Casa El Cajon

Allegation investigated: Facility elevator was in disrepair Facility wrongfully charged service fees to resident

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver investigative findings regarding the above mentioned allegation. LPA identified herself, explained the purpose of the visit and nature of the complaint to Eveline Denton, Med Tech. On February 16, 2024 the Department received this complaint which alleged facility elevator was in disrepair and facility wrongfully charged service fees to Resident #1 (R1) [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] The Department’s investigation included a facility tour, record reviews, as well as interviews with residents, staff and outside sources. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Regarding the allegation that facility elevator was in disrepair, interviews with facility staff reported that the elevator became inoperable after a severe rain fall. Records reviewed revealed that the facility had the elevator initially assessed for maintenance on January 29, 2024 and had subsequent visits for maintenance. On June 21, 2024, the State Department of Industrial Relations, Division of Occupational Safety and Health conducted an inspection for the conveyance permit and the facility was granted the permit to operate the elevator again. Regarding the allegation that facility wrongfully charged service fees to R1, an interview done with R1 reported not being charged any extra fees and paying the same amount of rent every month. Interviews with staff stated they had never charged additional fees to R1. The Department has investigated the above mentioned allegations. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. An exit interview was conducted with Eveline Denton, Med Tech, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 08-AS-20240216091808

Allegation investigated: Staff do not ensure residents are provided a comfortable environment

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver investigative findings regarding the above mentioned allegation. LPA identified herself, explained the purpose of the visit and nature of the complaint to staff Maresulyn Ocenar. On March 2, 2026 the Department received this complaint which alleged staff do not ensure residents are provided a comfortable environment. The Department’s investigation included a facility tour as well as interviews with residents, staff, and outside sources. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) LPA interviewed Outside Source #1 (OS1) who frequents the facility often. OS1 reported that the facility is always clean. OS1 did not report concerns about the cleanliness or sanitization of the facility. Additionally, OS1 reported that they have observed staff prompt residents to wash their hands, use hand sanitizer, and provide other general hygienic reminders. OS1 reported that they have observed the facility to maintain a comfortable environment for residents. Interviews with residents reported that they observe staff clean the dining room after mealtimes and clean other areas of the facility every day. Residents reported feeling like the facility provides a comfortable and accommodating environment. Interviews with staff reported cleaning the dining room after meals and wiping commonly touched surfaces with disinfectants at least once a day. LPA observations during facility visits did not raise concerns regarding staff providing a comfortable or clean environment for residents. The Department has investigated the allegations that staff do not ensure residents are provided a comfortable environment. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. An exit interview was conducted with Maresulyn Ocenar, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 08-AS-20260302082547

Allegation investigated: Lack of supervision, resulting in resident on resident harrassment

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver investigative findings regarding the above mentioned allegation. LPA identified herself, explained the purpose of the visit and nature of the complaint to staff Maresulyn Ocenar. On February 2, 2026 the Department received this complaint which alleged lack of supervision resulted in resident on resident harassment. The Department’s investigation included a facility tour, record reviews, as well as interviews with residents and staff. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) The allegation stated that Resident #1 (R1) was harassed by Resident #2 (R2) at the end of a group activity at the facility when everyone was lined up to leave. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] LPA interviewed R1, who reported the incident occurred during the group activity while everyone was sat in a circle. Records reviewed revealed that R1 has a diagnosis of schizoaffective disorder, and per staff interviews has a history of making accusations against other residents and staff. LPA interviewed R2 who denied doing anything to harass R1. A review of R2’s Needs and Service Plan stated that they “express self appropriately” and their Physician’s Report noted that they do not display aggressive or inappropriate behavior. LPA interviewed other residents who were reportedly present during the group activity. These residents reported not observing any harassment take place and also stated that facility staff were present throughout the activity. Interview with staff who were present during the duration of the group activity reported not observing any harassment and did not report R1 or R2 acting in any way outside of their baseline. The Department has investigated the allegation that lack of supervision resulted in resident on resident harassment. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. An exit interview was conducted with Maresulyn Ocenar, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 08-AS-20260202113311

