Casa De Castro III

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 Caretaker (S1). LPA arrived at 8:30 AM, and requested staff and residents records. At 10:35 AM, LPA and S1 toured the facility’s interior and exterior, and inspected each residents’ rooms, one staff room, as well as two bathrooms and garage. 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, poisons were locked in a cabinet, however, the same cabinet has a different unlocked door which makes it accessible to clients. A drawer containing two small 8 inches knives was found. LPA measured the water temperature in two bathrooms and the kitchen sink in Fahrenheit degrees: B1 105, B2, 108.3 kitchen 108. {CONTINUED ON LIC809-C] [CONTINUED FROM LIC809} Medications were labeled, as required, and stored in locked areas. No bodies of water on the premises, one fireplace was on the premises with a door that made it inaccessible to clients. Per S1, 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 a client, and reviewed facility records. The files reviewed by LPA were complete. Confidential records were stored in locked areas. One deficiency weas cited per California Code of Regulations. No civil penalties were assessed. An exit interview was conducted with Caretaker, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Feb 19, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: POC

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit to amend a Plan of Correction and conduct a health and safety check for the residents on care. Additionally, LPA took this opportunity to review the clearance documents submitted to LPA and attempt clear deficiencies. LPA Lopez identified herself and was allowed entry by caregiver, Elizabeth “Beth” Lim. LPA discussed the purpose of the visit with caregiver Lim, and met with Licensee Cheryl Castro, who later arrived and joined the visit. On 09/05/24, the facility was issued 5 deficiencies regarding the medication being provided, insufficient personnel, two residents' Personal Rights, and personal accommodations. During the visit of 09/05/25, two deficiencies were cleared, one for personal rights and the second for personal accommodation deficiencies. During today’s visit, LPA amended the plan of corrections (POC) reports, LIC809-D pages, to update the accurate deficiency types. Additionally, on 09/17/2025, LPA received an email indicating that the Licensee spoke with staff regarding implementation of the MAR system, personnel requirements, personal rights to make choices of their daily lives, managing incontinence, and personal accommodations and services. LPA reviewed the POC with licensee Cheryl Castro and established that the POCs needed additional information and not merely a training document. Licensee did not agree with the jointly developed POC, but said they will be clearing the staffing schedule and the MAR POC's and submit information to LPA. The licensee also acknowledged that they have spoken with the residents regarding the same information but did not have the residents sign the form at the time. During the today's visit, the licensee requested for the residents sign the document submitted to LPA on 09/17/25. Those residents who were present, 4 residents, acknowledged and complied. The last resident was no longer living at the facility. (Continuation on LIC809-C) (Continuation of LIC809-C) As such, one deficiency was corrected and is deemed cleared. The additional two deficiencies are pending and will be sent to LPA via email per the licensee. Lastly, during the visit on 09/05/25, the facility received a POC for complaint investigation 08-AS-20250827145528, for dignity. LPA received the documentation via email on 09/17/2025. During today’s visit, LPA cleared this deficiency. No deficiencies were observed or cited during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee Cheryl Castro at the conclusion of the visit. The signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 19, 2025

Allegation investigated: - Facility staff do not treat residents with dignity

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to open a complaint investigation. While at the facility, LPA investigated and delivered findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Elizabeth Lim, caregiver. LPA stated the purpose of the visit and reviewed the findings of the complaint with Licensee Cheryl Castro, who later arrived and joined the visit. The Department’s investigation consisted of interviews with staff and residents, and records review of relevant documents pertinent to this investigation. On August 27, 2025, it was said that the facility staff do not treat residents with dignity. It was specifically said that staff #1 (S1) and staff #2 (S2) verbally mistreated a resident in a different language due to R1’s incontinence issues by yelling, screaming and being disrespectful to R1. (Continuationo on LIC9099-C) Substantiated (Continuation of LIC9099) During the investigation, LPA spoke with staff and residents who confirmed that there has been yelling occurring at the facility. According to residents (R1, R2, and R5), S1 has yelled at resident(s). According to R4, they have not heard yelling but acknowledged that S1 is always rushed and in a hurry. According to staff, they confirmed that they do yell in a different language but towards each other, S1 and S2, and not to residents. S1 said that they only spoke with R3 regarding their incontinence and not to defecate on their bed. Resident records show that R1, R2, R4, and R5’s mental conditions are good, and they are able to follow instructions and communicate their needs and are not confused or disoriented. LPA’s observations of the residents were coherent and sound of mind. They all spoke clearly during their interviews. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and resident interviews, records reviewed, and LPA observations, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D page of this report. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Licensee Cheryl Castro. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Licensee Castro at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Sep 5, 2025 · control 08-AS-20250827145528

