Casa Mahal

Allegation investigated: Staff do not properly dispose chemicals.

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 Caregiver Teresita Duclayan. On July 7, 2026 the Department received this complaint which alleged staff do not properly dispose chemicals. The Department’s investigation included a facility tour and interviews with staff and an outside source. (Continued on LIC9099-C) Substantiated (Continued from LIC9099) An interview with an Outside Source (OS1) reported that facility staff frequently dump water and chemicals against the fence after cleaning and it leaks under the fence. Pictures provided to LPA demonstrated how the water ends up soaking through to the other side of the fence into the neighbor’s backyard. OS1 reported not knowing what the water was but stated it must have been something unsanitary due to observing staff wearing masks and gloves while dumping it. OS1 reported that it smelled of waste and chemicals. Per LPA interviews with staff, when resident’s clothes or sheets are soaked with urine, they are washed in the backyard by being soaked in a basin filled with water and cleaning agents. Staff reported the laundry is not done in the washing machine because they do not want to contaminate the other laundry with urine. Staff reported the water waste is then dumped against the fence into the plants. Staff reported understanding that the water dumped included urine and cleaning chemicals and it is unsanitary to dump it. During unannounced visits, LPA observed in the backyard against the fence a small tub where clothing was being soaked. Additionally, during today’s visit LPA observed next to the back sliding door a plastic bag containing soiled incontinence care items which was not properly disposed of. LPA was able to smell the malodor of urine immediately upon opening the sliding back door. The Department has investigated the allegation that facility staff do not properly dispose of chemicals. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was met to support or corroborate this allegations and therefore deemed substantiated. A deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A plan of correction was jointly developed with Caregiver Teresita Duclayan. An exit interview was conducted with Caregiver Teresita Duclayan, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 13, 2026 · control 08-AS-20260707113756

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(f) · Plan of correction due date: Aug 3, 2026

Maintenance and Operation (f) All waste shall be located, stored, and disposed of in a manner that will not transmit...diseases or odors, pose a risk to health and safety... This requirement was not met as evidenced by: Per LPA observations and interview with staff, incontinence waste and was not being properly disposed of. This poses a potential health and safety risk to 5 of 5 residents in care.the state’s words, verbatim · CDSS document, Jul 13, 2026

Plan of correction: Staff reported that they will no longer dump waste water in the backyard. Additionally, staff will complete a training on cleaning and disposing of incontinence waste and submit to LPA proof of training by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced Case Management visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Teresita Duclayan. Licensee Myrna Arcelao later joined the visit. When LPA arrived at the facility there was a couch blocking the front door preventing LPA from entering. Per interview with caregiver the couch was placed in front of the door to prevent Resident #1 (R1) from eloping. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] Caregiver reported they cannot keep an eye on R1 when tending to other residents because they were the only staff at the facility at that time. Caregiver immediately moved the couch to allow full access of the front door. LPA observed R1 exit the facility in an elopement attempt while staff was in the kitchen. LPA followed R1 out and was able to keep R1 from going into the street. LPA stayed with R1 for some time, who refused to go back inside the facility. Caregiver came outside to stay with R1 at which point LPA went inside the facility and there were no other staff inside the facility to provide supervision to the other residents. Additionally, LPA observed R1 to be restrained by a postural support. R1 was unable remove the restraint independently. A review of R1's records revealed that there is not a physician's order for postural support. Further, a review of all resident records revealed none of the residents had signed Personal Rights in their records. Four deficiencies were observed and cited during todays visit per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages), including a Civil Penalty totaling $500 (refer to LIC 421IM). A plan of correction was jointly developed with Licensee Myrna Arcelao. Due to three Type A deficiencies being cited, LPA informed Licensee that an office meeting will be scheduled at a later date. An exit interview was conducted with Licensee, to whom a copy of this report, the LIC 809-D, LIC 421IM, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Jul 24, 2026

Postural Supports(a)... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need...shall be maintained in the resident’s record... This requirement was not met as evidenced by: LPA observed R1 to be restrained to their wheelchair by postural supports wihout having a phsyician's order. This posed an immediate personal rights risk to 1 of 5 residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: Staff removed postural support restraint from R1 and Licensee stated she would obtain a physician's order and send to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: Jul 9, 2026

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 evidenced by: LPA observed only 1 staff on the facility premise which resulted in R1 attempted elopement. This posed an immediate health and safety risk to 5 of 5 residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: Staff called for additional staff to come to the facility. Licensee will provide LPA with an updated staff schedule that includes at least two staff during the day by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jul 8, 2026