Allegation investigated: Resident was sexually assaulted by facility staff

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver investigative findings regarding the above mentioned allegation. LPA identified herself, explained the purpose of the visit and nature of the complaint to Eveline Denton, Medical Representative. On October 29, 2025 the Department received this complaint which alleged Resident #1 (R1) was sexually assaulted by Staff #1 (S1) [See LIC811 Confidential Name List for a description of select person identifiers used in this report]. The Department’s investigation included a facility tour, record reviews, as well as interviews with residents, staff, and outside sources. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) According to R1’s most recent Physician’s Report, R1’s primary diagnoses is schizoaffective disorder, bipolar type. During an interview with the Department R1’s responses were incoherent and R1 was unable to stay on topic regarding the allegation. An interview with an outside source familiar with R1 reported they have frequent symptoms of auditory and visual hallucinations and delusions. Interviews with facility staff corroborated R1’s history of auditory and visual hallucinations. Additionally, an interview with S1 denied the allegation. During LPA unannounced visits LPA observed S1 to be treating residents with dignity and respect. The Department has investigated the allegation that R1 was sexually assaulted by S1. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. An exit interview was conducted with Eveline Denton, Medical Representative, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 08-AS-20251029092537

Allegation investigated: Staff did not prevent a resident from engaging in self harming behavior. Staff did not seek medical attention for resident in a timely manner.

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver investigative findings regarding the above mentioned allegations. LPA identified herself, explained the purpose of the visit and nature of the complaint to staff Eveline Denton. On December 26, 2025 the Department received this complaint which alleged staff did not prevent a resident from engaging in self harming behavior and staff did not seek medical attention for resident in a timely manner. The Department’s investigation included record reviews, as well as interviews with residents, staff and an outside source. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Regarding the allegation that staff did not prevent a resident from engaging in self harming behavior, specifically that Resident #1 (R1) [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] was engaging in self harming behavior due to not eating. In an interview with R1, it was reported that on the day they were hospitalized, they did not eat breakfast or lunch because they did not want to. R1 reported that staff did encourage them to eat their meals. Additionally, R1's records indicate they are able to communicate their needs appropriately and has the capacity for self care. Regarding the allegation that staff did not seek medical attention for R1 in a timely manner, per interview with staff, R1 initially declined to have ambulance services called to transport them to the hospital. Per staff interview, there were no symptoms that caused concern for immediate medical attention. Staff observed R1 to appear more “lethargic” than normal. After declining an ambulance service, facility staff then reached out to R1’s family to discuss their concern of R1’s symptoms of not appearing at baseline which ultimately led to R1 agreeing to call ambulance services a couple hours later. Interview with R1 and records reviewed corroborated this timeline of events. Additionally, an interview with an Outside Source (OS1) familiar with the facility reported that they have no concern when it comes to facility staff calling appropriate emergency services when needed. The Department has investigated the above mentioned allegations. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. An exit interview was conducted with Eveline Denton, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 08-AS-20251226125451

Allegation investigated: Staff retaliated against resident

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver investigative findings regarding the above mentioned allegation. LPA identified herself, explained the purpose of the visit and nature of the complaint to Administrator Rebecca Rayo. On February 26, 2024 the Department received this complaint which alleged staff retaliated against Resident #1 (R1). [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] The Department’s investigation included a facility tour, record reviews, as well as interviews with residents, staff and outside sources. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Interviews with residents did not disclose any evidence to support this allegation. During staff interviews, it was consistently stated that they had not witnessed any staff retaliating against R1 or any other resident living at the facility. Further, interviews with two outside sources familiar with the facility and residents in care did not report any concerns regarding residents being retaliated against. The Department has investigated the above-mentioned allegation. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate this allegation and therefore deemed unsubstantiated. An exit interview was conducted with Administrator Rebecca Rayo, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Dec 8, 2025 · control 08-AS-20240226164443

