Dutchollow Suites I

Allegation investigated: Facility staff do not keep facility free of pests Facility staff did not ensure that resident's oxygen needs are not met Facility staff accepted a resident with a higher level of care Facility staff used furniture to block resident from getting out of bed

Unannounced complaint visit made out to this facility on 07/20/2026 by Licensing Program Analysts (LPAs) Charlie Yang and Kimberly Kulich who were met by the facility designated Administrator, Cecilia Candido, who was interviewed at this time. Current census was 3 residents. The purpose of this visit was to deliver the findings of this investigation to this facility, and its representative, at this time. Based on interviews conducted during the course of this investigation, it was learned that the presence of cockroaches and other bugs/insects were present in the kitchen area and near the facility entrance. It was also observed that the food being left out and the amount of food items which were not properly stored led to the presence of bugs/insects to be present at this time. Based on interviews conducted during the course of this investigation, it was learned that chairs and other furniture items were being placed around the bed of a resident to prevent them from getting up and out of bed. It was learned that this was observed on several occasions and the practice was still being employed even after it was brought to the attention of the facility designated Administrator that this was a violation of Substantiated the resident’s personal rights. It was learned that this resident was beyond the level of care that could be provided by the current facility since this resident was unable to independently transfer or reposition in bed. It was learned that this resident required assistance with transferring and repositioning which was unable to be met by the current staff who were unable to properly physically assist this resident when needed. Based on interviews conducted during the course of this investigation, it was learned that a resident, R1, was in need of oxygen. It was learned that the machine had to plugged in and turned on so that the resident could wear the mask to receive the oxygen. It was learned that on multiple occasions, the oxygen mask for the resident was not on her face while the machine was not turned on. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jul 20, 2026 · control 27-AS-20260324091142

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Jul 21, 2026

Personal Rights of Residents in All Facilities To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This facility was found to be deficient as evidenced by blocking in a resident in their bed with chairs and other furniture posing an immediate threat to the Health, Safety, and Personal Rights of all residents in care.the state’s words, verbatim · CDSS document, Jul 20, 2026

Plan of correction: The facility designated Administrator stated that all residents should be afforded all of their personal rights at all times. A statement of correction, along with proof of updated staff training, for no less than (1) hour in duration, on the topic of residents personal rights will be completed and submitted into CCL by the due date for review by this LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87459(a)(4) · Plan of correction due date: Jul 21, 2026

Functional Capabilities The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to: Transferring, including the need for assistance in moving in and out of a bed or chair. This facility was found to be deficient as evidenced by the inability of the current staff to provide adequate assistance in repositioning or transferring of residents which poses an immediate threat to the Health, Safety, and Personal Rights of all residents in care.the state’s words, verbatim · CDSS document, Jul 20, 2026

Plan of correction: The facility designated Administrator stated that all residents' needs should be addressed and met by all facility staff at all times. A statement of correction, along with an updated LIC 500 for additional staff hires, will be updated and submitted into CCL by the due date for review by this LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87618(b)(1) · Plan of correction due date: Jul 21, 2026

In addition to Section 87611(b), the licensee shall be responsible for the following: (1) Monitoring of the resident's ongoing ability to operate the equipment in accordance with the physician's orders. This facility was found to be deficient as evidenced by observations that a resident was unable to use and manipulate their oxygen machine to make sure that they were receiving it as prescribed by their licensed medical professional which posed a immediate threat to the Health, Safety, and Personal Rights to all residents in care.the state’s words, verbatim · CDSS document, Jul 20, 2026

Plan of correction: The facility designated Administrator stated that all residents should be afforded all of their personal rights at all times. A statement of correction, along with proof of updated staff training, for no less than (1) hour in duration, on the topic of care and supervision related to resident oxygen use, will be completed and submitted into CCL by the due date for review by this LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jul 21, 2026

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 facility was found to be deficient as evidenced by the presence of bugs and insects at the front door and in the kitchen area as well which posed an immediate threat to the Health, Safety, and Personal Rights of all residents in care.the state’s words, verbatim · CDSS document, Jul 20, 2026

Plan of correction: The facility designated Administrator stated that the kitchen area will be cleaned and kept clear of any old food items. A statement of correction, along with photos of the cleaned and cleared kitchen area, will be completed and submitted into CCL. In addition, a consultation will be made with the local pest control company to show that this facility is free of any pests or insects at that time. A statement of correction, along with updated consultation paperwork, will be completed and submitted into CCL by the due date for review by this LPA.

