Cottages of Carmel

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Vadim Gorban conducted an unannounced visit today to conduct a case management visit. LPA met with Administrator Kellie Shearer, and explained the purpose of the visit. During this visit LPA toured the facility and observed residents in care. The facility reported incident on June 24th, 2026 that occurred on June 23rd, 2026 with resident (R1) while providing care by staff (S1) in unpleasant manner. Staff made resident feel uncomfortable and scared by staff getting in personal space and raising her voice toward resident. Administrator was notified of the incident , Staff was immediately suspended pending investigation. LPA requested facility files for review by 7/10/26 . Exit interview conducted with Administrator, report signed and copy of this report with appeal rights provided for facility records.the state’s words, verbatim · CDSS document, Jul 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 10, 2026

87468.1 Personal Rights of Residents in All Facilities. (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not observed as evidenced by: The facility failed to provide safe accommodation to one out of 56 residents, which poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: The facility administrator will provide corrective actions and will submit to LPA by email by POC due date.

Allegation investigated: Staff are not documenting residents medication Staff are not meeting resident's hygiene needs Unqualified staff are administering medications

On 04/16/2026 Licensing Program Analyst (LPA) Gorban unannounced visited the facility to commence complaint investigation. LPA introduced self and met by Administrator; LPA stated purpose of the visit and was allowed entry. During the complaint investigation LPA toured the facility conducting health and safety checks, reviewed records, and interviews. Allegations: Staff are not documenting residents’ medication, Staff are not meeting resident's hygiene needs, and Unqualified staff are administering medications. Based records reviews resident’s medications record confirmed medication records confirmed proper documentation. Based on staff interviews, resident will maintain own dental hygiene. Based on records review and staff interviews, training on medication administration provided to staff that have access to med cart. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is Unsubstantiated. Report continues on attached LIC9099-A Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 16, 2026 · control 24-AS-20260115090814

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 21, 2026

87411 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 observed as evidenced by: The facility dementia resident was observed in the morning with facial injuries unknown to staff. Based on interviews, R1 did not have facial injuries day prior, which poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 16, 2026

Plan of correction: Administrator will review and provide a written plan of correction to LPA by email by POC due date.

Allegation investigated: Staff are not properly addressing resident’s pressure injuries Staff are not meeting resident’s incontinence needs Staff are not providing quality food service to residents Staff do not respond to residents calls for help

On 11/26/2025, Licensing Program Analyst (LPA) V Gorban conducted subsequent complaint inspection. LPA met with HSD. The purpose of this visit is to deliver the findings of the investigation completed by the Department. During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there is no potential or immediate health and safety risk at the facility. Allegation: Staff are not properly addressing resident’s pressure injuries. Based on records review no pressure injuries observed, reported or documented. 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. Report continues on attached LIC9099-C Unsubstantiated Allegation: Staff are not meeting resident’s incontinence needs. Based on staff interviews, residents are checked every two hours. Based on observation skin is intact and no redness or skin breakdown observed. 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. Allegation: Staff are not providing quality food service to residents. Based on observations during facility visits, food were observed to be stored according to regulation standards. The facility employs CA certified nutritionist/ dietitian. No concerns from residents were reported based on interviews conducted. 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. Allegation: Staff do not respond to residents’ calls for help. Based on interviews and records reviewed, facility employs three staff members per shift that provide care only for memory care section of the facility. Each resident room is equipped with call light system that is observed operational. 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. Report continues on attached LIC9099-Athe state’s words, verbatim · CDSS document, Nov 26, 2025 · control 24-AS-20250822153020

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 1, 2025

87303 Maintenance and Operation. a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not observed as evidenced by: The facility staff failed to ensure to follow title 22 regulation regarding facility cleanness, which poses potential health and safety to persons in care.the state’s words, verbatim · CDSS document, Nov 26, 2025

Plan of correction: The facility administrator will provide Licensing office plan of correction by POC due date (12/01/2025) describing (in formal letter) the measure taken to ensure regulation followed.

