Del Vista Residential Care

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced on 09/01/2026 to conduct a case management visit. LPA Lee met with care staff Rosamary Manaringkuba and explained the purpose of the visit. The facility census was six residents. A brief interview was conducted with Administrator Taty Sael via telephone. The purpose of today's visit was to follow up on a LIC 624 Incident Report received by the Department on 07/14/2026. According to the incident report, on 07/13/2026 at approximately 9:45 PM, care staff discovered that Resident 1 (R1) could not be located within the facility or the surrounding area. Staff reported that R1 was last seen at approximately 9:15 PM in their bedroom. After conducting a search of the facility and the immediate vicinity, staff were unable to locate R1. At approximately 10:20 PM, Administrator Taty Sael contacted law enforcement and reported R1 as a missing person. At approximately 11:00 PM, law enforcement located R1 at a nearby train station and returned the resident to the facility; however, the resident wanted to go to the hospital due to an injury. A review of R1's LIC 602, Physician's Report, dated 07/06/2026, documented that R1 is unable to leave the facility unsupervised and requires supervision or hands-on assistance. During the phone call with Administrator Sael, who stated that facility staff were already suspicious of R1’s behavior as R1 had their clothes hanging on their wheelchair. Based on the information obtained during today's case management visit, the facility did not provide adequate care and supervision to ensure R1's safety, resulting in R1 leaving the facility unsupervised and being reported as a missing person. This posed an immediate risk to the resident's health and safety. Therefore, a deficiency is being cited under California Code of Regulations, Title 22, Division 6, for lack of care and supervision. An immediate civil penalty of $500 was assessed on 09/01/2026. An exit interview was conducted with care staff Manaringkuba. A copy of this LIC 809, LIC 809-D, LIC 421D, and the Licensee/Appeal Rights was provided to the facility at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 1, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 15, 2026

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: This requirement was not met as evidenced by: Based on records review and interview, the facility did not ensure that a resident in care was kept under continuous supervision which resulted in elopement. On 7/13/2026 resident (R1) eloped from the facility, without facility staff awareness, and sustain injury which poses in immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 1, 2026

Plan of correction: The Licensee/Administrator will ensure the facility is in compliance with Title 22 regulation 87464 at all times. Per the Administrator, after the incident an alarm is also placed in the staff room to alarm staff when the front door is opened. The licensee will conduct training with all facility staff working in the facility on care and supervision, and resident elopement. Licensee will send LPA proof of training by 09/15/2026.

Type of visit: Required - 1 Year

On 01/26/2026, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with Administrator Taty Sael and explained the purpose of the visit. The current census is 6 with 2 facility staff. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room, garage, staff room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 117.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. The smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 12/10/2025. LPA Lee observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. Facility thermostat was observed at 70 degrees Fahrenheit, which is within the required regulation of 68 to 85 degrees Fahrenheit. LPA Lee observed toxins located in the kitchen sink and kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked in the kitchen cabinet and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. The first aid kit was checked and contained the required components. CONTINUED LIC 809-C LPA Lee audited medications for 3 out of 6 residents by comparing the medications on hand with their Medication Administration Records (MARs) and it was complete. LPA Lee reviewed 4 out of 6 resident files, and they were complete. LPA Lee reviewed 2 staff files, and it was also complete. LPAs reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents will be emailed to LPA Lee by 01/30/2026 end of day 5:00 PM: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC 500 Current Personnel Report As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted with Administrator Sael and a copy of these LIC 809 reports was provided to the facility.the state’s words, verbatim · CDSS document, Jan 26, 2026

