Casanova Care Home

Allegation investigated: Resident sustained unexplained injury while in care.

Licensing Program Analyst (LPA) Evelin Rios conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Marilyn Marbella and explained the reason for the visit. The investigation consisted of the following: On 7/01/25 LPA Rios conducted an initial complaint investigation visit. LPA requested a copy of the register of facility residents (LIC9020) and personnel report (LIC500). LPA conducted a physical plant tour of the facility inside and out. While conducting the physical plant tour LPA interviewed three (3) out of four (04) residents. LPA attempted to interview One (1) out of the four (04) residents. LPA Rios interviewed four (04) staff members and obtained copies of relevant documents pertinent to the investigation such as resident’s Medical Assessment, Appraisals, Unusual Incident Report. LPA also interviewed Resident #1’s (R1’s) family member. On today’s visit LPA delivered findings. (Continue LIC9099-C) Unsubstantiated The investigation revealed the following: Regarding the allegation: Resident sustained unexplained injury while in care. It is alleged R1 was observed with bruises to the left and right shoulder. Interviews conducted with residents revealed staff treat the residents with dignity and respect and are not aggressive when providing care. Interviews conducted with staff revealed staff were not aware of the cause of the bruises on R1 and did not know of R1 sustaining any falls. Interview conducted with staff revealed R1 is visited by family regularly and is also seen by Hospice staff. Documents reviewed revealed that staff keep notes of incidents/day to day of the residents. Facility notes dated: 06/20/25 note, R1 was observed with bruises, and on 6/23/25, staff noted R1 was seen by nurse and an x-ray was ordered by hospice. According to the administrator the x-ray ruled out possible fracture or dislocation. R1 was admitted to hospice on 10/17/24, no observations or conditions that may cause bruising were noted. Physician’s report dated: 3/23/22 notes R1 is non-ambulatory and no history of conditions that may cause bruising were noted. Although the allegation may have happened. There is not enough evidence to note the bruises developed due to neglect or abuse. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies observed during this visit. Exit interview conducted and a copy of this report was provided administrator designee.the state’s words, verbatim · CDSS document, Aug 17, 2026 · control 31-AS-20250626091834

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conducted an Annual Required Inspection visit. When LPA arrived she was greeted by the designee, Marilyn Marbella. Staff contacted the Administrator, Roderick Flores and informed him LPA was at the facility. LPA explained the purpose of the visit. Administrator arrived 1:30 PM and met with LPA in the facility. In the facility LPA observed two (2) residents sitting at the dinning table eating breakfast. At approximately 8:21 AM, LPA initiated the physical plant tour of the facility inside and out. At the entrance LPA observed appropriate postings and a sign in log for visitors. At 8:23 AM LPA requested a copy of the facility's Emergency Disaster Plan (610E) for review and to update the Regional Office file. The administrator certificate posted is active. LPA observed the fire extinguisher on a wall in the common area. The fire extinguisher was fully charged and had a service tag indicating it was last serviced on 09/05/2025. The facility has an open concept layout that includes the kitchen, living area, and dining area. In the kitchen LPA observed appliances and fixtures were functional. LPA observed cookware and residents’ tableware to be in good repair. LPA observed a sufficient amount of two-day perishable and 7 day non-perishable food in the refrigerator and pantry. Knives and sharps were stored in a locked cabinet. LPA observed a staff washing dishes and cleaning the kitchen counters. The facility telephone is accessible to residents on the kitchen counter. (Continue to LIC809-C) In the living area and dining area LPA observed the furniture to be in good repair and sit the capacity of the facility. There is a television, activity books and puzzles for residents. LPA did not observe tripping hazards. Doors leading to the outside have auditory alarms there were on and functioning properly during the visit. There are five (5) bedrooms designated for residents. Bedroom #5 can be shared. The facility has a fire clearance (STD850) dated 01/07/2026, designating Bedroom #2 for a bedridden resident and all other bedrooms for non ambulatory residents. Bedroom designated for residents use were furnished with a bed, night stand, chair, dresser, bedding, sufficient lighting and closet space. LPA observed half bed rails on Resident #1's (R1's) bed in bedroom #1. LPA observed full beds rails on Resident #2's (R2's) bed in bedroom #2. In the hallway leading to bedrooms #4 and #5, a carbon monoxide detector was observed and tested at 8:36 AM, and it was functioning properly. LPA observed smoke detectors through out the facility. LPA observed the designee test them at XX:XX PM and they were observed functioning. The facility has two (2) bathrooms. Bedroom #5 has a private bathroom. The other bathroom is located in the hallway, outside of bedroom #4 and #5. LPA observed the bathrooms had functioning plumbing and fixtures equipped with grab bars, and non-skid mats. The hot water delivered in the common bathroom was measured at 8:40 AM and read 113.8 degrees Fahrenheit, within regulation. The backyard has a shaded area with a table. LPA observed the passageways to the exit were clear of obstruction. The facility had removed pavers and will remodel backyard. Currently the backyard has a space with concrete flooring and dirt but still offers a sufficient amount of out door space for residents. There is no swimming pool or bodies of water. The garage is attached to the facility and has an entrance through the laundry room. Detergents and cleaning supplies are kept locked, in the laundry room. LPA observed a second refrigerator in the garage where the overflow of food is stored. The garage is also used for storage and has emergency food and water. (Continue to LIC809-C) Page 2 of 3 (Continued from LIC809-C) Facility records for staff and residents along with medication were observed locked in hallway cabinets. From 9:25 AM to 12:00 PM, LPA conducted a file review of five (5) resident files to ensure licensing forms were complete and in compliance. Review of the medical assessment (LIC 602A) indicated that R1's ambulatory status is bedridden due to physical condition. R1 is residing in a non ambulatory bedroom. According to designee, R2 is in bedroom #2 because they are bedridden. LPA's review of medical assessment (LIC602) identifies R2 as non ambulatory although LPA observed other documentation indicating a bedridden status. LPA could not find and was not provided a half bed rail order for R1. LPA could not find and was not provided a full bed rail order for R2. LPA's review of Resident #4's (R4) file revealed R4 did not have a re appraisal completed since resident was admitted and later discharged from skilled nursing on 08/08/2025. LPA also observed a medical assessment (LIC602) for R4 from 2022 but no routine annual visit was on file for R4. In addition, LPA also conducted a file review of three (3) staff records to insure training documents are in compliance and complete. Medication and Medication Records were reviewed for proper storage and documentation. LPA reviewed and obtained copies of the Register of Facility Residents (LIC9020), Personnel Report (LIC500), and the facility’s liability insurance to update the Regional Office file. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were deficiencies observed during the visit. Refer to LIC809-D. An immediate Civil Penalty was assessed. Exit Interview was conducted and a copy of the report was provided to the Administrator. Page of 3 of 3the state’s words, verbatim · CDSS document, Feb 28, 2026