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: LPA observed a couch blocking the front door. This caused an immediate health and safety risk to 5 of 5 resdients in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: Staff immediately removed the couch from blocking the front door and stated it would not be placed in front of the door again. Therefore, this deficiency has been cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468(b)(1)(A) · Plan of correction due date: Jul 24, 2026

Personal Rights (b)...a resident...shall be personally advised of and given a copy of: (1) The personal rights (A)...and the signed copy shall be included in the resident's record. This requirement was not met as evidenced by: Records reviewed revealed 5 out of 5 residents did not have a signed copy of the Perosnal Rights in their records. This poses a potential personal rights risk to 5 out of 5 residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: Licensee agreed to submit copies of all residents signed Personal Rights to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angelica Boyles made an unannounced Case Management visit to the facility in order to review facility records. LPA was welcomed by and discussed the purpose of the visit with Caregiver Melia Ebuen and also spoke to Administrator Myrna Arcelao over the phone. LPA conducted a brief facility tour and reviewed resident records. A record review and interview with the Administrator confirmed that the facility no longer maintained records for Resident #1 (R1), who no longer resides at the facility. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] One citation is being cited per California Code of Regulations, Title 22 (refer to the attached LIC809-D page. A plan of correction was jointly developed with the Administrator. An exit interview was conducted with staff Melia Ebuen to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Jul 24, 2026

Resident Recordds (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not maintain records for R1. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 26, 2026

Plan of correction: Licensee agreed to attend outside vendor training regarding Residents Records and provide proof of training to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA identified herself to Caregiver Euben and explained the purpose of the visit. The facility is licensed to six (6) residents of whom five (5) can be non-ambulatory, one bed-ridden, and 5 receiving hospice services. During today’s visit, LPA Correia conducted an interior and exterior tour of the facility and resident and staff records reviews. LPA also briefly spoke to a resident in care and interviewed facility staff. The facility's physical plant and staff and resident records were observed to be in compliance. One deficiency was observed and cited during today's annual inspection. An exit interview was conducted with Caregiver Euben to whom a copy of this report and deficiency statement (LIC 9099 and LIC 9099D) and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit. Signature on this form acknowledges receipt of the rights and a copy of this reports.the state’s words, verbatim · CDSS document, Apr 24, 2026

Allegation investigated: Staff handled resident in a rough manner.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation and to deliver the finding regarding the above-mentioned allegation. LPA was greeted by Caregiver Nelia Ebuen, identified herself, and discussed the purpose of their visit.. LPA was later joined by Caregiver Myrna Arcelao. The Department’s investigation included staff and outside source interviews, and reviews of resident, staff, and outside source records. On October 15, 2025, Community Care Licensing (CCL) received a complaint that alleged staff (S1) handled a resident (R1) in a rough manner. A review of R1’s records revealed they were admitted to the facility in August of 2018, with a diagnosis of Dementia. Additional review of R1’s records dated January 9, 2021, also revealed R1 was non-ambulatory, confused, and had a history of wandering behavior. During LPA’s initial visit she visited R1 in their facility room. LPA observed R1 to be disoriented to place and time and was unable to stand up without assistance. [Continued on LIC 9099C] Substantiated An interview conducted with an outside source (OS1) revealed upon the transport driver's (OS2) arrival at R1's appointment they refused to exit the transport van. OS1 disclosed that OS2 revealed they returned R1 to the facility and upon arrival OS2 went to the front door for assistance getting R1 out of the van and two staff members (S1 and S2) came out to assist. S1 entered the van, while S2 stayed outside the van with OS2, and S1 was observed to be rough and abrasive when they assisted R1 out of the transport van. OS2 also disclosed that the other staff member (S2) did not intervene. An interview conducted with OS2 corroborated OS1’s statement and disclosed upon arrival to R1’s appointment contacted the transport agency's dispatch line to notify them they would be returning R1 to the facility because R1 would not get out of the van. The interview with OS2 also corroborated they observed S1 was rough with R1 and stated S1 grabbed R1 by the arm and forced them out of the van, and they rushed R1 by making comments such as “hurry up” “come on”. The Department also received footage of the incident that corroborated the chain of events described above, and from a different point or view (from the footage) S1 is also seen grabbing R1 by the seat of their pants. A review of the facility staff schedule confirmed S1 was the staff in question. [See LIC 811 for confidential names] Based on interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. Deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC9099-D). An exit interview was conducted with Caregiver Arcelao, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) will be provided at the conclusion of the visit. Caregiver Arcelao's signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Oct 29, 2025 · control 08-AS-20251015152339