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Angelica Boyles, made an unannounced visit to conduct the required One Year Inspection to ensure substantial compliance with Title 22 regulations. LPA identified herself, stated the purpose of the visit, and was granted entry into the facility by Administrator Rebecca Rayo. This facility is licensed to serve ninety-nine residents sixty and above; of which twenty-two may be non-ambulatory. LPA and Administrator toured the interior and exterior of the facility and inspected rooms at random. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. resident's bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility is operating in accordance with their fire clearance. The smoke and carbon monoxide alarms were present in the building. Emergency lighting, and facility telephone were all working. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. No pools or bodies of water exist on the premises. Per Administrator, no firearms or ammunition are kept at the facility. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] The facility has a 2 day supply of perishable food and a 7 day supply of nonperishable food items. The food supply is replenished frequently by outside vendors. Food was observed to be properly labeled. The food service area was observed to be clean and sanitary. Food menus and activities schedule were posted. Centrally stored medications were properly stored and locked in medication carts inside a locked medication room. LPA reviewed staff and resident records. Records reviewed contained the required documentation. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPA conducted a review of In-service training procedures. LPA interviewed staff and was assured transportation procedures as well as outside medical and dental assistance procedure are compliant. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Administrator Rayo to whom copies of this report, Licensee/Appeal Rights (LIC9058 03/22), was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Dec 8, 2025

Allegation investigated: Staff neglect/lack of supervision led to resident falling and sustaining a fractured right shoulder. Facility did not perform a reappraisal to confirm resident needed a higher level of care.

Licensing Program Analyst (LPA) Sarah Hurt conducted a telephone call on 09/26/2025 to deliver Complaint findings. LPA spoke with facility Admininstrator Rebecca Rayo and expalined the purpose of the phone call. Regarding the allegation staff neglect/ lack of supervision led to resident falling and sustaining a fractured right shoulder. On 03/30/2024, Resident 1 sustained an unwitnessed fall while walking and was transported to Grossmont Hospital. Resident 1 reported they lost their balance and fell on their right shoulder, denying head trauma or loss of consciousness. Resident 1 was discharged the same day with a non-surgical fracture and pain management instructions. On 03/31/2024 facility noted Resident 1 was lethargic, unable to ambulate, or perform basic tasks. Administrator transported Resident 1 back to the hospital, where the social worker determined he required a higher level of care. Unsubstantiated Resident 1 was later transferred to a skilled nursing facility for short-term rehabilitation before returning to the facility with Home Health services. Although Resident 1 did sustain an injury, evidence shows facility staff responded appropriately by seeking medical treatment and monitoring his condition. There is insufficient evidence to prove neglect or lack of supervision directly caused the fall or injury. Based on interviews conducted and records reviewed, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged did or did not occur. Regarding the allegation facility did not perform a reappraisal to confirm resident needed a higher level of care. On 03/31/2024, Facility Administrators observed Resident 1’s change in condition and immediately arranged for his return to the hospital, informing staff he could not return to the facility unless independent. Resident 1 was placed at skilled nursing for physical therapy and later cleared by a physician to return to the facility with Home Health support. The facility Administrator identified Resident 1’s increased care needs, initiated transfer to a higher level of care, and coordinated follow-up. Upon re-evaluation, Resident 1 was determined to again meet the criteria for independent living with Home Health assistance. Based on interviews conducted and records reviewed, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged did or did not occur. No deficiencies cited Per title 22 regulations. Exit interview was conducted with facility Administrator Rebecca Rayo. A copy of this report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 08-AS-20240403084231

