Divine Light Care Home

Allegation investigated: Facility admissions contract includes incorrect stipulations

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegation. LPA was allowed entry by the caregiver. LPA identified herself and disclosed the purpose of the visit and elements of the complaint to the caregiver and was later joined by the Licensee. On February 3, 2026, the Department received a complaint alleging that the facility revised its Admission Agreement to state that no refunds would be issued to responsible parties, including in the event of a resident’s death, which is in violation of Title 22 regulations. During the complaint investigation, the LPA reviewed the Admission Agreements for 7 residents and 2 of 7 residents currently residing at the facility had 18A clause in the agreement. The LPA determined that the Admission Agreements had been modified after the initial application packet was submitted to the Department. Continued on 9099C Substantiated The revised Admission Agreements included language stating that the facility would not provide refunds to responsible parties under any circumstances, including upon a resident’s death. Title 22, California Code of Regulations, Section 87507(g)(5) requires that Admission Agreements include refund conditions, including refunds upon termination of residency. The facility’s revised Admission Agreements (number 18A for hospice care) failed to comply with this regulation by eliminating refunds, upon a resident’s death. Based on records review, the allegation that the facility changed its Admission Agreement to not provide refunds to responsible parties, upon resident death for residents on hospice care, is substantiated: as there is a preponderance of evidence to prove the alleged violation occurred. An exit interview was conducted; a copy of this report along with Licensee Appeal Rights LIC 9058 (REV 3/22) were provided to the Licensee and his signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Feb 9, 2026 · control 08-AS-20260203081128

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(5)(A) · Plan of correction due date: Feb 9, 2026

(5)Refund conditions. (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652. The facility’s revised Admission Agreements for 2 of 7 residents eliminated refund provisions and were modified...This poses a potential financial harm to residents and responsible parties.. improperly denied refunds upon death.the state’s words, verbatim · CDSS document, Feb 9, 2026

Plan of correction: To provided admended to admission agreement to the repsponsible parties that elimanates 18A clause for no refund for hospice care. By February 27, 2026

Allegation investigated: Staff did not follow admissions agreement. Staff force fed resident. Staff did not administer medication as prescribed.

