good” about diaper changes, and also stated that, at the moment, R1 felt clean and had no concerns regarding diaper changes in the evening. (CONTINUED ON LIC 809C, NEXT PG) Unsubstantiated (PAGE 2 0F 4- CONTINUED FROM PAGE 1, LIC 809) An interview with Home Health Representative #1 (HHR1) who visits R1 two times per week also revealed that R1 is clean when HHR1 visits and HHR1 believes that the caregivers are “really, really good” about changing R1’s incontinence briefs. An interview with Staff #1 (S1) also revealed that S1 conducts diaper checks in the evenings and recently, changed R1’s diapers in the evening. There was not enough evidence to support this allegation. It was also alleged that facility staff do not answer the facility phone. A records review revealed that there are two live-in care staff assigned daily to cook, clean and provide caregiving services. During the evening, the care staff rest and are on-call if there are any emergencies, or if residents need assistance. A Department interview with Home Health Representative #1 (HHR1), who visits the facility weekly, revealed that while sometimes care staff do not answer the phone, HHR1 stated that during busy hours from breakfast to dinner, they have observed staff assisting residents with feeding, toileting and other caregiving services. HHR1 stated that they did not believe staff are intentionally not answering the phone and when they have called the facility early, staff answer. An interview with the Responsible Relative (RR) for a resident revealed that they do not have problems having calls answered and stated that they also have the option to call the Licensee/Administrator. An interview with the Licensee/Administrator also revealed that while the facility policy is that staff are required to answer the phone, the priority is to provide caregiving services timely. The Licensee/Administrator provides an alternative contact number for resident representatives to call with any issues and concerns. Finally, Department interviews with the two care staff revealed that if they are feeding the residents, assisting them with toileting or changing their incontinence briefs, they are unable to answer calls, but do try to answer the phone during downtime. There was not enough evidence to support this allegation. It was also alleged that the Administrator is not present at the facility a sufficient amount of hours to manage the facility. The Department conducted an unannounced visit to the facility on October 8, 2025. The visit was not announced to the Administrators and during the visit, the back-up Administrator arrived to check-in and to conduct on-site staff training. Interviews with two residents revealed that they are familiar with the Administrators and one resident stated “they come all the time.” Interviews with two care staff revealed that the Administrator checks in often, sometimes in the late evening to check-up on the residents. (CONTINUED ON NEXT PAGE, LIC 809C) (PAGE 3 OF 4- CONTINUED FROM LIC 809-C) Finally, an interview with a resident’s Responsible Relative also revealed that they do not believe there are issues with the Administrator not being present at the facility. There was not enough evidence to support this allegation. It was also alleged that the Licensee accepted R1 into the facility even though R1 requires a higher level of care. Specifically, it was alleged that the resident requires care at the Skilled Nursing Facility (SNF) level and should not have been placed in a Residential Care Facility for the Elderly (RCFE). The Department conducted a records review. A review of R1’s Physician’s Report for Community Care Facilities, dated September 4, 2025, revealed that R1’s primary diagnosis is hemiplegia and hemiparesis, following cerebral infraction. R1 has incontinence issues and motor/impairment/paralysis, requiring assistance with Activities of Daily Living (ADLs). A review of R1’s Discharge Summary/Post-Care Instructions (DSPCI) from a Skilled Nursing Facility (SNF) revealed that R1 was discharged on September 6, 2025 with the following reason: “resident’s health has improved sufficiently, so the resident no longer needs the services provided by the facility.” The summary also indicated that R1 was discharged to a Board & Care and was enrolled to receive Home Health Services, including nursing and physical therapy. A Department interview with R1’s Home Health Clinical Director (HHCD) also revealed that, based on the doctor’s orders received by Home Health, R1 is currently receiving assistance from four clinicians, who visit twice per week to provide the following services: occupational therapy, physical therapy, bathing assistance and assessments conducted by a registered nurse. There was not enough evidence to support this allegation. Finally, it was alleged that staff are not meeting the resident’s care needs. Specifically, that staff are not assisting the resident to get out of bed and move daily. The Department interview with the Homed Health Clinical Director (HHCD) revealed that based on doctor’s orders, R1 was assigned to 2 days of physical therapy to get the resident out of bed and move. The HHCD clarified that the Home Health doctor’s order does not indicate that getting out of bed more than two days is required, but it is “preferred.” The review of R1’s Physician’s Report and their SNF Discharge Report revealed that there were no doctor’s orders indicating that the resident needed to be moved out of bed daily. An interview with R1’s Home Health Physical Therapist (HHPT) revealed that they assist R1 with physical therapy sessions two times per week based on doctor’s orders. The HHPT stated that they recently completed training with facility staff on how to use R1’s Hoyer lift to assist R1 to move out of bed. (CONTINUED ON NEXT PAGE, LIC 809-C) (PAGE 4 OF 4- CONTINUED FROM PAGE 3, LIC 809-C) The HHPT stated that they have requested R1’s family to assist R1 in moving more and have also requested facility staff to assist the resident in getting out of bed a few times per week, based on HHPT recommendations for R1 to move more. Department interviews with the two facility care staff revealed that they were recently finishing training on how to use the Hoyer lift for R1. Finally, an interview with the Licensee/Administrator revealed that due to health and safety concerns, the Licensee instructed care staff not to move R1 until Home Health provided training and instructions. There was not enough evidence to support this allegation. Due to a lack of corroborating evidence, the allegations that: staff do not ensure that resident's incontinence needs are met, that staff do not answer facility phone when resident's responsible party calls, that the Administrator is not present at facility a sufficient amount of hours to manage facility, that the Licensee accepted Resident #1 into the facility even though resident required a higher level of care and that staff are not meeting Resident #1’s care needs are unsubstantiated. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations occurred, therefore, the allegations are unsubstantiated. This report was discussed with Cheryl Castro. A copy of this report, along with Licensee/Appeal Rights, (LIC 9058 03/22) were provided. Signature below acknowledges receipt of the documents.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 08-AS-20250929095042

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced visit to commence a Required Annual Inspection. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Rodel Manahan. LPA also discussed the purpose of the visit with Licensee Cheryl Castro via phone call. During today’s visit, LPA spoke briefly to staff and residents. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. No deficiencies were cited during today’s visit. An exit interview was conducted with Rodel. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. .the state’s words, verbatim · CDSS document, Feb 28, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Caregiver Maria Ligaya Sunguad, to discuss the purpose of the visit. Today's visit was in response to Administrator’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 10/21/2024. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 10/15/2024. During today’s visit, LPA performed a brief facility tour and welfare check on remaining residents, finding no safety concerns. LPA spoke with Licensee/Administrator Cheryl Castro via telephone. LPA also collected copies of and reviewed pertinent records and interviewed relevant staff. No deficiencies were cited or observed on this date. An exit interview was conducted with Maria Ligaya Sunguad. who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Oct 21, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced case management visit to clear Plans of Correction. LPA identified herself, was granted entry into the facility, and met with Julia Abastillas, Staff, to whom she disclosed the purpose of the visit. LPA previously conducted a required annual inspection visit at the facility on 01/16/2024. On that date, Type B deficiencies were cited. On today's date, the deficiencies previously cited under sections 87309(a) and 87705(f)(1) of Title 22 Regulations and 1569.618(c)(3) of the Health and Safety Code are being cleared as having been corrected. Additional deficiencies that were cited under 87608(a)(1) and 1569.311 and plans of correction that were previously due and submitted to Community Care Licensing by the POC due date were cleared during today's visit as well. An exit interview was conducted with Julia Abastillas, to whom copies of this report and Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.the state’s words, verbatim · CDSS document, Feb 12, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced required annual inspection. LPA identified herself and disclosed the purpose of the visit to facility staff and was granted entry into the facility. Co-administrator, Celeste Castro, arrived a short time later. According to the facility’s license, the facility is licensed for six (6) residents, all of whom may be non-ambulatory. Licensee also has a waiver for one hospice resident. During today’s inspection, there were six (6) residents in care, one of whom receives hospice services. The facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by co-administrator, toured the interior and exterior of the facility. Pathways were free of obstruction and slip hazards. Doors, windows and screens were present and sinks and toilets were in working order. Hygiene supplies and Personal Protective Equipment were present. The facility had sufficient space and equipment to facilitate visitation. The facility’s internal temperature was 75 degrees F. Hot water temperature in bathroom sink in a bathroom that is accessible to residents measured at 112.8 degrees F. During the tour of the facility, LPA observed a knife and scissors stored in an unlocked kitchen drawer. Toxic cleaning supplies and bleach were observed in accessible bathroom cabinets, and AJAX cleaner was observed on a resident bathroom sink. No open-faced heaters, pools, or bodies of water were observed on the premises. Per the administrator, no firearms or ammunition are kept at the facility. Smoke alarms and facility telephone were all in working order. A carbon monoxide detector was observed present in the facility; however, the carbon monoxide detector was not in working order. Prior to the end of the visit, a new carbon monoxide detector was delivered to the facility, installed, and observed to be in working order. Fire extinguisher present in the home was serviced within the last 12 months. LPA observed the use of a postural support for Resident 1 (R1) [LIC 811 Confidential Names List]; however, there was no physician’s order maintained for the use of the postural support. LPA interviewed staff and residents. The interviews did not produce any significant licensing concerns. LPA also reviewed staff and resident records/files. Staff who was present and working in the facility at the time of the visit did not have current first aid/CPR training. Medications were stored in a locked cabinet with appropriate labels. Plans of Correction were jointly developed with the administrator. An exit interview was conducted with Celeste Castro to whom a copy of this report, the LIC 809-D, LIC 811 Confidential Names List, LIC 9102 TAs/TV, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.the state’s words, verbatim · CDSS document, Jan 16, 2024

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.