Eleonor's Place 4

Allegation investigated: Facility staff is not adequately assisting resident with toileting care. Facility staff are not managing medication as needed.

Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit for the purpose of initiating the complaint investigation into the above allegations. LPA met with Administrator (Admin) Mark Cruz and stated the reason for the visit. During the course of the investigation, LPA successfully interviewed two out of five residents and five out of five staff. LPA also obtained copies of the Resident and staff roster, Face Sheet, Physician's Report, Admission Agreement, care plan, ISP, and progress notes. The investigation revealed the following: Regarding the allegation, Facility staff is not adequately assisting resident with toileting care, it was reported that Resident #1's (R1) commode is not being emptied in a timely manner and the two bathrooms available are often occupied. LPA observed R1's room and observed that the commode had not been emptied at the time of the visit. LPA observed that the two bathrooms are not always occupied. Two out of two residents denied the allegation and four out of five staff stated the commode is cleaned on a regular basis and the bathrooms are available for use. Continued on LIC9099-C. Unsubstantiated Regarding the allegation, Facility staff are not managing medication as needed, it was reported that R1 was not informed about medication being delivered. Based on record review, R1 is ambulatory, independent with activities of daily living, and manages their own medications. Based on the interviews, two out of two residents stated their medications are administered timely. Four out of five staff interviewed stated the medication is provided to R1 upon receipt. Based on interviews, there was a delivery error of the pharmacy at the facility. Based on the observations made, interviews conducted, and the records reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: Facility staff is not adequately assisting resident with toileting care and Facility staff are not managing medication as needed are deemed Unsubstantiated. An exit interview was conducted with Administrator Mark Cruz, and a copy of this report was provided at the exit. Based on evidence gathered through interviews and document review, the preponderance of evidence has been met, therefore, the above allegation is found to be Substantiated. Violations are being cited per Title 22 of California Code of Regulations. See LIC 9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator and a copy of this LIC9099-D, along with a copy of the Appeal Rights were left at the facility.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 22-AS-20260630144428