Licensing Program Analyst (LPA) Hall conducted an unannounced visit to deliver complaint findings. LPA identified herself and disclosed the purpose of the visit and elements of the complaint to the Caregiver. During the course of the investigation, LPA conducted interviews with the Reporting Party (RP), facility staff, outside sources, and reviewed resident records, medication administration records (MAR), and tour of the facility. Resident 1 (R1) was admitted to the facility on June 23, 2025, and was on hospice care effective the same date. R1 was non-ambulatory with a primary diagnosis of dementia. Secondary diagnoses included hyperlipidemia unspecified, cerebral infarction due to thrombosis of the right middle cerebral artery, cerebral infarction due to unspecified occlusion or stenosis of the right carotid artery, hemiplegia following cerebral infarction affecting the left non-dominant side, presence of a right artificial hip joint, and history of falling. Continued on 9099C1&C2 Unsubstantiated On July 3, 2025, the new physician’s orders for morphine sulfate 20 mg/mL, 5 mg every 4 hours as needed (PRN). The order was faxed to the facility on July 4, 2025. Facility documentation indicates that medication was administered in accordance with hospice instructions beginning on July 4, 2025. The June 22, 2025, discharge notes indicated R1’s diet consisted of a combination of regular and modified texture diet with 1:1 supervision and no straws. The after-visit summary dated June 24, 2025, showed medication changes including acetaminophen, amoxicillin, sennosides-docusate sodium, sodium chloride, and spironolactone, while several medications were discontinued, including vitamin D3, meloxicam, quetiapine, and spironolactone (replaced by similar medicines). RP stated that a refund was received on July 23, 2025, and denied saying that the facility failed to adhere to the admission agreement. RP alleged that morphine was not given as prescribed and stated the last dose was administered at 9:30 p.m. the previous night, with instructions for administration every 4 hours as needed. RP also reported that R1 was not supposed to receive food, but staff gave oatmeal. RP stated that when visiting, they did not observe food in R1’s mouth or witness feeding. RP indicated they typically visited the facility daily at 5:30 p.m., except for a few missed days, and were unaware of R1’s specific diet plan or morphine administration schedule. RP provided the name of an additional hospice nurse who was present during the days before R1’s passing on July 8, 2025. Outside Source 1 (OS1) reported being a covering hospice nurse and not the regular case manager. OS1 visited R1 on July 4 and July 5, 2025, and administered morphine at 9:36 a.m. on both days. OS1 stated that they did not observe mistreatment or neglect by staff and confirmed that their involvement was limited to coverage during the specified dates. No response or returned call from case-carrying hospice nurse. On October 9, 2025, LPA spoke with the OS2 who could not recall the case regarding the administration of morphine to the resident. LPA asked OS2 about a handwritten schedule for administering morphine. OS2 stated that the handwritten schedule was probably written by the resident’s family member. Staff 1 (S1) reported working two days per week and stated that R1 was provided soft foods such as oatmeal for breakfast and pureed foods for lunch and dinner. S1 noted that when R1 declined food, R1 turned their head away. S1 denied administering morphine and stated that they waited for a physician’s order prior to administration. S2 stated that R1 received oatmeal for breakfast and pureed food for other meals. S2 confirmed R1 was declining and eating less. S2 denied administering morphine and confirmed that only regular medications were provided. S3 stated that R1’s family requested morphine to be administered, but S3 explained that he could not do so without a physician’s order. The family contacted the police, and S3 explained to responding officers that morphine could not be administered without proper authorization. The physician’s order for morphine was prescribed on July 3, 2025. S3 also reported that the family requested S3 to sign documents related to long-term care benefits, which S3 declined as the facility is not a skilled nursing facility. A refund was issued and cashed on July 23, 2025. S3 confirmed R1 received oatmeal for breakfast and pureed food for other meals. Based on the information obtained through interviews, record review, and hospice documentation, there is insufficient evidence to support the allegation that the facility failed to administer morphine as prescribed or provide food contrary to dietary orders. Records and hospice documentation support that morphine was administered as ordered beginning July 4, 2025. Additionally, dietary notes confirm that soft and pureed foods were consistent with R1’s prescribed diet. The allegation regarding non-adherence to the admission agreement was not supported, as the RP denied making such a statement, and documentation supports that the refund was processed and received by the family on July 23, 2025. Therefore, the allegations are determined to be: UNSUBSTANTIATED – Meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred. An exit interview was conducted with the Caregiver. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Caregiver, and his signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 08-AS-20250801102701

Allegation investigated: Facility had more residents than licensed for

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegation. LPA was allowed entry by the Licensee. LPA identified herself and disclosed the purpose of the visit and elements of the complaint to the Licensee. This is an Amended reflect the Cenus at the time of visit was 7 instead of 6. On May 12, 2025, the Department conducted a visit. During the visit, LPA conducted a tour of the facility and collected resident records. On May 2, 2025, a complaint was filed with the department by the Reporting Party that alleged the facility operated over capacity. Resident 1 (R1) resided at the facility from December 14, 2024, to February 3, 2025, in room #8. During this time, the facility was licensed for a capacity of six residents but was in the process of obtaining an increase to seven. However, the fire clearance was not granted for room #8 to house a non-ambulatory resident due to construction requirements that had not yet been completed. Continued on 9099C Substantiated Despite being aware that they could not operate over their licensed capacity, the facility admitted R1 before receiving the necessary fire clearance and license update. The Department was aware of the fire clearance issue in May 2024; however, R1 was no longer in care at the time of discovery. On May 9, 2025, the facility was officially granted an increase in capacity to seven. Health and Safety Code 87204 (a) cited for the deficiency. Based on the information obtained, the allegation that the facility operated over capacity is substantiated, as there is a preponderance of evidence to prove the alleged violation occurred. An exit interview was conducted; a copy of this report, along with Licensee Appeal Rights LIC 9058 (REV 3/22), was provided to the Licensee, and his signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 12, 2025 · control 08-AS-20250502143825

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: May 12, 2025

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. This requirement was not met: This is evidence by: LPA review of license capacity and admission agreement. This causes a Health and Safety violations for residents in carethe state’s words, verbatim · CDSS document, May 12, 2025

