Eclc - Wake Forest Villa

Type of visit: Case Management - Licensee Initiated

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced visit to verify facility closure, and to ensure no clients were receiving care and supervision at the facility. LPA was greeted by Licensee Angelita David. Licensee informed LPA that last client's day on site was on June 30, 2025. On today's date, LPA conducted a tour of the physical plant. LPA observed no signs of residents or the facility in operation. Licensee stated she has converted the facility into her private residence. LPA requested the facility license as it is part of the closure process, and the license was surrendered during the visit. LPA informed the licensee of the licensing procedure for future facility operation if desired. Licensee has decided to permanently close the facility at this time. The Department will proceed with the closure as of June 29, 2026. An exit interview was conducted with staff representative and a copy of the report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Jun 29, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Administrator (AD) Angelita David. AD's certificate expires on 7/16/2025. The facility is a single story building with an approved fire clearance of six non-ambulatory residents and a hospice waiver for three. The facility currently has no residents in care. LPA along with AD toured the facility at 9:15 AM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 3 resident bedrooms, living room, dining room, 3 staff rooms, and kitchen as well as 5 bathrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. LPA toured the kitchen. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Outside grounds were toured. Walkways around the home were clear of hazards. First aid kit contained all required items including tweezers, scissors and thermometer. There is shaded outdoor seating for residents. Exit gates are unlocked and operational. LPA observed the emergency food supply. LPA reviewed 2 staff files and 4 former resident files. LPA interviewed AD regarding the reason for no residents. AD planned to close the business but will now have a family member assume day to day activities. Continued on LIC809-C dated 07/08/2025 Four out of four former residents were not provided proper eviction notices. LPA advised AD to inform the LPA and/or the Department prior to accepting new residents. Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Jul 8, 2025

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 11/19/2024, LPA Mason arrived at the facility for the purpose of amending deficiencies cited on 10/30/2024 as part of the Department's investigation into complaint #22-AS-20241021103457. LPA was greeted and granted entry by facility staff and met with Angelita David, Licensee. LPA amended the LIC809-D to update the section cited to: 87468.1(a)(15). LPA stated to staff that the plan of correction would not change. LPA observed no resident mail in the facility staff room during the inspection. LPA cleared the deficiency during the visit. A copy of this report, deficiency page, appeal rights and clear letter were provided to the facility.the state’s words, verbatim · CDSS document, Nov 19, 2024

Allegation investigated: Facility is withholding resident's mail.

This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to initiate and conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by facility staff. LPA met with Angelita David, Administrator and explained the nature of the inspection. The department received a complaint on 10/21/2024 stating Facility is withholding resident's mail. During the investigation, the department interviewed the Administrator (AD), staff and residents in care. On 10/30/2024 LPA conducted a visit to the facility. LPA obtained copies of personnel reports, resident roster, photos of resident's physician's report, admission agreement,resident mail and photos of text messages. (continued on LIC9099-C) Substantiated (continued from LIC9099) LPA conducted interviews with Residents (R2, R3 and R4). Based on these interviews, LPA was unable to determine if the facility is withholding other R2, R3 or R4's mail. LPA conducted interviews with R1 and AD. R1 and AD both stated R1 is able to manage their own mail. R1 and AD both confirmed that R1 sent AD a text message on August 23, 2024 stating "as of this date I would like all my mail given to me". During the facility tour, LPA observed a box of documents in the Administrator's bedroom. LPA observed unopened checks, medical reports, invoices and other documents addressed to R1 in the box in the Administrator's room. Based on record review, LPA determined the facility is not R1's conservator or responsible party and R1 does not have any diagnoses that would indicate they are unable to manage their own mail. R1's most recent physician's report indicates that R1 is able to manage their own cash resources as well. Per Title 22 Regulation 87468.2(a)(1) "To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups." Based on interviews conducted, records reviewed and observations made, the facility did not comply with the regulation stated above due to the observation of R1's mail in the AD's room after R1 had requested AD give them all of their mail. The preponderance of evidence standard has been met. The allegation is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Oct 30, 2024 · control 22-AS-20241021103457

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(15) · Plan of correction due date: Nov 26, 2024

(15) To send and receive unopened correspondence in a prompt manner. This licensee did not comply with the section cited above due to R1's mail being observed in the AD's bedroom after R1 requested all their mail be given to them on 8/23/24.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: LPA observed facility staff return all of R1's mail during the visit on 10/30/2024. LPA observed no resident mail in facility staff room on 11/19/2024. LPA cleared the deficiency during the visit.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of issuing deficiencies and to follow-up on the Plan of Corrections (POCs) in connection to complaint #22-AS-20240930123543. On October 10, 2024, two Type B citations were issued with the due date of October 18, 2024. The POCs were received via email on October 18, 2024 at 11:36am. Based on the review of the POCs with Administrator (Admin) Angelita David and her family members, the POCs require a revision. The new deadline to complete the POCs with the supporting documents is due on October 31, 2024. Based on the interviews conducted during the complaint investigation mentioned above, three out of the six staff confirmed medications were being prepared in advance. LPA has reached the decision that Administrator Angelita David is not in good health and incapable of performing all tasks and therefore will be relieved from her duties as an administrator based on the following areas observed on October 3, 2024 and October 10, 2024: 1. medication preparation, storing, and dispensing 2. Admin's lack of judgment and inability to retain information 3. Admin's physical illness that may pose a threat to the well-being of the residents Therefore, based on LPA's observations and interviews which were conducted, the preponderance of evidence standard has been met. Deficiencies are being cited on the attached LIC9099D as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. An exit interview was conducted with Administrator Angelita David, Volunteers Maria Berli David, La Purisima Chang, and Caregiver Bernardito David, and a copy of this report including the LIC9099D, and the appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Oct 24, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Oct 31, 2024