Allegation investigated: Lack of supervision resulting in drug use

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver findings regarding the above mentioned allegation. LPA identified herself, explained the purpose of the visit and nature of the complaint to Administrator Becky Rayo. On May 27, 2025 the Department received this complaint which alleged lack of supervision resulted in drug use. The Department’s investigation included facility tours and interviews with residents, staff, and outside sources. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) The Reporting Party (RP) alleged that her brother, Resident #1 (R1) was given drugs while in his room. [See LIC811 Confidential Name List for a description of select person identifiers used in this report]. LPA interview with RP revealed that RP did not witness this alleged incident. LPA interview with the Administrator reported that drug and alcohol use is not permitted on the property, but there are designated smoking areas outside the property. The facility is not a locked facility, and per the admissions agreement, residents are allowed to come and go freely but they must sign in and out of the logbook. Interviews with other staff corroborated that clients are allowed to smoke outside in designated areas and if residents are caught smoking inside their rooms, they are reminded of the admissions agreement. Staff interviews also mention how illegal substances are not allowed on the facility grounds. Interviews with residents reported being aware that if housekeeping finds any evidence of smoking or other drugs in their room, the Administrator is notified and appropriate action is taken. Residents did not report observing any use of illegal substances inside or outside the facility property. LPA interview with outside sources familiar with the facility corroborated no concern regarding lack of supervision or drug use at the facility. Further, during unannounced facility visits LPA did not observe any prohibited drug use. The Department has investigated the lack of supervision resulting in drug use. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. And exit interview was conducted with Administrator Becky Rayo, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Aug 19, 2025 · control 08-AS-20250527140804

Allegation investigated: Staff had an inappropriate conversation with another adult while in the presence of a resident in care

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver findings regarding the above mentioned allegation. LPA identified herself, explained the purpose of the visit and nature of the complaint to Administrator Becky Rayo. On June 5, 2025 the Department received this complaint which alleged staff had an inappropriate conversation with another adult while in the presence of Resident #1 (R1) [See LIC811 Confidential Name List for a description of select person identifiers used in this report]. Specifically, that staff threatened to evict R1. The Department’s investigation included interviews with residents, staff and outside sources. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Per LPA interview with R1, R1 did not report ever being threatened with eviction by any staff. R1 reported to LPA never making any comments regarding being threatened with eviction to the Reporting Party. Interviews with other residents revealed that there have been no witnesses to staff threatening to evict residents. Further, LPA interview with outside sources familiar with the facility corroborated no concern regarding staff threatening to evict residents. The Department has investigated the allegation that staff had an inappropriate conversation with another adult while in the presence of a resident in care. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. And exit interview was conducted with Administrator Becky Rayo, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Aug 19, 2025 · control 08-AS-20250605094913

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced Case Management - Incident visit. LPA was welcomed by and identified herself to Administrator Becky Rayo and discussed the purpose of the visit. Today's visit was in response to an LIC624 Incident Report, which licensee self submitted to the CCLD San Diego Regional Office (received on 8/18/2025). According to the LIC624: on 8/16/2025, Resident #1 (R1) signed out to leave the facility's logbook at 1:40PM and did not return. [See LIC 811 Confidential Names List for a description of R1.] The facility is not a locked facility, and per the admissions agreement, residents are allowed to come and go freely but they must sign in and out of the logbook. As of today’s visit, R1 has not yet returned to the facility. LPA performed a facility tour and welfare check on the other remaining residents in care, finding no immediate health or safety concerns. LPA also reviewed pertinent records and interviewed relevant staff. According to R1’s latest LIC602 Physician’s Report (dated 7/21/2025): R1’s primary diagnoses is schizophrenia and hypertension. Their physician determined that R1 was able to safely leave the facility unassisted. (Continued on LIC809C) (Continued from LIC809) According to the facility’s Absentee Notification Plan: The Administrator of the facility or his/her designee, will inform the resident's authorized representative, if any, when the resident is missing from the facility. In addition, the Administrator or designee will notify local law enforcement when there is a reason for concern, or within 24 hours. For residents with a Dementia diagnosis, facility will notify law enforcement within 30 minutes after facility and neighborhood search. The policy will be updated on all Needs and Service Plan. Records and interviews revealed: R1 had lived at the facility since 7/22/2025 and this is R1's first time leaving the facility and not returning. Facility staff called law enforcement and notified R1’s responsible person and case manager. Facility staff conducted a search of the surrounding area when R1 was not present for dinner. At about 8PM, after unsuccessful searching, the Administrator filed a missing person’s report with law enforcement and telephoned R1’s responsible person and case manager to notify them. CCLD concluded: Facility staff provided needed supervision to R1 leading up to the incident. Licensee had a written Absentee Notification Plan as part of R1’s record of care, and staff followed this plan. No deficiencies were cited for the above incident. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Administrator Becky Rayo, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 19, 2025

