Casa Del Sol

Allegation investigated: Staff dropped resident in care resulting in an injury. Staff slapped resident in care. Staff threatened to fight resident in care. Staff did not meet resident's diapering needs. Staff fell asleep while on shift. Staff threatened to evict resident in care.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to continue the investigation into the above allegations. LPA was greeted and granted entry after explaining the reason for the visit. During the course of the investigation, interviews with two current residents, five staff, and one witness were conducted. LPA attempted to interview the remaining current two residents, Resident #1 (R1), and two former staff but statements could not be obtained. LPA also obtained the following documentation for review: Resident Rosters, Personnel Schedule, Face Sheets, Physician's Reports for current residents, and R1's Preplacement Appraisal, Care Plan, Physician's Report, Admission Agreement, and text message receipts. The investigation is as follows: Regarding the allegation, Staff dropped resident in care resulting in an injury, it is alleged two staff had dropped R1 twice in one day approximately June 2023. R1 was admitted to the facility on February 1, 2023 and moved out approximately January 2024. Unsubstantiated R1 had advanced stage of Dementia per Physician's Report dated February 11, 2023 and was disoriented to person, place, and time. LPA was unable to interview R1 as R1 passed away on May 23, 2026 at another licensed facility per incident report. In review of the monthly nursing notes, there are no documentation of a fall that had occurred in June 2023. The current residents and staff were not present during the period in which R1 resided at the facility. Based on the interviews with two staff who had provided care to R1, denied working the same shift and dropping R1. Both staff denied the allegation. Regarding the allegation, Staff slapped resident in care, it is alleged Staff #1 (S1) slapped R1 on the head. S1 and Witness #1 (W1) denied the allegation. Due to R1's passing, LPA was unable to obtain a R1's statement. The current residents and staff were not present during the period in which R1 resided at the facility. Regarding the allegation, Staff threatened to fight the resident in care, Staff #2 (S2) tried to incite a fight with R1 who was frightened and asked their representative to come over. Based on an interview with W1, W1 did not witness S2 inciting a fight with R1. LPA was unable to obtain R1's statement due to their passing. LPA was also unable to interview the current residents and staff as they were not present during the period in which R1 resided at the facility. Regarding the allegation, Staff did not meet resident's diapering needs, it is alleged R1's soiled brief with feces was not changed timely, and R1 was not assisted to the bathroom twice a day to empty their bladder causing a urinary tract infection. Based on the review of the care plan dated March 19, 2023, R1 requires total assistance including toileting. R1 is incontinent and requires change of briefs and toileting schedule is needed day and night. Based on record reviews and interviews, the current residents and staff were not present during the period in which R1 resided at the facility. R1 moved out of the facility approximately January 2024, and R1 could not be interviewed due to R1's passing. Interviews with two staff who were employed at the time R1 resided at the facility, denied the allegation indicating that diapers were changed every 2 hours or as needed for all residents. One of the two interviewed staff indicated being assigned to female residents at the time. Current three of three staff and one of four residents who require changes did not corroborate with the allegation indicating that diapers are changed upon request and in a timely manner. Regarding the allegation, Staff fell asleep while on shift, Staff #3 (S3) was observed sleeping sitting on the couch during the middle of the day making it difficult to assist R1 to get by with their wheelchair. LPA did not observe any staff sleeping upon arrival. Investigation revealed S3 is no longer employed at the facility, so LPA was unable to interview S3. Based on interviews, two of four current residents and three of three staff denied the allegation. Regarding the allegation, Staff threatened to evict resident in care, it is alleged Staff #4 (S4) called R1's representative by phone stating that they had been doing nothing but complaining and would send an eviction notice the same day. Based on the interviews, S4 confirmed not getting along with R1's representative and had advised them that they would be able to look for other facilities. The text message receipts between S4 and R1's representative reveal that on December 9, 2023 at 1:38pm, S4 indicated that they will provide an eviction notice with the accurate terms however R1 moved out before an eviction notice was ever iissued. S4 denied threatening to evict R1, thus denied the allegation. Therefore, based on interviews and record review, 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 all allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Irvin Mendoza, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 22-AS-20231229160237

Allegation investigated: Staff did not seek medical attention for resident in care in a timely manner.

