Devon Place Home Care

Type of visit: Required - 1 Year

On July 23, 2026, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced. LPA conducted the Required Annual visit and met with the Caregiver Gloria Bataican. LPA introduced herself and stated the purpose of the visit. Please see the summary of today’s visit. LPA Mixson toured the facility, along with the Administrator and made observations. LPA inspected the facility inside and outside there were no observable obstructions or debris to the inside or outside of the facility. The physical plant is clean, neat, and orderly on the inside the outside will need some attention. But the outdoor and indoor passageways were free of obstruction at the time of the inspection. The facility has six bedrooms, and each bedroom has the required furniture and storage space, and sufficient lighting. Five of the bedrooms were utilized for residents and one bedroom was assigned to staff. Each bedroom was equipped with the required items and organized neatly at the time of this visit. Three restrooms were equipped with liquid soap and paper towels, for hand washing currently. The kitchen, living room and the TV room were clean and arranged for easy movement. The food requirements were met, the seven day supply of nonperishable, and the two day supply of perishable. The laundry room. Smoke detectors were in the green and operable. Fire extinguisher was green and brand-new. The carbon monoxide detectors, along with smoke detectors were observed, and operable at the time of this visit. There was a locked and centralized storage cabinet for medications near the kitchen. TA was discussed for resident missing signature on LIC 602, An exit interview was conducted, and a copy of this report was discussed and given to caregiver.the state’s words, verbatim · CDSS document, Jul 23, 2026

Type of visit: Required - 1 Year

On July 23, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection. LPA Mixson toured the facility, along with the Administrator and made observations following is a summary. LPA inspected the facility inside and outside there were no observable obstructions or debris to the inside or outside of the facility. The facility is a single story home located at 1814 Devon Place, Vista, Ca. 92084. Physical Plant: The physical plant is clean, neat, and orderly. Outdoor and indoor passageways are free of obstruction at the time of the inspection. The facility has six bedrooms, and each bedroom has the required furniture and storage space, and sufficient lighting. The bedrooms were equipped with the required items as per Title 22 regulations. The hot water temperature was tested and within regulations. Three restrooms were equipped with liquid soap and paper towels. LPA toured the kitchen, living room and the TV room. The kitchen area was clean, organized, and free or odors. LPA Mixson observed the menu posted. Two caregivers and a Hospice nurse are present attending to the residents. The food requirements were met, the seven day supply of non perishables, and the two day supply of perishable. LPA inspected the common areas, and the laundry room. Smoke detectors were in the green and operable. Fire extinguisher was in the green, and last reviewed for services in 2024. Carbon monoxide detectors, along with smoke detectors were observed, and were operable. There was a locked and centralized storage cabinet area for medications. Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit. Administrator informed LPA Fire extinguisher is scheduled to be serviced by State Fire Marshal 07/30/2025. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. Care & Supervision/Administration: Adequate staff are present for the supervision of resident in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses a current administrator’s certificate with an expiration date of 02/03/2026, Sherryl Rafals Records Reviewed and Resident/Staff Files: LPA reviewed staff files and reviewed the facility's staff schedule. The staff files reviewed maintain updated criminal clearance and updated training along with First Aid Certification. Resident files reviewed possessed required paperwork, and updated Physicians Orders at the time of this visit. Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards, and was conducted by XXXXXXX Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures. There were observable TA deficiencies observed or cited per Title 22, Division 6 of the California Code of Regulations at the time of this visit An exit interview was conducted where a copy of this report was discussed and given to Administrator,the state’s words, verbatim · CDSS document, Jul 23, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with caregiver Edmund De La Calzada, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and six (6) residents present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: LPA observed a three (3) inch oval shaped hole in the floor near the dining room area. A deficiency will be issued under Title 22 Regulation 87303(a). Washer and dryer is located outside in the backyard. LPA observed laundry detergent and bleach out and inaccessible to residents in care. Kitchen cabinet under the sink was unlocked and had bug spray and cleaning solutions accessible to residents in care. A deficiency will be issued under Title 22 regulation 87309(a). Sharp objects in a kitchen drawer was unlocked and accessible to residents diagnosed with dementia in care. A deficiency will be issued under Title 22 regulation 87705(f)(1).The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA reviewed three (3) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid. LPA was informed Staff Two (S2) was not fingerprint cleared and had assisted Staff One (S1) for the day due to a staff call off. A deficiency and civil penalty will be issued under Title 22 Regulation 87355(e). S2 was informed they had to leave the facility and could not continue to provide care and supervision to the residents in care. Six (6) resident files were reviewed. Resident One (R1), Resident Two (R2), and Resident Three (R3) did not have a resident pre-appraisal in their file for review during the visit. A deficiency will be issued under Title 22 Regulation 87457(c). Resident Two (R2), Resident Three (R3), Resident Four (R4), and Resident Five (R5) who are diagnosed with Dementia did not have an updated LIC 602 Physician's Orders during LPA's visit. A deficiency will be issued under Title 22 Regulation 87705(c)(5). Resident medication was centrally stored and locked in a cabinet located in the dining room. LPA observed PRN medication for Resident One (R1) and R2 administered to residents by staff without documenting the date and/or time PRN was given to the resident. A deficiency will be issued under Title 22 regulation 87465(d)(3). LPA observed medication prescribed to Resident Six (R6) in a ziplock back with "back-up meds" written in sharpie. R6's medication had a "use before" date of 10/01/2022. A deficiency will be issued under Title 22 Regulation 87465(i). LPA reviewed the facility's emergency and disaster plan. Facility does not have an updated resident roster for staff readily available in preparations for an emergency. A deficiency will be issued under Health and Safety Code 1569.695(e)(1). Facility has not conducted and documented a quarterly disaster drill with staff from each shift. A deficiency will be issued under Health and Safety Code 1569.695(c). An exit interview was conducted where a copy of this report, deficiency page(s) LIC 809-D, Confidential Names LIC 811, Civil Penalty, and Appeal rights were provide to caregiver Calzada.the state’s words, verbatim · CDSS document, Jul 26, 2024