Allegation investigated: Illegal eviction Staff retaliated against a resident due to a complaint being filed against facility Staff did not assist a resident in ambulating to the restroom Staff did not allow residents to participate in activities of their own choosing Staff yelled at a resident

Unannounced complaint visit made out to this facility on 02/25/2026 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Cecilia Candido, who was interviewed at this time. Current census was 4 residents. The purpose of this visit was to deliver the findings of this investigation to this facility, and its representative, at this time. Based on a review of the forms and documents gathered during the course of this investigation, it was learned that R1 had been a resident with this Licensee dating back to a prior licensed care facility in the Merced area. It was learned that this facility in the Merced area was closed and R1 was then relocated to this facility here in the Modesto area. It was observed that the only LIC 602 completed was performed and signed by the attending physician on 06/20/2025. There were no other LIC 602s completed or updated at this time. A records request from this LPA in regards to the LIC 602 for R1 only produced this single document that was completed on 06/20/2025. Substantiated In addition, a review of the forms and documents gathered during the course of this investigation produced a Preplacement Appraisal Information (LIC 603) that was signed and dated on 12/05/2025 which was almost a month after the initial admission of R1 into this facility on 11/15/2025. It was learned that this initial appraisal cited excessive wandering within the confines of this facility and poor boundary limits by R1. It also cited cursing and threatening by R1 unto others in care with history of manipulation by R1 to gain an advantage. It was learned that the Appraisal/Needs and Services Plan, completed on 01/16/2026, was signed by R1 and facility designated Administrator Cecelia Candido but no date was recognized or noted on the LIC 625 at that time. This document stressed the same issues as indicated on the LIC 603 which was completed a month earlier. It was observed that these were the only versions that were present without any updated versions to present any changes to the needs and increased levels of behavior that would warrant a higher level of care for R1. It was learned that R1's level of care and needs were the same as when she was living in the licensed care facility in Merced and remained the same upon relocation to this Modesto care facility. All supporting documents (LIC 602, LIC 603, LIC 625) were completed around the admission date to this facility but were never updated or changed to reflect any needs to elevate the level of care for R1. It was learned that this was the main reason for grounds of eviction served unto R1 since it was alleged that R1 had become a danger to self and to others in the facility yet there weren't any updated forms and documents to note these changes since admission to this facility to prove any new threats to self or others in care. Based on statements attained during the course of this investigation, it was learned that facility staff have spoken to residents in care in a manner that violated their personal rights. It was learned that the tone and manner in which it was directed unto the residents was not professional but rather dismissive. It was learned that facility staff were not available when residents were in need of assistance so proper care and supervision was not being afforded to the residents in care. It was learned that facility staff dismissed a resident's call for assistance in going to the restroom determining that their request was not valid at that time. It was learned that facility residents were unable to move around to either change the television channels or manipulate the remote to change the stations in order to watch something that interested them. Instead, it was learned that facility residents were subject to watch what was already present on the television at that time and were not allowed to change the channels as they saw fit. Based on a review of the forms and documents gathered during the course of this investigation, it was learned there was a complaint filed in January of 2026 which involved R1. Shortly thereafter the eviction notice was served to R1 on 02/13/2026 which was only a few weeks after the filing of the complaint in January of 2026 with allegations surrounding R1. It was learned that the reason for eviction did not have any supporting evidence to signify why the eviction was being served. There was not any established grounds to note a change in condition nor support that a higher level of care was needed since follow up was not sought to address any of these concerns at that time. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 26, 2026 · control 27-AS-20260217144649

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(d) · Plan of correction due date: Jun 27, 2026

The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This facility was found to be deficient as evidenced by serving an eviction notice which did not have supporting information to note that a considerable change in behavior had occurred requring a higher level of care causing concern for harm to the resident and other residents in care. This posed an immediate threat to the health, safety, and personal rights to all residents in care.the state’s words, verbatim · CDSS document, Jun 26, 2026

Plan of correction: The facility designated Administrator stated that all facility staff will undergo training, for no less than (1) hour in duration, on the topic of proper eviction procedures from a vendorized entity set forth on the CCLD website. A statement of correction, along with proof of updated training, will be completed and submitted into CCL for review by this LPA by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(3) · Plan of correction due date: Jun 27, 2026

In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights. This facility was found to be deficient as evidenced by the execution of an eviction notice to a resident and their responsible party after a complaint was filed. This posed an immediate threat to the Health, Safety, and Personal Rights of all residents in care.the state’s words, verbatim · CDSS document, Jun 26, 2026

Plan of correction: The facility designated Administrator stated that all facility staff will undergo training, for no less than (2) hours in duration, on the topic of Personal Rights from a vendorized entity set forth on the CCLD website. A statement of correction, along with proof of updated training, will be completed and submitted into CCL for review by this LPA by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87219(a)(1) · Plan of correction due date: Jun 27, 2026

Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: Socialization to promote or enhance personal relationships. Activities may include, but are not limited, to: This facility was found to be deficient as evidenced by the lack of activities that were being offered and lack of involvement for the facility residents made by the facility staff. This posed an immediate threat to the Health, Safety, and Personal Rights to all residents in care.the state’s words, verbatim · CDSS document, Jun 26, 2026

Plan of correction: The facility designated Administrator stated that all facility staff will undergo training, for no less than (1) hour in duration, on the topic of proper resident activities from a vendorized entity set forth on the CCLD website. A statement of correction, along with proof of updated training, will be completed and submitted into CCLD for review by this LPA by the due date.