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Jul 22, 2026

(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. (cont.) This requirement was not met as evidenced by: Resident's piece of clothing was mixed up and found in another resident's closet.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: Licensee will train all staff to separate all articles of clothing accordingly during laundry services and provide proof of correction to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA was greeted and granted entry by Caregiver Medano Romuar after introducing self and stating the reason for the visit. Administrator (Admin) Mark Cruz arrived on premise shortly after to assist with the inspection. Admin has a valid certificate expiring on December 2, 2026 and March 28, 2026 for Daryll Avendano. The following was observed during the inspection: This is a single story property located in a residential neighborhood comprised of five resident bedrooms, one private staff bedroom, and two resident bathrooms. Facility operates within the conditions and limitations specified on the license. There are six residents in care, one of which is receiving hospice service. LPA along with Admin toured the facility. The facility is clean and in good repair. All common areas were inspected including the attached two car garage. LPA observed evidence of an inflatable mattress in the garage utilized by Staff #4 (S4) which was removed immediately. LPA inspected all resident bedrooms. The resident bedrooms' were appropriately furnished, beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage space for each residents' personal belongings were observed. All bathrooms were found be in compliance, clean, and operational. Slip resistant mats were available. The hot water temperature in the bathrooms measured at 108.8 and 107.0 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. The exit gate is operational, and there were sufficient seating and shading in the patio area. There are no bodies of water on premise. The fire extinguisher was mounted, charged, and serviced on March 5, 2025. Admin confirmed that the fire extinguisher will be serviced tomorrow. The auditory devices and smoke/carbon monoxide detectors were tested and operational. Facility maintains emergency food and water. LPA reviewed six of six resident and four personnel files in which no discrepancies were found. Medications were audited for three out of six residents. No discrepancies were found with medication administration and documentation. Staff training is up-to-date including CPR/First Aid. Present staff are background cleared and associated to the facility. Disaster drills are conducted quarterly and documented as required, however facility did not conduct drills accounting various emergency scenarios. Based on the observations made during today's visit, no deficiencies are being cited. Advisory notes are being issued. An exit interview was conducted with Administrator Mark Cruz, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Mar 4, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff locked resident out of the facility. Staff spoke to resident in an inappropriate manner. Staff did not respect resident’s right to privacy.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of initiating the complaint investigation into the above allegations. LPA met with Administrator (Admin) Mark Cruz and stated the reason for the visit. During the course of the investigation, LPA successfully interviewed two out of five residents and three out of four staff. LPA also obtained the following records for review: Resident Roster, Personnel Report Summary, Face Sheets, Physician's Reports, Admission Agreement, and care plans. The investigation revealed the following: Regarding the allegation, Staff locked resident out of facility, it is alleged that Resident #1 (R1) was locked out of the facility by Staff #1 (S1) on November 18, 2025 approximately 12:00am. Based on the observation of the exterior perimeter of the facility, there are no surveillance cameras and on the front door to verify said incident. One out of two residents confirmed the allegation while none of the three staff were present when R1 had allegedly been locked out. LPA was unable to obtain S1's statement during a phone interview after multiple attempts. Unsubstantiated Regarding the allegation, Staff spoke to resident in an inappropriate manner, it was alleged Staff #2 (S2) had yelled at R1 after obtaining knowledge R1 sneaking in an unidentified male visitor in the evening. The two staff that were present during the meeting did not corroborate with the allegation indicating R1 was yelled at S2. Regarding the allegation, Staff did not respect resident's right to privacy, it is alleged that staff follows and watches R1 outside compromising their personal freedom. Based on the review of records, R1 is ambulatory and independent with their activities of daily living and is able to leave the facility unassisted per the physician's report dated September 3, 2024. Based on the interviews, three out of three staff denied following R1 while one out of two residents confirmed the allegation. The three staff indicated that all staff maintains routine visual checks on R1 when they go outside to smoke in the late evening to ensure they remain safe and comfortable. Based on the observation made, interviews which were conducted, and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: Staff locked resident out of facility, Staff spoke to resident in an inappropriate manner, and staff did not respect resident's right to privacy are deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Mark Cruz, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 22-AS-20251217161706

Allegation investigated: Licensee did not maintain facility in good repair.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the allegations listed above. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Mark Ryan Cruz was notified of the visit and arrived later to assist. During the facility visit, LPA accompanied by staff conducted a tour of the physical plant and inspected the facility's shared bathroom. Resident records were requested and reviewed on site and copies obtained. Multiple resident interviews and three staff interviews were conducted while on the premises. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Licensee did not maintain facility in good repair, the following has been concluded: During the observation and review of the facility's physical plant, it was evidenced that one of the two shared bathrooms used to provide toileting care to the residents had a loose wall-mounted thermostatic handle resulting in difficulty adjusting the water temperature reliably. There are also two faucets in the same bathroom, one of which is observed to be rotating loosely around its axis, also making water dispensation adjustments difficult. Additionally, water is being dispensed at a temperature of 130F, creating a risk of scalding. This additional deficiency is documented in a separate inspection report form LIC809. Based on the observations and interviews conducted during the present visit, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the allegation is Substantiated. See LIC9099D for cited deficiency per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative. CONTINUED FROM FORM LIC9099-A Regarding the allegation that Licensee did not ensure resident received contracted service, the following has been concluded: Based on a review of admission agreements for the residents currently living at the facility, it was determined that Cable television was not explicitly listed as part of the basic services being provided upon admission and payment of the residence fee. A separate clause lists the provision of "Additional cable services" as "THIRD PARTY SERVICES: Provided at market rate and billed directly to the Resident or the authorized representative" with the clause verified to have been initialed by the resident upon signature of the admission agreement. Additionally, staff and resident interviews evidenced that there had been no additional charge to the residents related to cable service. As a result, the allegation is determined to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with the facility and a copy of the report was provided to a facility representative. CONTINUED FROM FORM LIC9099-A Regarding the allegation that Staff did not assist resident with care needs in a timely manner, the following has been concluded: It was alleged that resident beddings were not being replaced in a timely manner by facility staff. During a tour of the physical plant, LPA verified all beds to be appropriately equipped with clean linens. Resident interviews and staff interviews conducted appear to indicate there are frequent checks and linen replacement on a weekly basis. Based on the evidence gathered during the visit, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred. An exit interview was conducted with the facility and a copy of the report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 22-AS-20250609144753