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

This report was created during the annual inspection to include the time the smoke detectors were tested: LPA observed the administrator test smoke detectors at 1:45 PM and they were observed functioning properly. Exit interview conducted. Copy of report provided to administrator.the state’s words, verbatim · CDSS document, Feb 28, 2026

Type of visit: Prelicensing

On 12/17/2024 at 9:00 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing Inspection with the facility Administrator, Roderick Flores and Michael Mendoza the Applicant/Licensee representative. This is a Change of Ownership Application from facility #197610238 to operate a Residential Care Facility for the Elderly (RCFE). A Change in Ownership (CHOW) Application to operate an RCFE was received by Community Care Licensing (CCL) on 12/13/2023. A fire clearance was approved on 03/20/2024, for six (6) Non-Ambulatory residents for a total capacity of six (6). A tour of the physical plant was initiated at approximately 9:10 a.m., and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, gas stove, microwave and sink. There were adequate supplies of two (2) days of perishable and seven (7) days of nonperishable food, properly stored. LPA observed a sufficient amount dining ware to accommodate the maximum capacity of six (6) residents. Knives and other sharps were observed locked in a kitchen cabinet. BEDROOMS: The facility has five (5) bedrooms, and one (1) is shared. All resident bedrooms are furnished with beds, night stands, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. Additional linen is available in the closet located in the hallway. BATHROOMS: The facility has two (2) bathrooms. Both bathrooms were observed to have the proper fixtures, grab bars, non-skid mats, trash can with closed lids. The smoke alarms and detectors are hard wired and inter-connected, they were tested at 9:20 a.m. and were observed operational. The facility has one (1) fire extinguisher that was purchased on 6/06/2024 and is located by the kitchen. The facility has two carbon monoxide detectors that were observed operational. (Continue to LIC809-C) COMMON AREAS: These included living room and a dining room. The living room was equipped with furniture, a television, tables and chairs. There is a fireplace properly secured with a screen. The dining area has a dining room table to accommodate six (6) clients. There were no visible immediate hazards. LAUNDRY ROOM/GARAGE: The washer and dryer is located in a separate room that leads to the garage and designated office. Laundry chemicals are also kept in the laundry room which is kept locked and inaccessible to residents. The garage is used as extra storage for the facility. There is a deep freezer and second refrigerator in the garage for additional food items. SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. The backyard of the facility is properly fenced, has a covered patio and outdoor furniture to accommodate six (6) clients. There is no body of water. MEDICATIONS: The medications are kept locked in a cabinet located in the kitchen. LPA observed Centrally Stored Medication and Destruction Records for each resident. LPA discussed with the administrator and the licensee the importance of providing residents with medications that are prescribed to residents by an authorized physician. LPA observed a fully stocked First-aid kit in the linen closet. Resident Files/Staff Files: LPA conducted a file review of all resident records to ensure compliance of licensing forms. Clients’ files are complete and kept locked in a filing cabinet located in the office. LPA reminded administrator and licensee residents diagnosed with Dementia require an annual medical assessment/Physician's Report completed. Staff files are also kept in a locked cabinet located in the office. LPA discussed staff files with the administrator and licensee and reminded them to ensure compliance by having complete documents and up to date training. In addition to the Pre-Licensing inspection, a Component III Power Point presentation was also conducted with the administrator and licensee present. Pre-Licensing is complete and this facility has no deficiencies. CAB will be advised. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 17, 2024

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Aug 8, 2024