Type of visit: Required - 1 Year

On 09/25/2025, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA met with interim administrator Andrea Ramirez. LPA conducted tour inside and out of facility. Residents observed at the facility during lunch time. The facility was observed to be at a comfortable temperature of 76 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 06/16/2025. Last disaster drill recorded on August 07,2025 Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food is delivered by Sisco Foods twice a week on Mondays and Thursdays. Refrigerator temperature was maintained at 40.0-degree F. and freezer was maintained at -1-degree F. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested and within regulation requirements. LPA observed securely fastened grab bar and non-skid mat in shower area. All three facility buildings equipped with its medication room and storage. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. Adequate PPE supplies was observed. LPA toured laundry room and observed chemicals were stored and locked for staff use only. Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. Report continues on attached LIC809-C Residents’ files were reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below: Residential Care Facility for the Elderly (RCFE): · LIC 308 Designation of Facility Responsibility · LIC 309 Administrative Organization Please submit the above forms/information to Fresno CCL by: 09/29/2025 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed. No deficiencies issued during this inspection. An exit interview was conducted with the SEA. A copy of this report was given to the SEA, whose signature confirm receipt of this report.the state’s words, verbatim · CDSS document, Sep 25, 2025

Allegation investigated: Staff did not ensure that resident's toileting needs were met. Staff did not seek medical attention for resident in a timely manner. Facility is not adhering to infectious control protocols.

On 08/25/2025, Licensing Program Analyst (LPA) V Gorban conducted subsequent complaint inspection. LPA met with administrator Nelson Rubio. The purpose of this visit is to deliver the findings of the investigation completed by the Department. During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility. Regarding Staff did not ensure that resident's toileting needs were met. Based on observations and interviews no concerns reported or observed regarding patient care. Based on interviews, staff check on residents every two hours. Regarding Staff did not seek medical attention for resident in a timely manner. Based on interviews and record reviews resident R1 was taken to the hospital and responsible party was notifies on the day of the incident, May 11th, 2025. Report continues on attached LIC9099-C Unsubstantiated Regarding Facility is not adhering to infectious control protocols. Based on observations facility have substantial amount of PPE, based on interviews and records reviews, facility infection control requirements files are up to date. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Exit interview was conducted, and a copy of this report provided to administrator for facility records.the state’s words, verbatim · CDSS document, Aug 25, 2025 · control 24-AS-20250707165437

Allegation investigated: Facility allowed untrained staff to work independently with dementia care residents Facility does not have a certified administrator on the premises

On 08/25/2025, Licensing Program Analyst (LPA) V Gorban conducted subsequent complaint inspection. LPA met with administrator Nelson Rubio. The purpose of this visit is to deliver the findings of the investigation completed by the Department. During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility. Regarding the allegations: Facility allowed untrained staff to work independently with dementia care residents and Facility does not have a certified administrator on the premises. Base on interview and records reviews staff (S1) completed required training to work at the facility with dementia residents and facility provided files of certified administrator. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Exit interview was conducted, and a copy of this report provided to administrator for facility records. No deficiencies were cited during the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 25, 2025 · control 24-AS-20250821093230

Allegation investigated: Facility staff did not provide adequate supervision, resulting in sexual behavior amongst residents. Facility staff did not notify authorized representative of incidents. Facility staff do not ensure facility is free of pests. Facility staff do not ensure the facility is not clean/sanitary.

On 07/10/2025, Licensing Program Analyst (LPA) V Gorban conducted an unannounced complaint inspection. LPA met with administrator Julie Estrellado. The purpose of this visit is to deliver the finding of the investigation completed by the Department. During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility. On 05/13/2025, the Department received a report alleging that facility staff did not provide adequate supervision, resulting in sexual behavior amongst residents. According to the reporting party, the reporting party was told by other staff (name unknown) that Resident R1 sexually touched Resident R2 and Resident R3. However, the reporting party did not witness the incident. Staff denied any incidents involving R2. On 12/07/2024, there was an incident where R1 put R1’s hand inside R3’s pants. Staff intervened and separated both residents. Staff checked on R3 and no injuries or signs of discomfort were noted. Staff reported the incident to the licensing agency when it occurred. Report continues on attached LIC9099-C Unsubstantiated Regarding Facility staff did not notify authorized representative of incidents, facility administrator notified both responsible parties regarding the incident. Records reviewed and interviews were conducted were administrator confirmed notifying both responsible parties of the incident on 12/07/2024. Regarding the Facility staff do not ensure the facility is free of pests. Based on interviews and records review the facility utilize services by pest control agency to keep the facility in sanitary condition. The maintenance director placed additional traps for rodents when observed close to facility entries. Regarding Facility staff do not ensure the facility is not clean/sanitary. Per observation during facility visits, interviews and records review staff keep facility maintenance in sanitary and good repair. 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 above allegation is unsubstantiated, at this time. An exit interview was conducted, and a copy of this report provided to administrator for facility records. No deficiencies were cited during the visit.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 24-AS-20250513123829