Allegation investigated: - Resident sustained a stage 4 pressure injury while in care - Staff handled resident(s) in a rough manner - Staff did not transfer residents safely resulting in injuries - Staff are not able to communicate with residents - Staff did not meet the resident’s hygiene needs - Staff do not have medication training

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by caregiver Edmund De la Calzada. LPA stated the purpose of the visit and reviewed the findings of the complaint with caregiver Nestor Blay. The Department’s investigation consisted of interviews with staff and outside sources, records review of relevant documents pertinent to this investigation, and the Departments. On June 18, 2021, it was alleged that the a resident sustained a stage 4 pressure injury while in care; staff handled resident in a rough manner; staff did not transfer resident safely resulting in injuries; staff are unable to communicate with residents; staff did not meet resident’s hygiene needs; and staff do not have medication training. Records revealed that R1 had multiple falls and sustained fractures prior to being admitted to the facility. According to records, R1 had already been admitted to hospice prior to facility admission. Unsubstantiated (Continuation of LIC9099) Additional records revealed that R1 had sustained falls at their residence prior to hospice and facility admission. Records showed that R1 had diagnosis’ that would place them at risk for injuries. It was alleged that resident #1 (R1) sustained a stage 4 pressure injury due to staff being neglectful, not repositioning the resident and kept changing the bandage. Interviews with staff said they would reposition the resident, but the resident would never stay in the positions that either staff or their care agency would place R1 in. According to Administrator Rafols, the care agency had informed them, on 05/17/2021, that R1 was being provided wound care. The Administrator said that they provided wound care daily for R1. The care agency had instructed staff to dry, clean and reposition R1 every two hours which staff adhered to. According to Administrator Rafols, at night staff would also conduct their checks every two hours. Interview was conducted with an outside source who confirmed that the facility personnel followed instructions provided by R1s care agency. Per the outside source, R1 was at risk for skin breakdown from the beginning due to poor intake of food, lack of mobility, age, underlining medical conditions and repositioning self-back to the same position after being repositioned to an alternate position by facility staff and R1’s caring agency. This continued when R1 obtained the injury which did not allow the injury to breathe. Staff kept the bandage dry and clean as indicated by the care agency. According to the outside source, there was no evidence to prove that personnel were neglectful while caring for R1 or any other residents. Based on the information obtained there is insufficient evidence to support the allegation. It was alleged that staff #1 (S1) handled R1 in a rough manner pushing R1 against a railing. Interview with S1 said that they started to volunteer on 6/03/2021. According to S1, they denied hurting R1. R1 left 06/03/2021. S1 said that they and S2 would care for R1. According to Licensee, there was never a time where a family disclosed that a caregiver was rough with a resident nor a resident obtaining an injury due to staff. Interview with an outside source said that they had no issues with the staff at the facility. They were continuously there assisting R1 and saw that the staff were accommodating with the care they provided to them. There were no records to show that there were any incidents reported to the Regional Office by the facility or a third-party agency to indicate that R1 was being mishandled. Based on the information obtained, there is insufficient evidence to support the allegation. (Continuation of LIC9099-C) (Continuation of LIC9099-C) It was alleged that the facility staff attempted to transfer R1 from their bed resulting in R1 falling and sustaining injury to their leg and toes. Interviews with S1 and S2 they did not witness R1 falling. They did witness R1 placing their legs between their railings and at times attempt to get out of bed. Due to this, R1s care agency placed pads on the railings to prevent this from occurring. This assisted with preventing R1 placing their legs between the railings. This was confirmed by R1s care agency. According to staff, R1 stopped placing their legs on the railings once their care agency placed the pads on the railings. It should be noted that during the interview with RP, they did not specifically indicate any neglect when dealing with R1s care, only that S1 scraped their leg and toes and