Eastvale Senior Home Care II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver Nenita Gorospe and was granted entry to the facility. The facility is a (5) bedroom (2) bathroom home and, with a kitchen/dining area, living room, attached garage. LPA was accompanied by Administrator Jerome Alim to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. There was a designated office that stored resident/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed incomplete Appraisal/Needs and Services Plan for Resident #1 (R1) and and Resident #3 (R3). Deficiency will be issued. Additionally, LPA observed no Reappraisal forms for R1 and R3. Deficiency will be issued. A previous licensing report was issued on 03/27/2025 giving notice of the same violation. Because you have been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed until the violation is corrected. An immediate civil penalty of $250 is hereby assessed for the date of 03/27/2026. LPA reviewed (3) resident medications. LPA observed PRN medication for Resident #2 (R2) and Resident #3 (R3) to not be documented properly on Medication Administration Record (MAR). Deficiency will be issued. Additionally, LPA observed (2) medications not labeled or prescribed by a physician in Resident #3 (R3) medications. Deficiency will be issued. LPA also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. No issues observed. Per record review, LPA observed facility accepted (4) hospice residents when facility is only licensed for (2). Deficiency will be issued. Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), (LIC809D), and LIC421IM was discussed and provided to Administrator Jerome Alim. Along with copy of appeal rights.the state’s words, verbatim · CDSS document, Mar 27, 2026

Allegation investigated: Due to staff neglect, resident sustained a pressure injury Staff retained a resident with a prohibited health condition Staff did not notify authorized representative of change in condition Unqualified staff treating a pressure injury Questionable death

Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Administrator Arjan Marlo Banez and explained the purpose of the visit. On August 8, 2025, the Department received a complaint with allegation of personal rights violation resulting in R1 sustaining a pressure injury. The Department investigation consisted of review of facility and other records, observations, and interviews with pertinent individuals. Per facility records, R1 was admitted to the facility at the end of January 2025. According to physician report completed around this time, R1 did not have pressure injuries. However, records did indicate that R1 has history of skin condition or breakdown. Substantiated In addition, records indicated that R1 did not have capacity for self-care in areas including bathing, dressing, incontinent care, and medication administration. R1 was non-ambulatory, used wheelchair, and needed help with transferring, moving about facility. Also, R1 needed special observation/night supervision. Based upon further records review, there was no written record of the care R1 would be receiving in the facility. The written record of care would have included how facility would provide care to meet R1 care and observation needs. During the investigation, it was revealed that on or around June 13, 2025, R1 was observed with reddened area on tailbone (sacral area). Several facility staff, including administrator, acknowledged awareness of reddened area on R1 on June 13th, 2025. It is not indicated how long the reddened area was observed prior to June 13th , 2025. From around June 13th, 2025, until July 16, 2025, the reddened area on R1 sacral was not assessed by physician nor skilled medical professional. Facility staff acknowledged that during this time, the area was being treated with ointment, not authorized by physician or skilled medical professional. Responsible party of R1 was made aware of the “worsening” of the reddened area on July 12th, 2025. This prompted the responsible party, not facility staff, to make contact for medical assessment. When the area was assessed by medical professional on July 16th, 2025, it was found that R1 had an unstageable pressure injury. Per Title 22 regulations, "Pressure Injury" means localized damage to the skin and/or soft tissue under the skin that is usually over a bony part of the body or related to a medical or other device. This damage can appear as intact skin or an open ulcer and may be painful. It occurs as a result of intense and/or prolonged pressure on the affected part of the body or pressure combined with shear (an action or stress that causes internal parts of the body to become deformed). Based on appearance and severity, the damage to tissue is a Stage 1, 2, 3, or 4 pressure injury.” Unstageable pressure injury, according to the Mayo Clinic, is “an unstageable pressure ulcer (or bedsore) is a full-thickness skin and tissue loss where the wound bed is obscured by dead, yellow, brown, or black tissue (slough or eschar), preventing healthcare providers from determining the true depth and extent of the damage until that tissue is removed. It's considered a serious injury (Stage 3 or 4)………”. Based upon Department investigation, the allegation that due to staff neglect, R1 sustained an unstageable pressure injury is substantiated. Facility staff did not ensure that R1 received the care needed and identified in facility records. R1 was admitted to facility with no pressure injuries. R1 had history of skin condition or breakdown. However, no written record of care was documented to include how facility would provide care and observation to meet R1 needs. Prior to or around June 13th, 2025, R1 developed reddened area on sacral area, but facility staff neglected to obtain appropriate assistance for care. The area continued to worsen and then R1 was diagnosed with unstageable pressure injury to the area on July 16th, 2025. A deficiency is being issued per California Code of Regulations, Title 22. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to the Administrator Arjan Marlo Banez. Additionally, On August 08, 2025. The department received a complaint in regards to facility staff retained a resident with a prohibited health condition. Through interviews, it was revealed R1 had an unstageable pressure injury, which is a prohibited health condition in Title 22 Regulations. The department observed the facility staff did not attempt to relocate or notify department of prohibited health condition. The finding is substantiated A deficiency is being issued per California Code of Regulations, Title 22. Furthermore, on August 08, 2025 the department received a complaint regarding facility staff not notifying authorized representative of change in condition. Interviews revealed R1’s responsible party was made aware of pressure injury on 07/12/2025, however, facility staff stated R1’s responsible party was made aware of pressure injury on 06/13/2025. The department determined there is not sufficient evidence to support R1’s responsible party was informed of change in condition of R1. A deficiency is being issued per California Code of Regulations, Title 22. Moreover, on August 08, 2025 the department received an additional complaint regarding untrained staff treating a pressure injury. Interviews revealed that facility staff confirmed to treating R1’s reddened area/stage wound with ointment that was not ordered from hospital or physician. Additionally, interviews and observations disclosed no documentation of turning or repositioning R1. The finding is substantiated. A deficiency is being issued per California Code of Regulations, Title 22. On August 8, 2025, the Department received a complaint with allegation of personal rights violation which contributed to R1 death/questionable death. The Department investigation consisted of review of facility and other records, observations, and interviews with pertinent individuals. R1 relocated from facility on July 18th , 2025, and subsequently passed away on August 1st , 2025. The sacral pressure injury was identified as condition contributing to R1 death. Based on the investigation, there is preponderance of evidence to support that facility staff neglected R1. Specifically, it was found that from around June 13th 2025, until July 16th, 2025, staff did not provide R1 with care and services to meet their needs. During this time, R1 sustained an unstageable pressure injury and subsequently passed away. The allegation that facility staff neglect contributed to R1 death/questionable death is substantiated. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to the Administrator Arjan Marlo Banez.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 56-AS-20250808100431

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 2, 2026

87468.2 Additional Personal Rights of Residents in Privately Operate Facilities (a) In addition to the rights listed... (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient... This requirement was not met as evidenced by: Based upon review of facility and other records, observations, and interviews with pertinent individuals, licensee failed to ensure that R1 was provided with care, supervision, and services required. As a result, R1 sustained an unstageable pressure injury while at facility. This violation posed an immediate health and saftey risk to residents in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee stated to read over regulation with facility staff and not allow facility staff to care for any residents with prohibited health conditions.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Feb 2, 2026

87615 Prohibited Health Conditions (a) ) Persons who require health services for or have a health condition...(1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not comply with section cited above by not ensuring that R1 was relocated due to pressure injury and or notified licensing department, which poses an immediate health, saftey and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee stated to read over regulation and to not accept residents with prohibited health care conditions without care by licensed care professional and/or notifying licensing department. POC will be cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 2, 2026