Allegation investigated: Facility is in disrepair. Illegal eviction.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation. LPA was granted entry after identifying herself to Medical Receptionist Eveline Denton. LPA discussed the purpose of the visit, and the basic elements of the allegations mentioned above with MR Denton. The Department's investigation included resident, staff, and outside source interviews, a facility, and a resident records reviews. It was alleged the facility was in disrepair. More specifically, it was alleged that water from recent rain falls had soak up through the foundation, and through the tile flooring and would create puddles in Resident's1 (R1's) room. A review of R1’s records revealed they were admitted to the facility on May 17, 2019, with a primary diagnosis of anxiety, depression, osteoarthritis, hypertension, and high cholesterol. R1’s records also revealed they were independent and only required medication management, and they were happy and easy going. Unsubstantiated An interview conducted with Staff1 (S1), the facility maintenance, revealed they never heard of water being soaked through foundation and tile flooring and never received a work order for this matter. S1 revealed a crack in the wall adjoining to R1’s room. Additionally, S1 accompanied LPA on a facility tour, including an inspection of R1’s room and LPA observed no issues. An interview with facility Staff2 (S2), the Administrator, corroborated they had never received a complaint regarding puddling in rooms after rain. Interviews with residents in care revealed no issues with the facility’s physical plant. It was also alleged facility staff served a resident an unlawful eviction. An interview with Outside Source1 (OS1) revealed R1 was very unhappy, claimed staff were rude and R1 would complain about everything and wanted to move out. OS1 and R1 worked together to find adequate placement for R1 as they would continuously express, they wanted to move out, and would have outbursts of behaviors, disrupting other residents in care. S2 revealed, also corroborated by OS1, that R1 was delinquent on their monthly payments. Interviews conducted with residents in care revealed they had no issues with facility staff or the facility in general. Based on interviews Due to lack of corroborating evidence, the finding regarding the above allegations were established to be unsubstantiated. This finding means there was not a preponderance of evidence to prove that the alleged violations occurred. LPA conducted an exit interview with MR Denton and was provided a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 01-2016) the conclusion of the visit and signature below acknowledges receipt of the documentsthe state’s words, verbatim · CDSS document, Jun 16, 2025 · control 08-AS-20250127120814

Allegation investigated: Staff threatened to evict resident.

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced subsequent visit to the facility to deliver investigative findings regarding the above mentioned allegation. LPA identified herself, explained the purpose of the visit and nature of the complaint to Licensee Lillian Franklin. On March 3, 2025 the Department received this complaint which alleged staff threatened to evict Resident #1 (R1) [See LIC811 Confidential Name List for a description of select person identifiers used in this report] . The Department’s investigation included a facility tour, in addition to interviews with residents, staff and outside sources. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Per LPA interview with R1, R1 did not report ever being threatened with eviction by any staff. R1 reported to LPA never making any comments regarding being threatened with eviction to the Reporting Party. Interviews with other residents revealed that there have been no witnesses to staff threatening to evict residents. Further, LPA interview with an outside source familiar with the facility and frequently visits corroborated no concern regarding staff threatening to evict residents. The Department has investigated the allegations that staff threatened to evict R1. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. And exit interview was conducted with Licensee Lillian Franklin, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 08-AS-20250303162344