Allegation investigated: Staff did not store medications locked and inaccessible to residents in care. Staff were asleep and left residents without supervision while in care. Staff did not ensure that hazardous objects were inaccessible to residents in care. Staff do not ensure that the facility is kept in a clean condition.

On 04/14/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to deliver complaint findings for the allegation above. LPA Pascua met with Facility Designated Representative (FDR), Cecilia Candido and explained the purpose of the visit. Current census was 4. A brief interview with FDA Candido was conducted. Allegation: Staff did not store medications locked and inaccessible to residents in care. It was alleged that staff did not store medications locked and inaccessible to residents in care. During the course of this investigation, the department conducted interviews, reviewed facility records, and reviewed video recordings. Interviews with two staff members indicated that medications are kept locked and inaccessible to residents in care. However, recordings obtained from approximately 01/13/2026 contradict this claim. In the footage, a responsible party is seen arriving at the facility and observing medications left on the kitchen table. Substantiated Further review shows approximately 15 medication bottles and a bubble pack placed on a wooden chair near the facility cabinets, making them accessible to residents. Although staff reported that medications were secured, the recording also shows that no staff members were awake at the time. Based on the information gathered, the facility staff did not store medications locked and inaccessible to the residents in care. Allegation: Staff were asleep and left residents without supervision while in care. It was alleged that staff were asleep and left residents without supervision while in care. During the course of this investigation, the department conducted interviews and reviewed video recordings. Interviews with two staff members indicated that staff were not asleep and that residents were not left without supervision. However, statements from outside parties reported that a responsible party arrived at the facility and was able to gain entry with assistance from a resident. Upon entry, the responsible party observed S1 seated in the middle recliner with their eyes closed. Recordings obtained from approximately 01/13/2026 further contradict staff statements. The video shows one resident in a recliner, one resident in a wheelchair, and two residents in a separate room. Additionally, upon entry into the living area, a male staff member wearing a dark green sweater and light-colored jeans is observed with his legs propped up and eyes closed, appearing unaware that a recording was being made at that time. Based on the information gathered, the staff were asleep and left residents without supervision while in care. Allegation: Staff did not ensure that hazardous objects were inaccessible to residents in care. It was alleged that staff did not ensure that hazardous objects were inaccessible to residents in care. During the course of this investigation, the department conducted interviews and reviewed video recordings. Based on interviews conducted, it was denied by 2 staff members that they did not ensure that hazardous objects were inaccessible to residents in care. It was stated that residents were unable to access the kitchen without staff knowledge however, further interviews revealed that around 01/13/2026, the kitchen was accessible to residents. During a family visit, items such as knives were observed, and the stove was on. Additionally, the staff member present at that time appeared to be asleep. A review of video footage confirmed that the kitchen was accessible to the visiting family member and showed a large silver knife on a cutting board with two pieces of zucchini beside it, along with the gas stove turned on.Based on the information gathered, the staff did not ensure that hazardous objects were inaccessible to residents in care. Allegation: Staff do not ensure that the facility is kept in a clean condition. It was alleged that staff do not ensure that the facility is kept in a clean condition. During the course of this investigation, the department conducted observations during their visit and conducted interviews. Interviews with two staff members indicated that the facility is maintained in a clean condition. Staff also stated that at the time of LPA Pascua’s visit on 01/16/2026, they were in the process of cleaning. However, interviews with responsible and outside parties reported observing significant clutter throughout the facility. During a subsequent tour conducted by LPA Pascua on 01/26/2026, which included the living areas, dining areas, bedrooms, and backyard, the facility was observed to have a heavy level of clutter across multiple areas, including the kitchen, living spaces, and bedrooms. In the kitchen, there were signs of inadequate sanitation, including cluttered countertops, food items left out, and a sink area with visible debris and buildup. The refrigerator appeared overfilled and disorganized, with food items stored without clear separation. Common living areas contained personal items and laundry that limited available space. The outdoor area also showed disorganization, with various items stored haphazardly and containers holding standing water. Based on the information gathered, the staff do not ensure that the facility is maintained in a clean condition. As a result of this investigation, the department found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. An immediate civil penalty of $500 was issued for Section 1569.312(e) for facility staff sleeping while supervising the residents. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. An exit interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit. Contact with the residents doctor was also conducted. Further review of the resident’s appraisal was conducted which did not identify a rash on the residents body however interviews were conducted which could not identify when the rash started and revealed contradicting information. Based on the information, there is not sufficient evidence to prove that the resident developed a rash due to staff neglect. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Apr 14, 2026 · control 27-AS-20260120140759