87468.2 Additional Personal Rights of Residents in Privately Operate Facilities (a) In addition to the rights listed... (4) To care, supervision... This requirement was not met as evidenced by: From around June 13th 2025, until July 16th, 2025, R1 was not provided care and services to meet their needs. Records revealed that R1 needed care and assistance in ADLs, including incontinent care, as well as observation with history of skin condition or breakdown. Under the care of facility staff, R1 sustained an unstageable pressure injury, and subsequently passed away. This posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee stated to not admit any future residents with prohibited health conditions unless waiver is submitted to licensing department and care is provided by a licensed care professional.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 2, 2026

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... Based on observation and interviews, the licensee did not comply with section cited above by not ensuring R1's responsible party was notified of change of condition in R1, which poses an immediate health, saftey, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee stated to read over regulation with facility staff on Observation of the Resident. POC will be cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(5) · Plan of correction due date: Feb 2, 2026

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them... (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not comply with section cited above by not ensuring R1 received care from an appropriate skilled professional and having staff care for R1 instead, which poses an immediate health, saftey, and personal rights risk to residents in care,the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee stated to read over regulation with facility staff and acknowledged having only appropriate skilled professionals care for residents with prohibited/restricted health care conditions. POC will be cleared.

Type of visit: Case Management - Deficiencies

On 01/30/2026 Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit in regards to complaint 56-AS-20250808100431. LPA met with facility staff and explained purpose of visit. During investigation of complaint, it was revealed Staff #1 (S1) was not associated to facility until 9/25/2025, however, S1 became employed several months prior to association. Additionally, Resident #1 (R1) care plan was not complete. Based on the observations made during today’s visit, deficencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) (LIC809D) was discussed and provided to Administrator Arjan Marlo Banez. Along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Jan 30, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Feb 2, 2026

87355(e)(1) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall...facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: Based on observations and record review, the Administrator did not comply with section cited above by not obtaining a criminal record clearance for Staff #1 (S1) prior to working at the facility, which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee stated to understand regulation and will ensure facility staff are background cleared prior to working at the facility. POC will be cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87467(a) · Plan of correction due date: Feb 2, 2026

87467 Resident Participation in Decisionmaking (a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident... Based on observation and record review, the licensee did not comply with section cited above by not ensuring R1 had a completed care plan while living at the facility, which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee stated to understand regulation and moving forward will ensure each resident's care plan will be completed. POC will be cleared.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver Nenita Gorospe and was granted entry to the facility. The facility is a (5) bedroom (2) bathroom home and, with a kitchen/dining area, living room, attach garage. LPA was accompanied by Caregiver to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed Resident #4 (R4) to have a full bed rail and not currently on hospice care services or doctor ordered. Deficiency will be issued. LPA observed water temperature to test at 120 degrees Fahrenheit. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. LPA observed toilet bowl bleach cleaner located underneath Resident #1 (R1) and Resident #2 (R2) bathroom sink unlocked accessible to residents in care. Deficiency will be issued. There was a designated office for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (4) resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed incomplete Appraisal/Needs and Services Plan for Resident #3 (R3) and Resident #4 (R4). Deficiency will be issued. Additionally, LPA observed no Reappraisal forms for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4). Deficiency will be issued. LPA reviewed (4) resident medications. LPA Hernandez observed for Resident #2 (R2), Resident #4 (R4) and Resident #5 (R5) no documentation for daily medications in Medication Administration Record (MAR). Deficiency will be issued. Additionally for R2, R4 and R5 PRN medication was not documented correctly. Deficiency will be issued. LPA also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. No issues observed. Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), (LIC809-D) was discussed and provided to Administrator Rea Badillo Alim. Along with copy of appeal rights.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with caregiver Rosendo Lara and was granted entry to the facility. The facility is a (5) bedroom (2) bathroom home and, with a kitchen/dining area, living room, attach garage. LPA was accompanied by Administrator Rea Badillo Alim to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated space for client/staff files. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: Based on record review 1 out 2 dementia residents did not have an updated Physician Report. LPA also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. Based on the observations made during today’s visit, one (1) Type A deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) (LIC809D) was discussed and provided to Administrator Rea Badillo Alim. Along with the appeal rights.the state’s words, verbatim · CDSS document, Mar 5, 2024