Allegation investigated: Facility staff are not allowing resident to attend Adult Day Program Facility staff are not assisting resident with medical appointments Facility staff are not answering communications from resident’s representative appropriately

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver investigative findings regarding the above mentioned allegation. LPA identified herself, explained the purpose of the visit and nature of the complaint to Licensee Lillian Franklin. On February 10, 2025 the Department received the complaints which alleged facility staff are not allowing resident to attend Adult Day Program, facility staff are not assisting resident with medical appointments, and facility staff are not answering communications from resident’s representative appropriately. The Department’s investigation included a facility tour, record reviews, as well as interviews with residents, staff and outside sources. (Continued on LIC9099-C). Unsubstantiated (Continued from LIC9099) Regarding the allegation that facility staff not allowing resident to attend Adult Day Program, R1 did not report being prohibited from going to Day Program. LPA interview with two facility staff reported that they do not prevent residents from going to Day Program. In fact, staff reported having to encourage residents to attend program and if residents do not attend it is because they do not want to. Additional interviews with residents corroborate being encouraged to attend day program. Regarding the allegation that facility staff are not assisting resident with medical appointments, R1 reported staff does help with arranging medical appointments and stated that Staff #1 (S1) assisted with a medical appointment later in the week. Interview with S1 corroborated this statement and reported assisting most residents with medical appointments because they can easily arrange transportation for residents. Regarding the allegation that facility staff are not answering communications from resident’s representative appropriately, facility staff reported that there may be occasions when they are unable to answer the phone due to tending to higher priorities. However, staff reported that they will always return voicemails left. According to an outside source familiar with the facility and frequently visits reported not being aware of any concerns involving resident representatives not being communicated with. The Department has investigated the above mentioned allegations. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. An exit interview was conducted with Licensee Lillian Franklin, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 08-AS-20250210110911

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ryan Fulton conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Beccy Rayo. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/19/2024). According to the LIC624: on 12/18/2024, Client #1 (C1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of C1.] C1 has not returned to the facility at of present time. During today’s visit, LPA performed a facility tour / welfare check, collected records, and interviewed pertinent individuals. According to C1’s latest LIC602 Physician’s Report (dated 11/11/2024), their doctor determined that C1 was able to safely leave the facility unassisted. Interviews and records showed that Licensee had a written Absentee Notification Plan as part of C1’s record of care, and that staff followed this plan. No deficiencies were cited for this incident. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Administrator Beccy Rayo, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Dec 20, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ryan Fulton conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Administrator Beccy Reyes Rayo. The facility's license shows a maximum capacity of ninty-nine (99) residents. During today’s inspection there were ninty-five (95) residents in care. LPA and Administrator Beccy Reyes Rayo toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. resident's bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens 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. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all of which are safely stored. Cooking/dining equipment and utensils were present. Toxic chemicals/poisons were locked and inaccessible to residents. Medications were labeled, as required, and stored in locked areas. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to residents were all compliant: Kitchen sink was not accessible to residents; bathroom #1 sink was 114.5 F bathroom #2 sink was 116.3 F. bathroom #3 sink was 120.0 F bathroom #4 sink was 120.0 F bathroom #5 sink was 120.0 F. No pools or bodies of water exist on the premises. Per licensee, no firearms or ammunition are kept at the facility. Carbon monoxide/Smoke detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Beccy Reyes Rayo to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 12, 2024

Allegation investigated: Licensee did not safeguard resident's money.