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 14, 2026

(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This is not met as evidenced by: Based on interview and record review, the licensee did not ensure that medication was locked and made inaccessible to the residents in care. This poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Apr 14, 2026

Plan of correction: Medications were observed to be locked and made inaccessible at the time of this visit. Facility Administrator stated that a review of the section will be conducted. A statement of correction, along with proof of staff training from an outside vendor for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov. by the due date. Information submitted must include attendees, trainers, and information discussed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: May 14, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This is not met as evidenced by: Based on observations, the licensee did not ensure that knives and hazardous materials were locked and made inaccessible to the residents in care. This poses an immediate health, safety, and personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Apr 14, 2026

Plan of correction: Facility Administrator stated that a review of the section will be conducted. A statement of correction, along with proof of staff training from an outside vendor for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov. by the due date. Information submitted must include attendees, trainers, and information discussed.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Apr 15, 2026

Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This is not met as evidenced by: Based on interview and record review, this Licensee did not ensure that S1 supervised the residents in care. It was stated through interviews that S1 was witnessed to be sleeping at the time of a family visit which was corroborated through a video recording. This poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Apr 14, 2026

Plan of correction: Facility Administrator stated that a review of the section will be conducted. A statement of correction, along with proof of staff training from an outside vendor for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov. by the due date. Information submitted must include attendees, trainers, and information discussed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 14, 2026

(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 is not met as evidenced by: Based on observations, the licensee did not ensure that the facility was in a clean manner. It was observed that that facility had clutter across multiple areas, including the kitchen, living spaces, and bedrooms. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Apr 14, 2026

Plan of correction: Facility Administrator stated that a review of the section will be conducted. A statement of correction, along with proof of cleaning and cleaning schedule will sent to the LPA by POC date.

Type of visit: Required - 1 Year

On 9/25/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required 1-year annual inspection. LPA was greeted by Administrator Cecilia Candido. LPA Lindstrom introduced herself and explained the purpose of the visit. The co-Administrator Nikolas Adamsson was also present. Both Administrators have valid Administrator’s certificates. The facility has four bedrooms and two bathrooms. The current census is two residents. Two bedrooms were in use by residents, and the third and fourth bedrooms have been designated as office and storage. The LPA toured the interior of the facility. The interior is decorated and contained adequate furniture for residents in the living room, entertainment room, and dining room. The bedrooms were clean and contained the required furniture. The bathrooms were clean. The water temperature in the hallway bathroom was 119 degrees Fahrenheit. The smoke and carbon monoxide detectors were wired together and in working order. The fire extinguisher was purchased on 11/8/2024 and had been checked monthly by staff. The administrator reviewed the emergency disaster plan last month and there were logs of quarterly disaster drills. The LPA inspected the kitchen. The LPA observed that several opened food items that require refrigeration after opening were in the kitchen cabinets, unrefrigerated. There were several perishable and nonperishable food items in the refrigerator and pantry that were expired. There were cleaners and chemicals stored in kitchen cabinets with food. There was a two-day supply of perishable food and seven-day supply of non-perishable food in the kitchen and garage. The LPA inspected the medication storage and records. Medication was stored in a locked cabinet in the kitchen. The paper-based medication administration record produced by the pharmacy was complete and up to date. (Continued on LIC809-C) The LPA inspected the grounds. The front yard was manicured and contained decorative plantings. The backyard contained a large pool that was behind a locked gate. The walkways were free of obstruction. There was no shaded outdoor activity area for residents. The LPA inspected two staff and two client files, which were compete. As a result of this inspection, deficiencies were cited. The facility was not in compliance with California Code of Regulations (CCR), Title 22, Division 6. The deficiencies are listed on the attached LIC 809D. Failure to correct deficiencies by the noted due date may result in the assessment of civil penalties. An exit interview was conducted with the Administrator, to whom a copy of this LIC809 report, the LIC 809D, and the appeals rights was provided. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, Sep 25, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 9/25/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a one year annual inspection. LPA Jensen met with Administrator Cecelia Candido and explained the purpose of today's visit. The current census is 3. LPA Jensen toured the grounds and observed the paths to be free of obstruction. The facility has a swimming pool that was observed to be locked and inaccessible to residents. The front side yard has numerous bags of items for disposal waiting to be picked up. The Administrator advised that the debris form the side yard will be removed by 9/26/24. LPA Jensen toured the interior of the facility. LPA Jensen observed the facility to be adequately furnished and free of odor. There are 4 bedrooms, 3 of which are designated for client use. LPA Jensen observed 1 client room being used for storage. The Licensee has agreed to submit an LIC 200 with a request to reduce capacity to 4 with the intention of designating 2 of the 4 bedrooms for clients and both client bedrooms will be double occupancy. The fire extinguisher was purchased on October of 2023 and is in compliance. The smoke detectors and carbon monoxide detectors were determined to be in good working order. The water temperature was tested in the hallway bathroom and was determined to be in compliance. The facility maintains several first aid kits. Knives, toxins and medications were observed to be locked and inaccessible to residents in care. LPA Jensen inspected the kitchen and observed a 2 day supply of perishable food and a 7 day supply of non-perishable food. Several food items that require refrigeration after opening were observed in the kitchen cupboards. The food items had been opened but were not refrigerated. Several dry food items were observed that had been removed out of there original packaging and put in to containers with no dates or labels. LPA Jensen observed medications to be removed from their original packaging and transferred to alternate containers for AM and PM medication passes. LPA Jensen reviewed resident files. It was observed that 1 of 3 resident admission agreements stated no refund upon death. The Licensee revised the admission agreement and and had the resident sign the new agreement in the presence of the LPA. Technical assistance was provided. It was observed that 1 of 3 resdient's had an outdated LIC 602 (physician's report). The LIC 602 was from the year 2022. At this time the Administrator/Licensee and Co-Administrator are live-in and the only staff. Cecelia Candido's Administrator certificate expired in June of 2024 and her renewal application was submitted in May. A copy of the liability insurance was obtained and remains current. LPA Jensen interviewed 2 of 3 residents who both advised they are satisfied with all aspects of care. 1 of 3 residents was sleeping for the entirety of the visit. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 25, 2024