On 3/25/2026, Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of continuing the investigation into the above allegation. LPA notified Director/Administrator Daniel Rescia by telephone and explained the reason for the visit. Administrator Irvin Mendoza arrived on premise on behalf of Director Rescia and remained throughout the visit. On January 8, 2026, the Department received the complaint. The complaint was initiated by LPA on January 12, 2026. During the course of the investigation, LPA interviewed two of four residents as the remaining two residents were unable to provide a statement due to their medical condition. LPA also interviewed three staff, four witnesses, and obtained the following documentation for review: Resident Rosters, Staff Roster, Face Sheets and Physician's Reports for all residents including Resident #1 (R1) as well as R1's Admission Agreement, Needs and Services Plan, Care Notes, and medical records. The investigation is as follows: It is alleged that Staff did not seek medical attention for resident in care in a timely manner. Substantiated R1 suffered an unwitnessed fall on December 24, 2025 at 4:30am per the incident report dated December 26, 2025. Staff #1 (S1) discovered R1 on the floor calling for help while on their way to use the bathroom. Based on the admission agreement signed by R1 on April 3, 2024, page 2 of the admission agreement states that the facility does not provide a 24-hour awake staff, however staff would be on site in case of an emergency. Upon S1's initial assessment, there were no visible injuries, so S1 safely transferred R1 back to bed. The same day at 7:59am, S1 reported the fall to Staff #2 (S2) via text message. S1 subsequently reported the fall to hospice the same day approximately 9am per the incident report where S1 was advised to administer Tylenol for pain. On December 25th approximately 11am, R1 began complaining of left foot pain per the incident report. Hospice staff arrived to assess R1 and placed an order for a mobile X-ray. On December 26th, the X-ray technician arrived approximately 3:45pm to obtain X-rays. The X-ray results dated December 26th at 3:13pm indicated displaced partially impacted inter/subtrochanteric fracture with varus deformity, femoral diaphysis intact, right hip fracture. Hospice contacted R1's representative, and a decision was made to send R1 to the emergency room for further evaluation and treatment. Based on the interviews, one of three staff confirmed R1 expressed pain the day of the fall evidenced by groaning, however the two remaining staff denied R1 was in pain the day of the fall. It was not until December 26th when S1 observed R1's leg swelling when hospice staff alerted S1 prior to R1's shower approximately 8-9am. The investigation revealed that facility staff failed to immediately notify hospice after the fall which was discovered approximately 4:30am. S1 reported to S2, their direct supervisor, approximately 3.5 hours later after the fall, and an hour later to hospice. Although there were no visible injuries per the statement of three of three staff; it was not until two days later, December 26th, where visible changes to the leg was observed where R1's leg became swollen approximately 8:30am per S1. At this point, it was the responsibility of the facility to seek emergency medical attention prior to the X-ray technician arriving. Per the Department's Provider Information Notice (PIN) 25-06-ASC released on June 24, 2025, the PIN outlines protocols in Residential Care for the Elderly (RCFEs) when emergency services may be necessary and to help ensure residents receive timely medical care. The PIN indicates that the licensee shall immediately place a 9-1-1 call if a resident is experiencing any "imminent threat" and any symptoms which includes "falls with complaints of pain or loss of range of motion" or "obvious broken bones" which caused R1's leg to swell that facility failed to do. Therefore, based on interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff did not seek medical attention for resident in care in a timely manner is deemed SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D. An exit interview was conducted with Administrator Irvin Mendoza, and a copy of this report including the appeal rights and Confidential Names (LIC 811) were provided at exit.the state’s words, verbatim · CDSS document, Mar 25, 2026 · control 22-AS-20260108144042

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 26, 2026

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by: Based on interviews and record review, S1 observed swelling of the leg 2 days after the fall delaying the need for medical attention which poses an immediate Health, Safety, and/or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: Admin Mendoza stated and agreed to forward proof of an in-service training reviewing PIN 25-06-AC and placing 911 calls in the event of an incident/emergency for hospice residents and an Acknowledgement of Understanding of the said deficiency will be submitted to LPA by POC due date.