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by: Based on observation and interviews in three out of six staff confirmed medications were being prepared in advance dispensed in a paper cup which poses a potential Health and Safety Risk to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: Administrator stated that medications will be prepared for that day effective today and caregivers will receive hands-on medication training as well as provide proof of staff training and an Acknowledgement of Understanding of the said regulation to LPA via email by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Nov 27, 2024

87411 Personnel Requirements – General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks… Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement was not met as evidenced by: Based on observations, interviews, and record review, Administrator Angelita David is unable to fulfill their duties/tasks as an administrator.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: Administrator has stated under the presence of 3 family members that she will relieve her duties as an administrator after reaching a decision from one of the following options: employing a new adminstrator, moving forward with a CHOW, or closing the facility. Administrator will provide their decision to LPA in writing by POC due date.

Allegation investigated: Caregiver did not meet resident's needs. Caregiver did not treat resident with dignity and respect.

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of continuing the investigation and delivering the findings into the above allegations. LPA was greeted and allowed entry by Caregiver Juanita Sotta. Administrator Angelita David arrived approximately an hour later to assist with the investigation. On October 3, 2024, LPA initiated the complaint investigation. During the course of the investigation, LPA interviewed a total of six staff and five residents. Out of the five resident interviews, LPA was unable to qualify one resident’s statement due to their medical condition. During the visit, copies of documentations were obtained for review which includes the Face sheets, Physician’s Reports, Needs and Services Plans, Admission Agreements for all residents, Medication Administration Records (MARs) for September 2024, Staffs’ Face Sheets, and other pertinent records. On today's date, LPA interviewed additional staff and audited the medications for all residents. Substantiated Regarding the allegation, Caregiver did not meet the resident’s needs, the investigation revealed the following: Per interviews conducted with the residents, one out of the four residents reported facility not arranging their medical transportation. Based on the review of the needs and services plans of the resident, facility is responsible for arranging medical care transportation. Additionally, four out of the six staff corroborated with the allegation indicating that the resident has been arranging their own transportation recently. LPA conducted an audit of the medications for all residents. Based on the review, LPA observed medication errors in five out of five residents. Administrator acknowledged all errors during the audit. Regarding the allegation, Caregiver did not treat the resident with dignity and respect. Although four out of the five residents did not corroborate with the allegation, Staff #1 (S1) confirmed yelling at Resident #1 (R1) during the interview. In addition, six out of the six staff confirmed S1 avoiding and ignoring the resident. Therefore, based on LPA's interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Caregiver did not meet the resident’s needs and Caregiver did not treat resident with dignity and respect are deemed SUBSTANTIATED. Deficiencies are being cited as per the Title 22, Division 6, Chapter 8 of California Code of Regulations. See the attached LIC9099D. An exit interview was conducted with Administrator Angelita David and Caregiver Bernardito David, and a copy of this report including the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 22-AS-20240930123543

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(2)&(6) · Plan of correction due date: Oct 18, 2024

Type B: 87464 Basic Services (f) Basic services shall at a minimum include: (2) Safe and healthful living accommodations and services… & (6) Arrangements to meet health needs, including arranging transportation… This requirement was not met as evidenced by: Based on interviews and record review, facility did not follow the needs and services plan by arranging transportation for one resident and making medication errors in five out of the five residents which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Administrator stated that they will adhere to the needs and services plan of all residents and to submit a plan indicating the roles and responsibilities of each staff involved in medication prepping and passing. In addition, administrator will submit an Acknowledgement of Understanding of this said regulation as well as 87465 Incidental Medical and Dental Care to LPA via email by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 18, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews, S1 acknowledged yelling at the resident and six out of the six staff confirmed S1 avoid/ignoring resident which poses a potential Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Administrator stated that the conflict will be resolved with resident and will submit an Acknowledgement of Understanding of the said regulation to LPA via email by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Juanita Sotto, Caregiver. During today’s visit, LPA met with Angelita David, Administrator. The facility is a single story building with an approved fire clearance of six non-ambulatory residents and a hospice waiver for three. The facility currently has a census of six residents in care. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in three of three resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 114.6 and 116.6 degrees Fahrenheit and all smoke detectors were operational. Both fire extinguishers are charged and were purchased on April 5, 2024. The facility has not conducted a fire/disaster drill this year. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications appear to be being given as prescribed. LPA conducted a complete review of staff and resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on July 16, 2025. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Angelita David, Administrator and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D and Appeal Rights.the state’s words, verbatim · CDSS document, Jul 18, 2024