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 5/10/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management related to a complaint investigation for complaint control number 27-AS-20231213133955. LPA Jensen met with Administrator Cecelia Candido and explained the purpose of today's visit. During a Non-Compliance Conference on 2/13/24, a discussion took place regarding a wound that Resident 1 (R1) developed while under facility care. The Administrator stated that facility protocol was not followed as the Administrator only called the hospital advice nurse as opposed to sending the resident out to be evaluated by a medical professional. On 3/12/24 LPA Jensen issued a citation under the above listed compliant number for an allegation that a “resident developed a pressure injury while in care”. The citation issued pursuant to the California Code of Regulations (CCR), Section 87464(f)(1) has been repealed. The repealed citation is being replaced with a citation under CCR section 87466 and civil penalties are being assessed. See complaint control number 27-AS-20231213133955 for additional investigation details. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 10, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 10, 2024

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided when such observation reveals unmet needs. When changes ... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician ... This requirement was not met as evidenced by Based on an interview with the Administrator and a review of facility records, medical records and photographs, R1 developed a wound while under facility care that was not reported to R1’s physician. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: The Licensee has already completed the plan of correction under compliant number 27-AS-20231213133955. No further plan of correction required.

Type of visit: Case Management - Health Checks

On 5/10/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly visit. LPA Jensen met with Licensee Cecelia Candido and explained the purpose of today's visit. There are currently 2 clients in care. LPA Jensen checked the water temperature in the hallway bathroom and it was 118 degrees Fahrenheit which is in compliance. LPA Jensen observed the fire extinguisher to have been purchased new on 10/17/23 which is in compliance. The Emergency disaster plan was last updated on 4/18/24 to reflect a change in facility vehicles. LPA obtained a copy of the updated Emergency disaster plan for the master file. LPA Jensen toured the backyard and observed the pool to be locked and inaccessible to residents in care. LPA Jensen interviewed co-administrator Nikolas Adamsson who explained that the facility is in the process of digitizing all facility records. LPA Jensen observed the medication cabinet to be locked and inaccessible to residents in care. LPA Jensen provided technical assistance on waiver programs and HCBS. No deficiencies were issued as a result of this visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 10, 2024

Allegation investigated: Resident developed a pressure injury while in care

On 3/12/24 Licensing Program Analysts (LPAs) Maja Jensen and Kesha Lewis arrived at facility unannounced to continue a compliant investigation in to the above listed allegations. LPAs Jensen and Lewis met with Administrator Cecelia Candido and explained the purpose of today's visit. During the course of the investigation LPA Jensen conducted interviews with 2 residents, a family member of a resident, a home health aide, a hospital social worker, 3 facility staff and the Ombudsman. LPA Jensen also reviewed records pertaining to Resident 1 (R1) that includes medical records, hospital letter of agreement records, needs and service plans, facility incontinence care plans, facility wound care plans and wound photos. The Administrator provided photos of a wound to R1's posterior dated 9/25/23 and 9/28/23. Based on the photos provided by the Administrator the resident had a significant wound while in facility care. The Administrator confirmed that she took the photos herself and that R1 was receiving wound care. Substantiated During an office meeting on 2/13/24 the Administrator also confirmed that the resident was in facility care with the wound as shown in the photos from 9/25/23 and 9/28/23. There was no documentation to support the wound condition was pre-existing when the resident entered the facility therefore the allegation of "resident developed a pressure injury while in care" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited pursuant to the California Code of Regulations, Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 12, 2024 · control 27-AS-20231213133955

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 13, 2024

Basic Services 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: Based on interviews conducted, facility records, medical records and photographs taken by the Administrator, R1 did not receive the care and supervision needed to prevent a wound which endangered their physical health. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: R1 no longer resides at the facility. The facility has conducted additional training on wound care and personal rights. The facility has also increased resident observation and documentation. No further plan of correction is required.