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Sep 19, 2025

87468.2 (a)(8) Additional Personal Rights of Residents in All Facilities: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.… this requirement was not met as evidence by: Based on interviews, staff yelled while working at the facility which affected 5 of 5 resident in care which posed a potential personal rights risk to 5 of 5 residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: Licensee agreed to speak with the staff and document it and send the document to LPA by POC due date, 09/19/2025.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced visit to conduct an investigation and in conjunction, conducted this case management visit due to deficiencies found during the investigation. LPA identified herself and was granted entry by Elizabeth Lim, caregiver. LPA stated the purpose of the visit and reviewed the basic elements of this visit with Licensee Cheryl Castro. During the Department’s investigation of complaint control # 08-AS-20250827145528, there were additional discrepancies found, which are being addressed during today’s visit. During the investigation, which consisted of interviews with staff, and residents, and records review of relevant documents, the investigation uncovered that the facility was not providing medication as prescribed, there is insufficient staff to meet the resident’s needs, residents are unable to leave their bedrooms after 6:00 PM, a resident who needed incontinence assistance was malodorous, and resident had dirty bedsheets. During today’s visit, LPA spoke with the residents (R2, R4, and R5), and staff #1 (S1) and staff #2 (S2) who confirmed that caregivers send residents to their room at 6:00 PM after their shift to rest for the night. According to interviews with residents and staff, S1 and S2 are the only caregivers who work at this facility and also reside at the facility. After review of records, it showed that S1 works at the facility from 6:00 AM – 12:00 PM and S2 works from 12:00 PM – 6:00 PM, which leaves the NOC shift unavailable. According to S1 and S2, they care for the resident after their shift if they require assistance throughout the night. Residents interviewed said they were not allowed out of their rooms after 6:00 PM but may yell for staff if they need assistance. During an interview of R3, LPA observed the resident to be malodorous of urine. LPA observed that the resident’s bedsheets were stained of dried fecal matter. (Continuation on LIC809-C) (Continuation of LIC809) According to staff, R3, had to be changed throughout the night because they had gone “poo poo.” While LPA spoke with the Licensee, they observed that the Medication Administration Records (MARs) had been compiled inside manila envelopes and LPA inquired how the staff are aware that they provide the medications to the residents. According to the Licensee, they write the medication timing on top of the bottle – either AM or PM or both. That is how staff know when the residents are to take the medications. LPA further inquired if they used the MARs and Licensee said no. LPA asked if bubble packs would be easier for staff and Licensee said that it would be more difficult for staff as there are too many packs to keep track of. LPA asked if they could demonstrate with one residents’ medication. When LPA opened two medications for R1 they found that medications were missing. There were two pill medications from one bottle missing and 5 pill medications from another bottle missing for R1 which LPA explained to the Licensee and counted in front of them. Based on the information obtained during the investigation, there are deficiencies observed and being cited during this visit and may be found on the LIC809-D page of this report . The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with licensee Cheryl Castro. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) were provided to licensee Castro at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Sep 5, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 19, 2025