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 14, 2025

Per CCR Section 87303(a) Maintenance and Operation: "(a) The facility shall be clean, safe, sanitary and in good repair at all times". This requirement is not met as evidenced by: Based on observation, two thermostatic faucets in one of the shared bathrooms were found to be loose and difficult to adjust. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Jun 13, 2025

Plan of correction: Licensee initiated measures to repair the defective faucets during the present visit. If the repair attempt is unsuccessful, a plumbing vendor will be contracted in coordination with the facility's landlord.

Type of visit: Case Management - Deficiencies

On June 13, 2025, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a case management visit for in order to issue a citation for a deficiency observed during the investigation of complaint 22-AS-20250609144753 and unrelated to the allegations listed on the complaint. During the tour of the physical plant, LPA measured the temperature of the water dispensed by two faucets used for personal grooming in a shared bathroom along with the temperature of the water dispensed by the wall-mounted shower in the same bathroom. Water was measured to be delivered at 130F at all three outlets. A type A deficiency is issued during the visit. Facility staff was able to adjust the water heater during the visit. A second measurement was made in two separate bathrooms and showed the adjusted water temperature to be approximately 112F in both locations. Deficiency cleared during the visit. Based on the observation made during today's visit, one type A deficiency is being cited. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Jun 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jun 14, 2025

Per CCR 87303(2): "Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F". This requirement is not met as evidenced by: Based on observation conducted during the visit, water temperature was measured in three separate locations to be provided at a temperature in excess of 130F which constitutes an immediate risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Jun 13, 2025

Plan of correction: Licensee adjusted the water heater during the visit and LPA was able to verify water was dispensed at 112F. Deficiency cleared during the visit.

Allegation investigated: Staff did not ensure that resident was transported to medical appointments.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the allegation listed above. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Mark Ryan Cruz was notified of the visit via telephone and arrived later to assist. During the present visit, LPA accompanied by staff conducted a tour of the facility's physical plant. Records for all six currently admitted residents were requested and obtained. One staff interview, three resident interviews and an additional witness interview were conducted during the visit. Regarding the allegation that Staff did not ensure that resident was transported to medical appointments, the following has been concluded: Based on records reviewed and interviews conducted, a majority of statements made denied any issues in meeting resident health needs due to a lack of available transportation. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Multiple residents interviewed indicated that their preferred mode of transportation to scheduled medical and dental appointments was provided by their family or responsible parties, but also stated that alternative modes of transportation such as paramedics and non-emergency ambulance were also utilized to meet health needs. One resident stated that they had been experiencing difficulty getting on demand transportation through means provided by the local transportation authority, but the evidence gathered could not confirm whether these issues had an impact on getting their health needs met. The facility's admission agreement was reviewed and found to include "Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services" as part of the basic services being provided. A Technical Assistance Advisory Note reminding licensee of the requirements in the California Code of Regulations was provided during the visit. Based on the evidence gathered, the allegation listed above is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 22-AS-20250414153002