Type of visit: Case Management - Legal/Non-compliance

A Non-Compliance Conference (NCC) was conducted on this day, 2/13/24, by the Sacramento South Regional Office via Microsoft Teams. The purpose of this NCC meeting was to discuss the continued non-compliances and serious deficiencies observed while the facility has been undergoing increased monitoring. Present at the meeting were Regional Manager (RM), Stephenie Doub, Licensing Program Manager (LPM), Lisa Rios, Licensing Program Analyst (LPA), Maja Jensen, Licensees/Administrators, Cecelia Candido, and Nikolas Adamsson. The Non-Compliance Conference process was explained during this meeting to include the administrative process. An informal meeting was held on 10/12/22 to discuss concerns in the areas of: food service, medications accessible to residents, chemicals accessible to residents, knives accessible to residents, maintaining the facility in good repair and personal rights. As a result, increased monitoring was initiated and the Licensee engaged in the Technical Support Program. Over the course of the past year, the Department has continued to observe non-compliance in aforementioned areas of concern. Items discussed during the Non-Compliance Conference were: · Safe medication storage and administration · Storage of hazardous items · Fire Clearance compliance, adherence to facility sketch (LIC 9099) · Reporting Requirements and communication with the Department · Prohibited/restricted health conditions · Care Plans Continued on LIC 809C.... During the meeting the Licensee agreed to do the following: · Conduct and maintain logs of weekly facility inspections to ensure hazardous items and medication are secured with logs to be sent to the Department by 3/1/24 · Staff training regarding protocols for restricted/prohibited health conditions and safe storage of hazardous items due by 3/1/24 · Facility will document the date a medication was started Completing the non-compliance conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager. In the event that the Department determines that the licensee has violated the law/regulations or is inadequately implementing the approved plans, the Department, in its discretion, may seek formal legal action or other appropriate administrative action.the state’s words, verbatim · CDSS document, Feb 13, 2024

Type of visit: Case Management - Health Checks

On 1/25/24 Licensing Program Analyst (LPA) Maja Jensen and Stanislaus County Ombudsman Josey Samson arrived at facility unannounced to conduct a quarterly visit. LPA Jensen met with Licensee Cecelia Candido and Co-Administrator Nikolas Adamsson and explained the purpose of today's visit. The Licensee was informed that at any time if she wishes to use an interpreter the Department will provide an interpreter upon request. The facility currently has a census of 2. LPA Jensen requested the file for Resident 2 (R2). LPA Jensen observed an Admission agreement dated 4/13/2018 stating that the resident has a double room. LPA Jensen also observed 2 receipts billing for a private room. One receipt for April through June and one receipt for April through May of 2018. LPA Jensen asked the Licensee why there are receipts in the file billing for a private room and an admission agreement stating there R2 will occupy a double room. The Licensee stated the receipts in question were never sent and were placed in the file in error. The Licensee confirmed that the resident has always occupied a double occupancy room. LPA Jensen requested the correct receipts and was advised no other receipts were ever sent or generated. LPA Jensen observed the Needs and Service Plan for R2 to be dated April 2, 2018. The Licensee produced an additional Needs and Service Plan dated 3/23/2019 with no signatures. LPA Jensen reviewed the Medication Administration Record (MAR) for R2, the MAR reflects that on January 11 through and including January 15, 2024, R2 did not receive a prescribed dopamine promoter. LPA Jensen was advised that the prescription medication ran out on January 10, 2024 and the facility placed 3 calls to the pharmacy for a refill but these calls were not documented. LPA Jensen reviewed the Centrally Stored Medication and Destruction Record which shows that the prescription was refilled 12/21/23 and was started on 1/7/24. There was no explanation as to why these records were in conflict. LPA Jensen tested the water in the bathroom toward the rear of the facility and the temperature was measured at 103 degrees. Technical assistance was provided.the state’s words, verbatim · CDSS document, Jan 25, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.884 · Plan of correction due date: Jan 25, 2024

Contents of Residential Care Facility Admission Agreements The admission agreement shall include all of the following: (a) A comprehensive description of any items and services provided under a single fee, , such as a monthly fee for room, board... the resident shall receive a monthly statement itemizing all separate charges incurred by the resident. This requirement was not met as evidenced by Licensee's admission that file receipts were inaccurate and no other receipts were generated. This poses a potential risk to the health, safety and personal rights of residnets in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: The Licensee agrees to send monthly receipts to the payee effective immediately and retain those receipts in the file.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jan 26, 2024