87465 (c)(2) Incidental Medical and Dental Care: (2) Once ordered by the physician the medication is given according to the physician's directions..… this requirement was not met as evidence by: Based on observation, staff did not provide medications as prescribed for R1, [1 of 5] residents in care which posed a potential health risk to 1 of 5 residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: Licensee will be implementing the MAR system on a regular baisis and will send the updates to LPA via email by POC due date, 09/19/2025. This is an amended version to an original report delivered on 9/5/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: Sep 19, 2025

87411 (a) Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.… this requirement was not met as evidence by: Based on interviews, staff covered 2 shifts at the facility but the third shift was not being scheduled to be covered which posed a potential potential safety risk to 5 of 5 residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: Licensee agreed to give an additional 2 hours to each caregiver for a total of 4 hours and provide LPA documentation by POC due date, 09/19/2025. This is an amended version to an original report delivered on 9/5/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Sep 19, 2025

87468.2 (a)(6) Additional Personal Rights of Residents in All Facilities: (6) To make choices concerning their daily lives in the facility.… this requirement was not met as evidence by: Based on interviews with staff and residents, it was confirmed that residents are being sent to their rooms by 6:00 PM for 5 of 5 resident in care which posed a potential personal rights risk to 5 of 5 residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: Licensee agreed to speak with residents and inform them that they will be able to leave their rooms after 6PM and document and submit their documentation to LPA by POC due date. This is an amended version to an original report delivered on 9/5/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87625(b)(3) · Plan of correction due date: Sep 5, 2025

87625 (b)(3) Managed Incontinence: (3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence.… this requirement was not met as evidence by: Based on LPA observations and interviews, resident R3 was malodorous (of urine) during their interview, which posed a potential personal rights risk to 1 of 5 residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: Licensee had staff change R3 during the visit. This citation is deemed cleared during the visit. Licensee agreed to have R3 checked at least 5 times and changed as needed. Licensee will email LPA of the updates. This is an amended version to an original report delivered on 9/5/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Sep 5, 2025

87307 (a)(3)(C) Personal Accommodations and Services: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited..… this requirement was not met as evidence by: Based on LPA observations, residents bedspread had fecal matter on top of R3s bed which posed a potential health risk to 1 of 5 residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: Licensee had staff change the linens during LPA's visit. This citation was deemed cleared during the visit. This is an amended version to an original report delivered on 9/5/2025.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Liliana Silveira conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified herself to, and explained the purpose of the visit with Licensee Cheryl Castro and Administrator Celeste Castro. The facility fire clearance was granted on 08/26/24 and reflected that the facility was approved for six (6) non-ambulatory residents, 60 years or age or older. The facility's fire clearance did not include delayed-egress door or secured perimeter endorsements, and neither were present during today's visit. The submitted facility sketch was consistent with the current layout of the facility. During today’s visit, LPA, accompanied by Cheryl and Celeste, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets, sinks, and showers were in working order. The facility’s ambient internal temperature was compliant at 68 degrees F. Hot water temperature at taps accessible to residents were also compliant: Kitchen sink was 117.5 F, Bathroom #1 sink was 117.6 F, and Bathroom #2 sink was 117.4 F. The facility has enough linens, hygiene supplies, cooking and dining supplies, and food for future resident use. All kitchen appliances were in working order. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of sharp objects, medication, and confidential resident and staff records. (CONTINUED ON NEXT PAGE, LIC 809-C) (CONTINUED FROM FIRST PAGE, LIC 809) No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per Administrator, no firearms or ammunition are or will be stored at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. All fire extinguisher(s) were serviced within the last twelve months. A complete first aid kit was present. Required licensing postings were observed in visible areas of the facility. LPA also presented and discussed the Component III Training during today’s visit. The items reviewed were complaint with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. The applicant passed the pre-licensing inspection. Cheryl and Celeste were advised that the facility’s application is pending management final review and approval. An exit interview was conducted with the Cheryl and Celeste, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. Signature below confirms receipt of the documents.the state’s words, verbatim · CDSS document, Jan 14, 2025

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Interview Method: Telephone interview On 12/19/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Dec 19, 2024