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Mark Cruz was notified of the visit via telephone and arrived later to assist with the visit. There are currently six residents in care, three of which are receiving hospice care. LPA observed residents relaxing in their respective bedrooms and in the facility's common living areas, as well as having lunch in the facility's dining room. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage. The facility has four private bedrooms and one shared room, in addition to a room for use by staff which is confirmed to be locked and inaccessible to residents during the visit. There are two full bathrooms throughout the facility. Bedrooms appeared clean and sanitary. Three beds are equipped with full rails and one with half rails. Physician orders and/or hospice plan of care for the postural supports reviewed and confirmed to be present. LPA observed all the resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathroom are equipped with grab bars and slip mats. Hot water temperature measured at 119F in two separate bathrooms with faucets used for personal grooming. LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items are stored in a secure drawer. Fire extinguishers are charged and mounted, with up-to-date maintenance documented on the attached tags. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a secure closet. The attached garage is inaccessible to residents and is used for storage. Cleaning supplies are stored securely. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 LPA and facility staff toured the outside of the facility. LPA observed an shaded outdoor seating area with furniture for resident use. The perimeter gate on one side of the property is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises. Facility does not utilize locked perimeters or delayed egress. LPA reviewed six resident records which included all necessary components. LPA reviewed resident medication records and prescription orders for all residents with no discrepancies observed. There are no bedridden residents present on the premises. LPA reviewed four staff records which were found to be complete. Training and CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Mar 5, 2025

Allegation investigated: Staff did not ensure the back gate self-latches Facility is in disrepair

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation and deliver findings into the investigation of the two allegations listed above. LPA was greeted and granted entry by caregiving staff after stating the reason for the visit. Administrator Mark Cruz was notified and arrived later to assist with the visit. LPA accompanied by administrator conducted a tour of the facility's physical plant, both indoor and outdoors. Administrator demonstrated the current operation of the gate located on the evacuation route on the left side of the house. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff did not ensure the back gate self-latches, the following has been concluded: Based on observation made during the tour of the physical plant, the facility's administrator was able to demonstrate on multiple occasions that the self-latching mechanism for the outside gate was operating properly. A spring ensures that the gate is pulled back close whenever it is opened and the latch engages adequately. Administrator indicated that the slab under the gate had recently shifted lightly but current operations do not appear to be affected. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Regarding the allegation that Facility is in disrepair, LPA was unable to identify any major items of maintenance appearing to be neglected in the facility's physical plant. There is an apparent sprinkler system installed but facility staff confirms that it is not operational at this time. An application might be submitted to the Fire Marshall in the future. Existing sprinkler heads do not show any signs of disrepair. There are loose wires on the right side of the house, however they are observed to be connected to a satellite dish that is not currently in use and do not represent a safety issue for the residents in care. Outlet covers are also verified to be present throughout the premises. The allegation is also found to be Unsubstantiated, meaning that although the allegation may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation did or did not occur. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Mar 18, 2024 · control 22-AS-20240311121916

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting a Required Annual Inspection. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrator Mark Cruz was contacted by phone and arrived later to assist with the visit. During the inspection, LPA and administrator conducted a tour of the physical plant and observed the following: The facility is a one-story home with five resident bedrooms, one staff room and two bathrooms. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets and an adequate additional supply is present. The backyard has a shaded sitting area and the route of egress is free of clutter and obstructions. There are currently six residents in care at the facility, four of which are receiving hospice care. Bathrooms faucets and toilets were operational. Water temperature tested close to 120F which prompted LPA to provide a consultation on water temperatures. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Combined smoke and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with up-to-date maintenance. Sharps were observed locked in a drawer in the kitchen. LPA observed cleaning supplies to be stored in a locked cabinet under the kitchen sink and in the laundry area, however laundry detergent was observed to be accessible. A lock was installed on the laundry room's door during the visit. The medication central storage was also observed to be secure. LPA reviewed six resident files and four staff files and interviewed one staff present. Based on the observations made during today’s inspection, four type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. One Technical Advisory and one Technical Violation advisory notes are also being issued to the licensee. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Mar 18, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.