Allegation investigated: Facility is malodorous Staff leave residents sleeping in common areas Staff do not assist residents in changing into sleeping clothes Staff do not treat residents with respect Staff do not properly store food

On 07/10/2025, Licensing Program Analyst (LPA) V Gorban conducted an unannounced complaint inspection. LPA met with administrator Julie Estrellado. The purpose of this visit is to deliver the findings of the investigation completed by the Department. During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility. Regarding the allegation Facility is malodorous. Based on observations, interview and record reviews no concerns observed and/or reported. Interviews revealed the housekeeping staff able to complete assignment and maintain the facility clean and in good repair. Regarding staff leave residents sleeping in common areas. Staff interviews reported that residents spend evening time in the common room prior to be assisted back to the room for nigh time sleep. Based on family interviews, alleged violation is not witnessed or reported. Based on interviews residents spend time resting, watching television or playing games with other residents or family members. Report continues on attached LIC9099-C Unsubstantiated Regarding staff do not assist residents in changing into sleeping clothes. Based on interviews and records reviews no alleged violations observed or reported. Based on observations, each resident has personal belongings / sleep wear available for bed time. Based on interviews, residents assisted with dressing those that require assistance, for the rest, sleep clothes prepared for residents to be dressed by self when ready. Regarding Staff do not treat residents with respect. During the investigation, the department interviewed staff, family, and administrator. During record reviews no alleged violations observed or reported. Based on administrator interview no reports of alleged violation recorded or provided to administrator. Regarding staff do not properly store food. Based on observations during facility visit and staff interviews, food stored in refrigerating units in all three sections of the facility. The units observed to be operational with in the requirements. 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 above allegation is unsubstantiated, at this time. An exit interview was conducted, and a copy of this report provided to administrator for facility records. No deficiencies were cited during the visit.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 24-AS-20250602094900

Type of visit: Prelicensing

On 09/17/2024, Licensing Program Analyst (LPA) V Gorban conducted an announced Pre-licensing visit. LPA identified himself and discussed the purpose of the visit. LPA conducted the inspection with the facility Administrator (AD) Julie Estrellado. An inside and outside tour of the facility was conducted with AD. Home is fire cleared for 74 (seventy four) non-ambulatory and 4 (four) bed ridden residents. The facility provides 16 private rooms in memory care and 58 private rooms on assisted living portion of the facility. Resident’s each room have adequate furnishings and lighting and all the required furnishings. Mattress and linen appeared to be in good condition. LPA observed a supply of extra bed linens. Bathrooms were properly equipped, and trash cans had a fitting lid. Hot water temperature was observed to be 109 degrees F. Kitchen observed to have dishes, plates, utensils. Sharps/knives and medications are locked in the kitchen. Groceries are delivered to the facility every other day by Sysco food company. Cleaning supplies are stored. First aid kit contains all the required items. The facility equipped with fire pool boxes throughout. Fire extinguishers are present and was serviced on 06/27/2024. Smoke detectors and carbon monoxide are combined in one unit and were operating properly. Outside of the facility toured. Exits open free of obstruction. Gate is self-latching. No outside hazards were observed. All required postings are posted. Facility phone number will be 831-620-1800. Component III conducted during pre-licensing inspection. No deficiencies were observed during this inspection. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued. Pre-Licensing is complete, and this facility has no deficiencies. Exit interview conducted, report is signed and copy of the report provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 17, 2024