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a) · Plan of correction due date: Nov 28, 2025

Residents in all residential care facilities for the elderly shall have all the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This regulation was not met as evidenced by: Based on interviews and record reviews facility staff do not accord dignity to a resident in care [R1] by grabbing and shouting at them to force them out of a transport car. This posed a personal rights risk to 1:5 residents in care.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: Caregiver Arcelao recommended and agreed to have staff attend a CCL approved vendorized training conducted on personal rights for residents in care. Caregiver Arcelao will provide proof of completion by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Debbie Correia conducted an announced Case Management visit. LPA met with Caregiver/Applicant Arcelao, identified herself, and discussed the purpose of the visit with Caregiver Arcelao. During today's visit LPA discussed the status of the Change of Ownership (CHOW) with (current) Caregiver Arcelao and Applicant for the CHOW. Arcelao informed LPA that approximately two weeks ago they spoke with the Centralized Application Bureau (CAB) Analyst Fonteno regarding obtaining fire clearance. Arcelao revealed they received an invoice from the Fire Marshall and paid for it on October 22, 2025. Arcelao left a message to schedule an appointment for an inspection for fire clearance and is currently waiting for a response and will continue to follow up. No deficiencies were observed 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 Arcelao, whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Oct 29, 2025

Allegation investigated: Resident sustained a stage 2 pressure injury while in care. Resident's responsible party was not notified of change in condition. Staff do not meet resident's hygiene needs. Licensee did not follow physician's orders. Facility has insufficient staffing. Licensee does not provide adequate food service. Licensee does not offer any activities.

LPMII RA, Donna Teutschel, conducted a telephone interview with Theresa Frazier regarding the above allegations. Refer to complaint #08-AS-2021072110943 regarding same resident for additional interviews interviews and LPA observations. Allegation - Resident sustained a stage 2 pressure injury while in care. While it is established that R1 establised a stage 2 pressure injury on his coccyx as verified by R1's physician report dated 7/16/21, it was not determined that the pressure injury was caused by any staff neglect. Pressure injury was being treated by Unicare Home Health. Allegations - Resident's responsible party was not notified of change in condition;Staff do not meet resident's hygiene needs; Licensee did not follow physician's orders;Facility has insufficient staffing; Licensee does not provide adequate food service; Licensee does not offer any activities. Based upon interviews obtained there is insufficient evidence in support these allegations occurred. While R1 may have lost weight, he was offered choices of foods and was in a declining state which R1's responsible party was aware. It was not established that R1's declining condition had to do with inadequate food service,.insufficient staffing, not following physician's orders or not meeting hygiene needs. There was evidence acivities offered but no information from RP on this allegation. All allegations are determined to be Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 31, 2025 · control 08-AS-20210623111437

Type of visit: Case Management - Annual Continuation

LPA Correia conducted a continuation of the required annual inspection visit that commenced on April 29,2025. LPA Correia was greeted by Caregiver Teresita Duclayan, identified herself, and discussed the purpose of the visit. Facility records reviews and staff interviews revealed the facility underwent a structural change in Licensure without following the proper procedures as outlined in Health and Safety Code per Licensing mandate. Records reviews and interviews also revealed the facility did not change the Control of Property also required per mandate. Based on today’s inspection, the following page (LIC809D) lists the Health and Safety code deficiency observed at this time in the areas evaluated. An exit interview was conducted with Teresita Duclayan to whom a copy of this report, LIC809D, and Licensee's Rights (LIC9058,) as well as a copy of Health and Safety Code 1569.15. Signature below confirms receipt of the reports. LPA left during the inspection to conduct another annual inspection.the state’s words, verbatim · CDSS document, May 5, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced Required Annual Inspection. LPA was greeted, identified herself, and was allowed entry into the facility by Caregiver Teresita Duclayan to whom was explained the purpose of the visit. According to the facility’s license, the facility has a maximum capacity of six (6) residents, of whom one (1) can be bedridden, and five (5) can be non-ambulatory. The facility also has a hospice waiver for five (5) residents. LPA, accompanied by Caregiver, toured the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and 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 resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents in care. Medications were labeled, as required, and stored in locked areas. [Continued on LIC809C] [Continuation of LIC 809] No pools or bodies of water were observed on the premises. Per Caregiver, no firearms or ammunition are kept at the facility. Smoke alarms, emergency lighting, and facility telephone were all working. The facility does have a physical telephone. Fire extinguishers were newly purchased. First aid kit was complete and readily accessible. Due to time constraints LPA was unable to complete the annual inspection and will return at a later date. No deficiencies were cited during An exit interview was conducted with Caregiver Duclayan, and a copy of this report along with Licensee/Appeal Rights (LIC9058 FAS 01/16) was provided signature below confirms receipt of the reports.the state’s words, verbatim · CDSS document, Apr 29, 2025

Allegation investigated: Facility staff is sleeping during shift. Licensee did not follow universal precautions.