Licensing Program Analyst (LPA) Correia conducted an unannounced follow-up visit to a complaint investigation and delivered the finding to the above-mentioned allegation. LPA Correia identified herself, was granted entry, and explained the purpose of the visit to Administrator Rayo. The Department’s investigation consisted of staff, resident, and outside source interviews. The investigation also included facility, resident, and outside source records reviews. It was alleged that facility staff did not safeguard Resident’s (R1) cash resources. A resident records review revealed R1 was admitted to the facility on July 13, 2020, with a primary diagnosis of Schizophrenia. A review of R1’s resident records dated the day of admission revealed R1 was able to manage their own cash resources in small amounts, an additional records review dated 2 days later, July 15, 2020, revealed R1 was not able to manage their own cash resources. However, a review of facility records revealed per contractual agreement that the facility does not safeguard cash resources. [Continued on LIC 9099C] Unfounded [Continuation from LIC 9099] An initial interview conducted with R1 revealed they believed their roommate had stolen their money, subsequently a follow up interview with R1 disclosed they had lent money to several other residents and was never paid back. R1 also disclosed they had donated money to attending organizations. Interviews conducted with staff and other residents revealed no knowledge or experience of thefts that occurred while working or residing at the facility. An interview conducted with the Administrator confirmed the facility does not safeguard cash resources for any of the residents. An interview conducted with an Outside Source (OS1) revealed no knowledge of the alleged theft, and an additional review of Outside Source records (OS2) revealed there were no leads to pursue an investigation to the allegation (see LIC 811 for confidential names). LPA conducted an exit interview with Administrator Rayo who was notified that a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 01-2016) will be provided at the conclusion of the visit. Based on the information collected during the investigation CCL has deemed the complaint to be unfounded meaning that the allegation was false and/or is without a reasonable basis. Therefore, the Department has dismissed the complaint.the state’s words, verbatim · CDSS document, Nov 25, 2024 · control 08-AS-20210806114056