Plan of correction: Plan of Correction has been completed fire clearance obtained, case management was done, and new license increase capacity issued on May 9, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Renita Hall conducted a Case Management visit regarding an increase in capacity application. LPA identified herself and discussed the purpose of the visit with the caregiver. The licensee was available via phone. The licensee applied for an increase in capacity from a total of six (6) clients to a total of seven (7) clients, of whom seven (7) may be non-ambulatory with seven (7) hospice waivers. There is an approved Fire Clearance for the increase in capacity and non-ambulatory status. As of today, there are clients in care. LPA toured the facility and discussed with the licensee regarding operation. LPA toured the physical plant. Client bathrooms are equipped with cleaning products and paper towels; toxic substances are stored in a locked cabinet. Medication storage and administration logs are located locked box in the Kitchen. Sufficient space to conduct activities was present; facility posting requirements were present in a common area; per the Licensee there are no guns, weapons, or ammunition located on the property. No deficiencies were issued during this visit. An exit interview was conducted with Stephen Diaz, caregiver to whom a copy of this report, along with Licensee/Appeal Rights (LIC 9058 03/22), were provided after the visit.the state’s words, verbatim · CDSS document, Apr 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced, required one-year Annual Visit. Stephen Diaz, the Caregiver, allowed LPA entry. LPA identified herself and disclosed the purpose of the visit with the caregiver. Rogelio Diaz, the Licensee, later joined the visit. Physical Environment: The facility was clean, well-maintained, and free from any safety hazards. Adequate lighting and ventilation were observed in all areas of the facility. All necessary safety equipment, such as fire extinguishers and emergency exits, were present and in good working condition. The facility's outdoor spaces were properly maintained and accessible to residents. Staffing and Training: The facility had a sufficient number of qualified staff members to meet the needs of the residents. The staff member was observed to be professional, courteous, and knowledgeable in their respective roles. All staff members had completed the required training and certifications per the licensing regulations. Staffing schedules were posted and adhered to, ensuring adequate coverage at all times. Continued on 809C Resident Care and Services: Residents' care plans were reviewed and found to be comprehensive and up-to-date. Medication administration was observed to be in accordance with the facility's policies and procedures. Residents' nutritional needs were met, and the meals provided were nutritious and well-balanced. Recreational activities and social engagement opportunities were available to residents regularly. Health and Safety: Regular health assessments and monitoring of residents' well-being were conducted by qualified healthcare professionals. Infection control measures were in place and followed by staff members. The facility had established protocols for emergencies, and evacuation plans were readily available. Overall, the facility was found to comply with the licensing regulations. An exit interview was conducted, and a copy of this report, along with the Licensee Rights (LIC 9058), was provided to the Licensee. His signature on this form confirms receipt of the documents.the state’s words, verbatim · CDSS document, Mar 6, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced Required 1 year Annual Visit. LPA was allowed entry by Ester Villar, Caregiver and was later joined by Roger Diaz, Administrator. LPA identified herself and disclosed the purpose of the visit with the Administrator. Physical Environment: The facility from any safety hazards. Adequate lighting and ventilation were observed in all areas of the facility. All necessary safety equipment, such as fire extinguishers and emergency exits, were present and in working condition. The facility's outdoor spaces were accessible to residents. Staffing and Training: The facility had a sufficient number of qualified staff members to meet the needs of the residents. The staff member was observed to be professional, courteous, and knowledgeable in their respective roles. All staff members had completed the required training and certifications per the licensing regulations. Resident Care and Services: Residents' care plans were reviewed and found to be up-to-date. Medication administration was observed to be by the facility's policies and procedures. Recreational activities and social engagement opportunities were available to residents regularly. {Continued on 809C} Health and Safety: Regular health assessments and monitoring of residents' well-being were conducted by qualified healthcare professionals. Infection control measures were in place and followed by staff members. The facility had established protocols for emergencies and evacuation plans were readily available. Overall, the facility was found to comply with the licensing regulations. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) was provided to Roger Diaz Administrator. His signature on this form confirms receipt of the documents.the state’s words, verbatim · CDSS document, Mar 21, 2024