**This is an amended report*** Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit with Care GIver Teresita Duelayan. LPA Rodgers called Licensee Myrna Arecleo upon arrival to inform them of LPA Rodgers' presence and purpose in the facility, but they decided not to join the visit. On July 21, 2021, Community Care Licensing (CCL) received a complaint alleging that staff are sleeping during shift and the Licensee did not follow universal precautions. More specifically, staff had been seen sleeping in the chair while they were on shift in the facility, and for a period of time in July 2021, no symptom screening was conducted, temperature was not checked, and staff were not wearing any face covering. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, outside sources, and a records review. (Continued on 9099-c) Substantiated (Continued on 9099-C) ***This is an amended report** Staff was able to produce limited resident files upon CCLD’s request on October 24, 2024. The Licensee replied that they had destroyed most of the six resident records requested by CCLD. The licensee is required to maintain a resident's file for three (3) years after their move-out (which occurred in July of 2021). Regarding the allegation that the facility staff are sleeping at night. Staff interviews did reveal staff would occasionally sleep at night in the common room; however, Staff 1 (S1) indicated when on duty, they would wake up every 2-3 hours to meet incontinence needs and check on residents. The S1 interview revealed that on more than one occasion, they would sleep at the house and wake to find Staff #2 (S2) asleep during the night shift, and attempt to wake S2 many times unsuccessfully. Outside source interviews reveal they have witnessed (S2) sleeping in a chair while on shift. According to the record review, there was at least one resident with a diagnosis of dementia at the facility. According to Interviews with staff, there was at least one resident with a diagnosis of dementia and wandering behavior. Therefore, there should be at least one night staff person awake and on duty to supervise. It was also alleged that the Licensee did not follow universal precautions. CCLD interviews conducted with staff on July 27, 2021, reveal there were times that staff had to retrain on universal precautions. Staff interviews also revealed that all staff believed that staff did not have to wear masks because everyone was vaccinated. Additionally, staff revealed that no symptom screening was conducted during a period of approximately two months (June and July 2021), and some staff members did not wear masks for about a week or two during the same time period. An outside source also confirms that in the month of July 2021, the licensee's staff's universal precautions were not followed. Interviews conducted on October 24, 2024, reveal that staff were not able to recall following specific universal protocol precautions. Additionally, staff training logs for the Summer of 2021 could not be located. Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. Deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC9099-D pages ). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Licensee Arcelao, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. Care Giver Teresita Duclayan signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Apr 4, 2025 · control 08-AS-20210721101943

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 9, 2025

Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on LPA's interviews, licensee did not provide residents with safe and healthful accommodations. This posed a potential health risk to 5 of 5 residents in care.the state’s words, verbatim · CDSS document, Apr 4, 2025

Plan of correction: Administrator offered to conduct in-service training on universal precautionsls with all staff. Administrator offered to provide proof of training to Community Care Licensing by 5/4/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87055(b)(2) · Plan of correction due date: May 9, 2025

(2) For facilities..ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal,...addition to requirements specified in Section 87415, Night Supervision. This requirement was not met as evidence by: Based on LPA's interviews licensee did not provide residents with safe and healthful accommodations. This posed a potential health risk to 5 of 5 residents in care.the state’s words, verbatim · CDSS document, Apr 4, 2025

Plan of correction: Administrator offered to conduct in-service training on night staff requirements with all staff. Administrator offered to provide proof of training to Community Care Licensing by 5/4/2025

Allegation investigated: Licensee did not provide supporting care to meet the needs of the resident. Licensee did not safeguard resident's personal belonging.