Basic Services Basic services shall at a minimum include: ...assistance with taking prescribed medications...This requirement was not met as evidenced by: Based on LPA Jensen's review of the MAR, R2 did not receive a prescribed medication from 1/11/24 through 1/15/24. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: The Licensee agrees to document all communications with resident physicians and the pharmacy effective immediately and reconcile the MAR with the Centrally Stored Medication and Destruction Record.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87467(a)(3) · Plan of correction due date: Feb 22, 2024

Resident Participation in Decision Making The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident’s condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement was not met as evidenced by LPA Jensen's review of R2's file which contained a Needs and Service Plan conducted in 2018. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: The Licensee agrees to submit updated Needs and Service Plans that fully comply with this regulation by the POC due date.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 11/20/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to deliver an amended report from 10/31/23. LPA Jensen met with care provider Eleanor Aralar and explained the purpose of today's visit. LPA Jensen also spoke to care provider Marilou Oliver who is the designee in charge while the Administrator's absence. The facility currently has 1 resident on premises, 1 in the hospital and 1 in a skilled nursing facility. LPA Jensen provided technical assistance to Marilou Oliver in the areas of reporting requirements and restricted health conditions. No citations are being issued as a result of this visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 20, 2023

Type of visit: Case Management - Annual Continuation

LPA Jensen arrived at facility unannounced to continue an annual inspection that was commenced on 10/17/23. LPA Jensen met with care provider Marilou Oliver and explained the purpose of today's visit. On 10/17/23 LPA Jensen toured the grounds and interior physical plant. LPA Jensen observed a swimming pool in the backyard that was locked and inaccessible to residents in care. There was outdoor seating available for client activities. LPA Jensen observed 4 torn window screens in the backyard. The outdoor grounds appeared to be maintained and outdoor paths were clear of obstruction. LPA Jensen toured the facility kitchen. A 2 day supply of perishable food and a 7 day supply of non-perishable food was on hand. LPA Jensen did a random sampling of canned goods and observed 5 expired canned food products, rotting parsley in the refrigerator, salad that expired on 10/8/23, food in storage containers that was not labeled and several items with freezer burn. LPA Jensen toured the resident bedrooms and observed all required furniture present. The facility uses waterproof mattress covers on the beds. The facility maintains an adequate supply of linens and hygiene products. LPA Jensen observed the Resident 1 (R1) to be in bed. The bed is adjacent to the wall on one side and blocked on the other side by a chair, walker and portable commode in such a manner that R1's ability to get out of bed would be restricted. LPA Jensen attempted to conduct a random medication audit for Resident 2 (R2) but was unable as the facility does not maintain centrally stored medication and destruction records. LPA Jensen reviewed 3 of 3 resident files. 3 of 3 resident admission agreements state that an increase in the monthly rate charged may be initiated after 30 days of notice. 1 of 3 resident admission agreements states that there are no refunds provided. LPA Jensen reviewed the first aid kit and found it to be complete and in compliance. The carbon monoxide detector, smoke detector and fire extinguisher were determined to be in compliance. The facility maintains an adequate emergency supply of food and water. There is emergency lighting available. The facility conducts regular fire drills and is in compliance. The thermostat was set at 68 degrees which falls within the required range of 68-85 degrees Fahrenheit. The water temperature was measured in the bathroom in the main hall All required postings were observed to be easily viewable. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, the LIC 811 and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 31, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Nov 1, 2023

General Food Service Requirements ...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 LPA Jensen's observation of expired food in the pantry and refrigerator and food items requiring refrigeration being stored in the pantry. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: The facility staff began conducting an inventory of the food supply and discarding expired food. The Licensee agrees to conduct a monthly audit of the food supply to identify and discard of all expired food.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.655(a) · Plan of correction due date: Dec 8, 2023

If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives. This requirement was not met as evidenced by: Based on LPA Jensen's review of 3 of 3 resident files that indicate rate increases may be made after 30 days. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: The Licensee agrees to establish new admission agreements signed by the resident or responsible party if applicable that are in compliance with the HSC. The Licensee will send the admission agreement to LPA Jensen by the Plan of Correction due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Nov 1, 2023

Postural Supports A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement was not met as evidenced by: Based on LPA Jensen's observation of R1's bed being blocked by various items effectively restricting R1's mobility without a physician's order. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: The facility staff called the Primary Care Physician requesting authorization for postural supports for R1 during the course of this visit and in the presence of the LPA. The facility staff will either remove the postural supports or send confirmation that the physician has given approval by 11/6/23.