Type of visit: Required - 1 Year

On 01/22/24, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with direct care staff Rosemerry Manariangkuba and Rosita Sagala and explained the purpose of the visit. Direct care staff called and informed administrator Taty Sael to informed that CCLD was present in the facility. Administrator arrived at the facility approximately 20 minutes later and assisted with today’s visit. Administrator certificate # is 7034190740 and will expire on 06/02/25. The current census is 6 with 2 facility staff. This facility is a single story building licensed to six (6) non-ambulatory residents and approved for 3 hospice residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room, garage, and outside courtyards of the facility to ensure compliance with Title 22 regulations. It was observed the facility was free of odor and clean. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed the facility had sufficient seven day non-perishable food supplies and two day perishable food supplies at this time. Hot water temperature was measured at 114.6 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 11/26/24. The last fire drill was conducted on 10/08/24. LPA observed the facility has a has a public telephone in the kitchen. Facility thermostat observed at 72 degrees Fahrenheit. LPA observed toxins located in the garage and kept locked; however, LPA did observe a Lysol disinfectant spray in the hallway which was made accessible to residents in care at this time. LPA observed sharp knives kept locked and inaccessible to residents. LPA checked medication storage and found medication to be locked away and inaccessible to residents. Continued LIC 809-C LPA reviewed and 3 out of 6 residents medication administration record (MAR) along with residents medications and 2 out of 3 MAR was not complete. It was observed that 2 of the residents MARs did not have the correct physician's order and exact dosage. The first aid kit was checked, and it was complete. LPA requested resident and staff files for review. LPA Lee reviewed 5 out of 6 resident files and 1 out of 5 resident file was incomplete. Resident 1 (R1) did not have a complete LIC 625 Appraisal/Needs and Service. It was observed that the LIC 625 was blank with no signatures. LPA reviewed staff files and they were not complete. 1 out of 2 staff files were missing annual training's. LPA toured the courtyard and observed the emergency gate not in good repair. LPA reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, LIC 9102 Technical Violation and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jan 22, 2025

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

Type of visit: Case Management - Other

On 3/12/24, at 10:03am, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit to amend a LIC 809-D issued during a previous case management visit on 1/24/24. LPA Villanueva met with Taty Sael, facility administrator and explained the purpose of this visit. LPA Villanueva also conducted additional interview with Taty regarding R1 and requested copy of additional documents of R1. Per title 22 no deficiencies being cited during this visit. An exit interview was conducted with Taty Sael, Administratro and a copy of this report and an amended LIC 809-D page were provided.the state’s words, verbatim · CDSS document, Mar 12, 2024

Allegation investigated: Questionable death.

On 1/31/24, at 3/15pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to amend the report from the visit on 1/24/2024. LPA met with staff on duty and explained the purpose of the visit. The administrator, Taty Sael, was notified and arrived shortly after. Allegation: Questionable death. The department investigated the questionable death allegation and discovered that R1's cause of death was listed on R1's discharge summary from the hospital as severe sepsis with septic shock and community acquired pneumonia. Per statement of a clerk reveals that there was no foul play or trauma relating to R1’s death. The department has found that the allegation of questionable death is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Taty Sael, Administrator, and a copy of this report and appeal rights were provided Unfoundedthe state’s words, verbatim · CDSS document, Jan 31, 2024 · control 27-AS-20230712160817

Allegation investigated: - Resident sustained unexplained injuries while in care.

On 1/24/2024 at 10:15am Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to continue conducting a complaint investigation and to deliver findings for the allegations noted above. LPA Villanueva initially met with the staff on duty and explained the purpose of the visit. The Administrator, Taty Sael, was made aware of this visit and arrived shortly after. Throughout this investigation, the LPA conducted facility observation, staff interview, facility record review, staff record review, and resident record review. Allegation: Resident sustained unexplained injuries while in care. Per interview with the administrator on 11/3/23, the administrator was informed by R1’s nurse that R1 bruises easily due to a medication. Further interviews reveal that bruising would come and go and that bruising would sometimes appear when R1 would sleep on the side. Also, during an interview with the administrator reveal that R1’s overall health started declining in November 2022. {Con't to LIC9099...} Unsubstantiated {...Con't from LIC9099} R1's medication record also reviewed. Based on interview and record reviews, there is not a preponderance of evidence to conclude that R1 sustained unexplained injuries while in care. Therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with Taty Sael, Administrator, and a copy of this report and appeal rights were providedthe state’s words, verbatim · CDSS document, Jan 24, 2024 · control 27-AS-20230712160817