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Irvin Harris Mendoza and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 12:00PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 7-bedroom, 4-bathroom, one-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA and AD observed 2 staff and 4 residents present at the facility. Resident Bedrooms: the 6 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the one staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 113 and 114 degrees F in the 2 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 11:00AM, LPA reviewed 4 resident files and 3 staff files, interviewed 2 residents and 2 staff, and inspected medications for 4 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on documents, the physician's reports for R1, R2, and R3 are on the old form and do not contain required information, including behavioral expressions; based on documents, the appraisals for R2 and R3 are from 2024 and have not been updated; and based on documents, the physician's reports for R2 and R3 are more than a year old and there is no documentation of an annual visit within the last year. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 16, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to conduct a Required - 1 year inspection. LPA identified herself and was granted entry into the facility by Caregiver Julius Burnos. Administrator (AD) Irvin Harris Mendoza and Administrator Daniel Rescia arrived shortly after. AD Irvin Harris Mendoza's certificate expires on 02/03/2025. Four residents and one staff were present during today's visit. LPA, along with Caregiver Burnos toured the physical plant. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature. Resident bedrooms have the required furniture, bed linens and closet/drawer space to accommodate each Resident comfortably. Bathrooms were checked, toilets/water faucets worked properly and showers are free of mold/mildew. Hot water temperature is within regulatory requirements. Bath towels, toiletries and personal hygiene supplies are adequately stocked. Common areas were clean and clear of hazards, and doorways were free of obstructions. Kitchen is clean and organized. Perishable and non-perishable food supply was checked and adequately stocked. LPA observed sharps and cleaning supplies are inaccessible to the residents. Smoke detectors and carbon monoxide detector are operational. Fire extinguisher was fully charged and mounted. No bodies of water were observed outside. Walkways around the home were clear of hazards. Emergency/Fire Drills are conducted quarterly, last one conducted on 11/13/2024. LPA observed emergency supplies including food and water. LPA reviewed 4 resident files and 1 staff file. Medication was observed to be in a centrally stored location and medication reviewed appeared to have been dispensed accurately. Based on the observations made during today’s visit, no deficiency is being cited. This report was discussed with the Administrator Harris and a copy of the LIC809 and LIC9102 Advisory were sent to email on file.the state’s words, verbatim · CDSS document, Jan 14, 2025

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting a Required Annual Inspection. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrator Irvin Mendoza was contacted by phone and arrived later to assist with the visit. During the inspection, LPA and administrator conducted a tour of the physical plant and observed the following: The facility is a one-story home with six resident bedrooms, one staff room, three bathrooms, and attached two-car garage. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets and an adequate supply of linen is present in the hallway closet. The backyard has a shaded sitting area and the route of egress is free of clutter and obstructions. There are currently three residents in care at the facility. Bathrooms faucets and toilets were operational. Water temperature tested between 114F and 118F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguishers were observed to be fully charged with up-to-date maintenance. Sharps were observed locked in a drawer in the kitchen.LPA observed cleaning supplies to be stored in a locked cabinet under the kitchen sink, however some cleaning products such as bleach and Clorox were found in unlocked cabinets in other bathrooms. Additionally the staff room is observed to not be locked and a laundry unit in the backyard does not lock either. The medication central storage was observed to be locked. LPA reviewed three resident files and five staff files and interviewed staff and residents present. Based on the observations made during today’s inspection, three deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations along with two Advisory Notes issued. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Feb 14, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.