R1 was not transported to the hospital. During an interview with the outside care agency, they did not have any issues with the care provided by the facility staff. Based on the information obtained, there is insufficient evidence to support the allegation. It was alleged that S1 had a communication barrier with residents as they did not speak English. An interview was conducted with S1 who said that they and S2 provided care to R1. According to S2 the family visited R1 daily and R1s care agency came almost every morning. Administrator and Licensee were shocked to find that RP was moving R1 unexpectedly from the facility. They were unaware if there were issues with the services provided by the facility. According to Licensee, his caregivers have been able to communicate with the residents and the family’s. They do speak English but acknowledged that there may be times where a family may not understand what a caregiver may say but they have been able to schedule at least two caregivers one who is able to communicate with the residents and families, along with the Administrator who often go to the facility. According to the care agency, they had no issues with communicating the care needs of R1 to staff. They were able to educate the staff at the facility and the staff was able to comprehend the services that were required for R1s care. According to a letter directed to Licensee from RP, the letter did not indicate issues with staff not being able to communicate with residents. The letter demonstrated that there were personal matters that led to the removal of R1 from the facility. During a visit on 05/01/2024, LPA observed that current staff did speak enough English to be able to communicate with the residents. LPA was able to interview staff and obtain statements. Based on the information obtained, there is insufficient evidence to support the allegation that staff were unable to communicate with residents. It was alleged that on an unknown date, R1 had dried vomit on their shirt and staff did not notice it nor changed them. Staff who formerly worked at the facility were not present during a subsequent visit conducted by LPA on 05/01/24. (Continuation on LIC9099-C) (Continuation of LIC9099) LPA attempted to make contact with a former employee for interview to no avail. Current staff interviewed and they said that residents are usually showered about three times per week unless they are declining a shower. If a resident is on hospice, the hospice agency provides showers twice per week. At times residents only want to do bed baths which they provide but in these cases, CNA would conduct bed baths daily. According to the licensee, the caregivers have been able bathed residents about four times per week depending on the care plan of the resident and the residents and family’s wants and needs. There are some residents who bathe daily and other who bathe about every other day. He mentioned that he does not tolerate for staff to neglect residents’ hygiene. According to the Licensee, there have not been any families who have brought hygiene to his attention. Interview with an outside source, mentioned that every time they saw R1, they were well groomed and had been clean and dry. The only time they saw R1 somewhat oily was when R1 was feverish. They had no issues with R1’s hygiene. They would see R1 at least every other day if not more often. Based on the information obtained, there is insufficient evidence to support the allegation. It was alleged that staff were not trained to administer medication. According to the licensee, when staff are initially hired, they have a log for their 30-day requirements and medication training is included as a part of the initial training course. The initial medication training is provided by the licensee and the administrator. They licensee uses training material obtained during their Administrator’s course. He uses the book to provide caregivers insight of how to administer medications and includes how to audit medications. He also uses videos and hands on training for the caregivers. According to the licensee, he also has the Hospice Agency and/or Home Health Agency to give caregivers additional training yearly or on an as needed basis. R1s care agency confirmed that the Hospice agency for R1 provided caregivers medication training along with other care needs for R1. There were no issues with the medication annotated by R1s care agency regarding their medication. According to staff training records staff in 2021 received one hour of medication policies/ procedures training between 6/02-03/2021; and .50 hours of medications that are self-administered between 6/04-05/2021. According to a professional outside source, they went over R1s medication at every visit and staff were on the same page regarding resident’s care. Based on the information obtained, there is insufficient evidence to support the allegation. (Continuation on LIC9099-C) (Continuation of LIC9099-C) Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside sources interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Licensee Mark Loo and Administrator Sherryl Rafols. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to licensee at the conclusion of the visit. The signature below confirms the documents were received. According to staff, Administrator and R1’s care agency, R1 left the facility on June 12, 2021. Upon the initial interviews with the Licensee and the Administrator conducted during 2021, the resident was taken from the facility along with their belongings on June 12, 2021. According to the Admission Agreement, R1 moved into the facility on May 1, 2021, and was charged the prorated monthly admission rate with no extra fees being charged. During the visit on 05/01/2024, Licensee confirmed that they did not provide R1 or the family a refund upon their departure as they were unaware, they had to refund them. Based on the information obtained there is sufficient evidence to support the allegation. It was said that the facility had spoiled milk in the refrigerator and the refrigerator was dirty. According to Licensee, and the Administrator are the ones who do the grocery shopping for the facility and ensure that they have sufficient groceries. As far as the licensee was aware, the staff go through the refrigerator at least weekly to ensure there are no spoiled items in the refrigerator. They were not aware that there were any items kept that were spoiled in the refrigerator. As far as dietary needs, the licensee said that they follow residents’ dietary needs if they have a controlled diet. Although they have a general meal plan on the refrigerator door, licensee said that caregivers consult with the residents to inquire what they prefer to eat in an attempt to cater to the residents. During an interview with the outside care agency, they said that the staff acclimated with the diet orders that they left for R1 and had no additional information to provide. During the initial visit conducted on 6/22/21, the refrigerator did have ample food supply and did not appear unclean. LPA did observe that there were outdated chocolate and regular milk cartons that were about 9 days past the date of expiration. During a visit conducted by LPA on 5/01/2024, LPA observed that there were expired food items in the cupboard and in the refrigerator. The poultry in the refrigerator was 13 days old that needed to be used or frozen by 04/18/24. The poultry was browning in the side areas. According to staff they recently within the last 24-hours taken out. During this same visit, the pantry did have canned food items that has expired in December 2023. Based on the information obtained during the investigation, and LPA’s observations, there is sufficient evidence to support the allegation. Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside sources interviews and records reviewed, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with caregivers Nestor Blay and Edmund De la Calzada. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to caregiver Blay at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, May 31, 2024 · control 08-AS-20210618114156

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Jun 14, 2024

87555 (a) General Food Service Requirements - (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner… this requirement was not met as evidenced by: Based on two separate LPA observations, the Licensee did not comply with the section cited above in 5 out of 5 residents were being provided expired food which posed a potential health risk to 5 of 5 of residents in care.the state’s words, verbatim · CDSS document, May 31, 2024

Plan of correction: The facility staff will be discarding the outdated food items from the refrigerator/freezer and cabinets and send LPA an email for a visit by POC due date, 06/14/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2 · Plan of correction due date: Jun 14, 2024

87468.2 (a)(8) Additional Personal Rights of Residents in Privately Operated Facilities - To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse… this requirement was not met as evidenced by: Based on interviews and records review, the Licensee did not comply with the section cited above in 1 out of 1 resident was not refunded their allotted prepaid monthly fee’s which posed a potential personal rights risk to one of X of residents in care.the state’s words, verbatim · CDSS document, May 31, 2024

Plan of correction: The Licensee will be refunding R1s family the allowance of $2,700 that was owed and submit the check receipt and the mailing receipt by POC due date, 06/14/2024.