Type of visit: Case Management - Deficiencies

On 1/24/2024 at 11:30am, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit. During the course of the investigation in to complaint control number 27-AS-20230712160817, another deficiency was identified which is being addressed by this case management. LPA Villanueva met with Taty Sael, Administrator, and explained the purpose of the visit. During today’s visit, present were 3 residents in care with 2 staff on duty. During the course of the investigation for above listed complaint, file reviews were conducted. A review of R1’s care notes dating 07/02/23 indicates R1 “started coughing lastnight…saying she cannot breath…, 07/03/23 R1 did not have a good nights sleep lastnight, 7/07/2023 indicates that R1 was having difficulties sleeping the past 3 nights due to coughing. Additionally, R1 was noted to have hard time breathing with O2 level measured at 65. It was also noted that the administrator found R1’s right lower arm to be swollen and red/bluish. Administrator notified clinic physician via phone and was ordered Albuterol nebulizer increased to 6 times every 4 hours as needed. Also prescribed cough syrup 4 times daily and antibiotic to start on this date. Further review of R1’s care notes dating 7/9/2023 indicates that R1’s right arm (dialysis port) continues to be bleeding. It was noted that care staff did not change the dressing on the wound. On 7/10/2023 of the care notes, it was noted that care staff notice R1’s nose to be bleeding and a bruise on the corner of R1’s mouth was noted. It was also noted that R1’s physician was notified and a plan to send R1 to the hospital due to bleeding on R1’s nose and dialysis port. L PA cannot confirm from the R1’s note if R1 was sent to the hospital. By this time, R1’s condition appeared to have worsened. Although a physician was contacted on 7/7/2023 and medications were prescribed, the licensee did not ensure timely medical attention for R1 due to R1’s breathing problem with O2 stat level at 65. Additionally, R1’s change in condition worsened on 7/10/2023. {Con't to LIC809-C} {Con't from LIC809} During a review of R1's care notes, LPA Villanueva read that R1 was sent to emergency hospital on the following dates: 8/24/22, 2/22/23, and 3/23/23. Per interview with the administrator, incident reports on these incidents were not reported to the Department. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An immediate civil penalty in the amount of $500 is assessed in addition to the citations issued. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. An exit interview was conducted with Taty Sael, administrator and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2 · Plan of correction due date: Jan 25, 2024

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed... (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not ensure medical attention is sought timely for R1. R1 did not receive medical attention in a timely manner when changes in condition were observed that warrant hospitalization. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: Licensee/Administrator to submit a written program plan revision via an addendum to develop a new policy to ensure residents obtain timely medical attention. Policy to be submitted to the Department no later than POC due date 1/25/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Jan 31, 2024

Reporting Requirements 87211(a) (1) Each licensee shall furnish to the licensing agency such reports as the Department may require.. A written report shall be submitted to the licensing agency and to the person responsible ...This requirment was not met as evidence by: Based on interviews and file review, the licensee/administrator did not ensure all reporting requirments was met, as facility administrator did not submit incident reports of R1 on 8/24/22, 2/22/23, and 3/23/23 to the Department. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: Licensee/administrator agree to conduct reporting requirement training for all staff. All training material and sign in sheet shall be emailed to LPA Villanueva by POC Date 1/31/24.

Type of visit: Required - 1 Year

On 01/19/2024 at 8:21 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met administrator Taty Sael who assisted with today’s visit. LPA Lee explained the purpose of the visit. Administrator certificate # is 6002575740 and will expire on 06/02/2025. The current census is 5 with 2 facility staff. This facility is a single story building licensed to serve six (6) non-ambulatory residents and approved for hospice waiver for three residents in care. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient two-day perishable and seven-day non-perishable food supplies. LPA Lee observed sharp knives kept locked. Hot water temperature was measured at 117.5 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in entry way and was last serviced on 12/19/2023. The last fire drill was conducted on 12/29/2023. LPA observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. Facility thermostat observed at 70 degrees Fahrenheit. LPA Lee observed toxins made accessible to residents in care. LPA Lee observed nail polish remover and Vicks VapoRub in the linen closet. Furthermore, LPA Lee observed laundry detergent, plant food, fabric softener, and fabric odor eliminator in the garage made accessible to residents in care. During today’s visit LPA Lee observed administrator removed all toxins that was made accessible to resident and locked them in a locked cabinet. Continued LIC 809-C LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed and compared 3 out of 5 residents LIC 622 Centrally Stored Medication and Destruction Record with residents medications and is was complete and accurate. The first aid kit was checked and contained all the required components. LPA requested residents and staff files for review. LPA reviewed 5 out of 5 resident files and 3 staff files and they were all complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 01/26/2025 by 5:00 PM by end of day: (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Copy of Administrator Certificate (4) LIC 610 Emergency Disaster Plan (5) Proof of Current Liability Insurance As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jan 19, 2024