**This is an amended report*** Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit with Care GIver Teresita Duclayan. LPA Rodgers called Licensee Myrna Arceleo upon arrival to inform them of LPA Rodgers' presence and purpose in the facility, but they decided not to join the visit. On July 21, 2021, Community Care Licensing (CCL) received a complaint alleging that the LIcensee did not provide supporting care to meet the needs of the resident and the licensee did not safeguard the resident's personal belongings. More specifically, the facility staff did not follow the orders given by the home health service provider regarding Resident #1 (R1), such as food service and turning R1 every two hours. Additionally, the facility staff kept the remote control to R1's personal TV.The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, outside sources, and a records review. (Continued on 9099-C) Unsubstantiated ****this is an amended report**** (Continued on 9099-C) Regarding the allegation that the licensee did not provide care to meet the needs of the R1. All staff interviews acknowledge issues with being short-staffed, but most do not believe it directly caused resident needs to go unmet. Interviews with both Licensee and staff and in July of 2021 state R1's needs were being met. Interviews with R1's responsible party and Licensee reveal home health care was providing only OT (Occupational Therapy) and PT (Physical Therapy) to R1. R1's responsible party's email states that verbal orders were given by home health care to the facility to provide a high-protein diet to R1. Licensee response to interview questions in July of 2021 indicate that meal plans are provided to staff with a variety of options and the facility provides balanced meals. Licensee's response to interview questions also reveals R1's responsible party asked for R1 to be turned every 2 hours, not home health care. Although it was alleged that Licensee staff did not meet the needs of R1 Interviews and records reviews were unable to affirm that the facility staff did not follow the orders given by the home health service provider. Regarding the allegation that licensee did not safeguard residents personally belongs, specially the remote control for a TV. Licensee response to interview questions in July 2021 indicate Licensee owned TV equipment, including the remote control, therefore resident did not own personal equipment in question. Interviews and record reviews were unable to affirm that the Licensee did not return all personal belongings to R1 upon departure from facility. [See LIC 811 Confidential Names List for a description of person identifiers used in this report] Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred – therefore the allegations have been determined to be UNSUBSTANTIATED. An exit interview was conducted over the phone with Licensee Arcelao and Care Giver Teresita Duelayan to whom a copy of this report was reviewed and provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 08-AS-20210721101943

Allegation investigated: Staff administered a PRN without consulting a physician

Licensing Program Analyst Becky Kennedy concluded the investigation which began on 3/18/21. LPA Kennedy made an unannounced visit to the above facility today and met with Teresita Duclayan,caregiver. LPA advised them of the reason for today's visit and delivered the investigation findings on the above allegations. The investigation consisted of interviews with internal sources, a review of documents, and a tour of the facility. It was alleged that Resident 1 (R1) received PRN (As needed) medication without consulting a physician. Interviews with internal and external sources revealed that R1 was not able to express their needs for PRN medication. It was further revealed that facility staff would assist R1 using an inhaler when they displayed signs of breathing difficulty. Substantiated The allegation that the staff administered a PRN without consulting a physician is substantiated. The investigation did not reveal any adverse outcomes. LPA determined that there was no negative impact to R1 or other residents and did not affect the overall operation of the facility. This is considered a technical violation and no citation is being issued at this time. An exit interview was conducted with Teresita Duclayan,caregiver. A copy of this report along with Licensee Rights (LIC9058 01/2016) was left at the facility. R1 was being discharged from the facility. The individual transporting R1 noted that R1 was having breathing difficulties and took R1 to a medical provider and antibiotics were prescribed. R1 was not admitted to the hospital. Interviews revealed that R1 used their inhaler that morning. This is not unusual for R1. One of two individuals with knowledge of R1’s condition prior to R1 leaving the facility reported that R1 might have been getting a cold. The other reported that R1 was "normal". The investigation revealed no evidence to indicate that R1’s had a noticeable change in condition in the days prior to R1’s discharge. The preponderance of evidence standard has not been met to confirm that the staff failed to address a change in condition and this allegation is unsubstantiated. An exit interview was conducted with Teresita Duclayan,caregiver. A copy of this report along with Licensee Rights (LIC9058 01/2016) was left at the facility.the state’s words, verbatim · CDSS document, May 22, 2024 · control 08-AS-20210308094715

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct an annual licensing inspection. LPA identified herself to Caregiver Duclayan and explained the purpose of the visit. The facility is licensed to six (6) residents of whom five (5) must be ambulatory, one bed-ridden (1), and 5 receiving hospice services. During today’s visit, LPA Correia conducted a partial interior tour of the facility and resident records reviews. LPA also briefly spoke to a resident in care and interviewed facility staff. An overall inspection of the facility began today. However, due to time constraints LPA was unable to complete the visit and will return later time to conduct the remaining portion of this inspection. No deficiencies were cited during today's visit. This report was discussed with Caregiver Duclayan. A copy of the report and License Rights (01/2016) will be provided at the conclusion of the visit, and signature on this form acknowledges receipt of the rights and a copy of this report.the state’s words, verbatim · CDSS document, Apr 18, 2024