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Rebecca Rayo. Today's visit was in response to a LIC 624A Death Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 07/11/2024, updated report received on 07/12/24). According to the LIC624A: on 07/01/2024, Resident #1 (R1) was sent to the hospital due to a behavioral episode. R1 passed away at the hospital on 07/05/24 and the cause of death is unknown. During today’s visit, LPA performed a facility tour/welfare check, collected records, and interviewed the Administrator. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Rebecca, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jul 15, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Rebecca Rayo. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 06/18/2024). According to the LIC624: on 06/18/2024, Resident #1 (R1) eloped from the facility (didn't take their morning medications and didn't sign out). [See LIC 811 Confidential Names List for a description of R1.] R1 returned to the facility unharmed on the same day, 06/18/2024. During today’s visit, LPA performed a facility tour/welfare check, reviewed records, and interviewed the Administrator. According to R1’s latest LIC602 Physician’s Report (dated 06/27/23), their doctor determined that R1 was able to safely leave the facility unassisted. The resident returned and agreed to go the hospital for re-assessment. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Rebecca, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jun 19, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Med Receptionist Eveline Denton. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 03/04/2024). According to the LIC624: on 02/29/24, Resident #1 (R1) left the facility and did not return. [See LIC 811 Confidential Names List for a description of R1.] As of today’s (03/05/24) licensing visit, R1 has not yet returned to the facility. LPA performed a facility tour and welfare check on the other remaining clients in care, finding no immediate safety concerns. LPA also reviewed pertinent records and interviewed relevant staff and residents. According to R1’s latest LIC602 Physician’s Report (dated 08/31/22): R1’s primary diagnosis is schizophrenia. Their doctor determined that R1 was able to safely leave the facility unassisted. Interview with staff and residents did not reveal any information regarding changes in condition or issues with medication management. The facility Administrator filed a missing person's report with the local police department immediately. CCLD concluded: The Administrator followed appropriate CCLD regulatory protocols and reported the incident to the appropriate agencies and authorities. No deficiencies were cited for the above incident. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Eveline, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Mar 5, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Administrator Rebecca Rayo, after identifying herself and stating the purpose of the inspection. This facility serves ninety-nine, residents 60 and above; of which twenty-two may be non-ambulatory. A tour of the facility was conducted which included a sample of resident units, the dining area, common gathering areas, and food storage areas. There are no water features on site. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with the required furnishings. Overhead as well bedside lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Showers were equipped with grab bars and non-slip mats. Hot water temperature in residents’ bathrooms were compliant. The facility is operating in accordance with their fire clearance. The smoke and carbon monoxide alarms were present in the building. Emergency lighting, and facility telephone were all working. First aid kit(s) were complete and readily accessible in the medical rooms. Required licensing postings were observed in visible areas of the facility. PPE supplies are onsite. Indoor passageways were free from obstructions. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Some food supplies were kept in in an outdoor locked storage area. Food supply are replenished frequently by outside vendors. Food was observed to be properly labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Centrally stored medications were properly stored and locked in medication carts inside a locked medication room. Medications were labeled and kept in compliance with label instructions. Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPA conducted a review of In-service training procedures. LPA interviewed Administrator Rayo as well as staff and was assured transportation procedures as well as outside medical and dental assistance procedure are compliant. There are two large common rooms used for dining and activities. At the time of visit, LPA observed a few residents participating in a small group activity. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were issued at the time of visit. An exit interview was conducted with Administrator Rayo to whom copies of this report, Licensee/Appeal Rights (LIC9058 03/22), was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 25, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Rebecca “Becky” Rayo. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 11/07/2023). According to the LIC624, during the late evening of 11/06/2023, Resident #1 (R1) left the facility without informing staff or signing themselves out on the facility's logbook. [See LIC 811 Confidential Names List for a description of C1.] During today’s visit, LPA performed a brief facility tour and interviewed R1 (who had since returned to the facility), finding they were unharmed. LPA also collected copies of pertinent care records, and interviewed relevant staff and R1's roommate. According to R1’s latest LIC602 Physician’s Report (dated 06/27/2023): R1 was diagnosed with “Schizophrenia, bi-polar type,” but did not have Dementia or cognitive impairment. Their doctor determined that R1 was able to follow instructions, able to communicate needs, and “able to leave the facility on [their] own and return on [their] own.” R1 was also independent in all Activities of Daily Living (ADLs), except for medication assistance. R1’s independence with personal care was also evidenced in other facility and third-party care records. R1's Facesheet also showed that they were their own Responsible Person (RP). [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809-C] Interview of R1, their roommate, and staff, corroborated by dated and written progress notes, showed: During the 11/06/2023 incident, R1 left the facility without telling staff or signing themselves out on the logbook, as was required in the House Rules with R1 signed upon admission. Facility staff provided needed observation and timely recognized that R1 was not present during a routine room check. Staff followed the facility’s Absentee Notification Plan and timely notified law enforcement and R1’s psychiatrist. Around 24 hours later, R1 had returned to the facility on their own, unharmed. During review of the facility’s care records on R1: LPA observed that while R1 had a completed LIC9172 Functional Capabilities Assessment, the LIC603 Pre-Placement Appraisal which Licensee performed on R1 was incomplete (several missing fields). LPA also observed that R1’s LIC625 Appraisal/Needs and Services Plan was blank and not signed. Interview of the administrator confirmed that R1 was referred to the facility by their assigned psychiatrist, but the Licensee or their staff did not personally meet with R1 prior to move in, for the purpose of completing an independent, pre-admission appraisal interview. One (1) deficiency was thus cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Rayo, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Nov 13, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 13, 2023

87456 Evaluation of Suitability for Admission: “(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall…(1) Conduct an interview with the applicant…” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 98 residents (R1), Licensee did not interview the applicant to evaluate their suitability, prior to accepting them for care. This posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 13, 2023

Plan of correction: Licensee agreed to finish writing R1’s LIC603 Pre-Placement Appraisal and LIC625 Appraisal/Needs and Services Plan, and to E-mail signed copies of both to LPA, by the POC due date.