Type of visit: POC

LPA Jensen arrived at facility unannounced to conduct a Plan of Correction visit related to deficiencies that were cited on 10/17/23 during the course of a quarterly Health and Safety visit. LPA Jensen met with care provider Eleanor and explained the purpose of today's visit. Marilou Oliver is the acting Administrator due to the Licensee/Administrator of record currently being out of the country. On 10/17/23 the Licensee was cited for California Code of Regulations (CCR) 87208(a)(7)(A) - Plan of Operation. A plan of correction was received timely. The Licensee submitted a sketch and attestation that the usage of each room is accurately depicted by the sketch and corresponds to the original fire clearance granted. This report amends a report form 10/31/23 wherein a civil penalty was erroneously issued for failure to correct a deficiency. An exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 31, 2023

Type of visit: Case Management - Health Checks

On 10/17/23 at approximately 10:15 am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly visit and follow up on the progress and maintenance of previously discussed directives. LPA Jensen met with Nick Adamsson and explained the purpose of today's visit. On 10/12/22 an informal conference was held to discuss deficiencies in the areas of: Food service · Medications accessible to residents · Chemicals accessible to residents · Facility is not clean and in good repair · Swimming pool (empty) accessible to residents · Knives accessible to residents · Resident Personal Rights The facility agreed to do the following: - Lock all medications in a cabinet making them inaccessible to residents · Lock the pool making it inaccessible to residents · Keep chemicals in garage locked away · Combustible chemicals to be kept locked away near empty pool · Provide updated floor plan to include one storage room (store clutter) · Ensure the facility, and all resident bedrooms are clean and not full of clutter. The License agreed to engage in the Technical Support Program offered by the Department and a corresponding meeting on 5/11/23 during which the Licensee agreed to: - conduct Personal Rights Training every 6 months and upon new hire. -clean and organize the client/storage room prior to the next quarterly visit During the course of the visit LPA Jensen observed the following: -scissors accessible to residents in the night stand of the bedroom for resident 1(R2) -a nail gun, protractable knife and latex caulk in an unlocked closet -medication on the kitchen table not locked and accessible to residents -a gallon of bleach on the kitchen floor -numerous boxes of night time cold and flu medicine in a drawer under the TV stand for which there was no PRN -health related oral supplements for which there was no PRN -a case of Ensure in the bedroom of resident 2 (R2) -A hoyer lift blocking a fire exit in the bedroom of R1 -A clothes dresser and chair blocking a sliding glass door exit in the bedroom for R2 -A sign on a client bedroom that read STAFF which was removed when LPA Jensen brought this matter to the Licensee's attention -dead flies in the living room, hallway and bedroom of R2 LPA Jensen observed documentation showing personal rights training was conducted in June of 2023 and is therefore in compliance. LPA Jensen observed the outdoor pool to be locked and inaccessible to residents and therefore in compliance. Deficiencies are being cited from the California Code of Regulations (CCR) and/or the Health and Safety Code (HSC) Failure to correct deficiencies may result in the assessment of civil penalties and administrative action. An exit interview was conducted and a copy of this report, the LIC 811 and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 17, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Oct 18, 2023

Personal Accommodations and Services All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by: Based on LPA Jensen's observation of a bedroom sliding door and bedroom door blocked by equipment or furniture. This poses a potential threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: The Licensee removed the obstructions during the course of the visit. No further plan of correction is required.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87208(a)(7)(A) · Plan of correction due date: Oct 24, 2023

Plan of Operation Each facility shall have and maintain a current, written definitive plan of operation...The plan and related materials shall contain the following: Sketches...including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents. This requirement was not met as evidenced by LPA Jensen's observation that a client room had been converted in to a staff room. This poses a potential threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: The Licensee will submit a sketch that accurately depict the usage of each room or sign an attestation that the current sketch is accurate.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80087(a) · Plan of correction due date: Oct 18, 2023

Buildings and Grounds The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by: Based on LPA Jensen's observation of toxins, tools, sharp objects and insects. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: The Licensee removed all hazardous items and made them inaccessible during the course of the visit. No further plan of correction required.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Oct 18, 2023

Incidental Medical and Dental Care Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: Based on LPA Jensen's observation upon arrival of medication in the kicthen that was accessible to residents in care. This poses an immediate risk to the health, safety and personal rights of residdents in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: The Licensee agrees to conduct a daily walk through to ensure all medications are inaccessible to residents in care. The Licensee will email an attestation that daily walk throughs will be conducted.

Type of visit: Required - 1 Year

On 10/17/23 at approximately 1pm Licensing Program Analyst arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Licensee Cecelia Candido and explained the purpose of today's visit. Due to time constraints this annual inspection will require additional time to complete at a later date. No deficiencies are being issued at this time.the state’s words, verbatim · CDSS document, Oct 17, 2023