Escondido Senior Living

Type of visit: Required - 1 Year

On 11/07/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA met with Jessica Playa, Executive Director. The facility has an approved hospice waiver for (10) with (24) residents currently receiving hospice services, and an approved fire clearance for (10) bedridden residents, with currently (4) bed bound residents in care. There is total of (7) residents receiving home health services. The facility was observed to be clean with the passageways being free of any obstructions. The medications, chemicals and sharps were observed to be locked an inaccessible to residents in care. The fire extinguishers were last serviced on 03/19/25. The emergency disaster drills are being conducted on a quarterly basis with the last drill being on 10/27/25. The hot water was tested and was in within regulatory limits ranging from 105.1-114.6 in assisted living and 105.3-108.1 in memory care. The smoke and carbon monoxide detectors were tested and found to be operable. A records review was conducted, the facility annual fees were observed to have been paid, and for the governing body to be in good standing. The resident files were observed to have medical assessments and, and completed admissions agreements. The staff files reviewed were observed to have criminal record clearance and to be associated to the facility. The staff files reviewed were observed to have been completed initial and ongoing training, however there was an insufficient number of staff to have a staff with valid Cardio Pulmonary Resuscitation certification on the premises at all times. deficiency cited. Due to the facility having more residents receiving services in their care than approved for a citation is also being issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8), on the attached 809D. There are no guns or ammunition on the premises. An exit interview was conducted where a copy of this report 809C, 809D, and appeal rights was reviewed and provided to Jessica Playa, Executive Director.the state’s words, verbatim · CDSS document, Nov 7, 2025

Allegation investigated: Staff did not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation for the allegation listed above. LPA met with Jessica Playa, Executive Director and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, and the investigation consisted of observations, interviews and records review. On 03/19/25 Community Care Licensing received a complaint alleging that staff did not safeguard resident's personal belongings. It was alleged that on or around January 25, 2025 Resident #1 (R1)s dentures were lost as they could not be located in R1s room, or on their person. It was further alleged that the dentures were lost by a facility staff, and that the dentures would be replaced, and to provide the bill. Per an interview with Resident Care Coordinator Shawna Emery it is believed that the dentures may have accidentally been thrown inside the trash by one of the facility staff, as the dentures were allegedly placed inside a popcorn bag. Per Shawna the trash receptacles were searched but nothing was found. LPA conducted additional interviews that corroborated that previous administration did state that the facility would replace the lost Substantiated dentures, if the dentures were lost by one of the facility staff. Per an interview with Executive Director Jessica Playa and Shawna Emery, Resident Care Coordinator Staff #1 (S1) admitted that they may have misplaced R1s dentures. Additionally, LPA conducted a records review and the resident handbook states "we cannot be responsible for any items brought into the facility that is not listed on the resident personal property and values form". LPA reviewed R1s personal property and values sheet dated 9/22/24, and it does note for R1 to have partial dentures. Further LPA reviewed correspondence an email dated 2/12/25 which included an invoice stating the replacement dentures would cost $4,480.00. The next email reviewed dated 2/19/25 shows that the facility was going to conduct an internal investigation, and there is no further written correspondence to date in regards to the matter. Based on observation, interview and records review the allegation of Staff did not safeguard resident's personal belongings is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of this report, 9099D, appeal rights and LIC811-Confidential names list was reviewed and provided to Jessica Playa, Executive Director.the state’s words, verbatim · CDSS document, Mar 28, 2025 · control 18-AS-20250319111801

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(2) · Plan of correction due date: Apr 11, 2025

87218 (a)The licensee shall ensure an adequate theft and loss program as specified in H&S code 1569.153. (2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The Licensee shall be resumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts....This requirement is not met as evidenced by: R1 dentures being lost by facility staff. This poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 28, 2025

Plan of correction: The licensee agrees to replace in the form of a credit to R1s account for the amount of the dentures quoted on bill provided on 2/12/25 for $4,480.00 Proof of POC is to be submitted to the department by 5pm on the due date (4/11/25) indicated.

Allegation investigated: Facility staff left residents in soiled clothing. Facility staff do not keep the facility free of odors.

Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Sales Director, Carline Callaghan, where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observations, interviews with staff members and residents, and a review of records. On January 23, 2024, Community Care Licensing received a complaint alleging that the facility staff left residents in soiled clothing and that the facility staff do not keep the facility free of odors. It was alleged that a resident was left in soiled diapers and that Resident (1) R1’s wheelchair was soaked in urine. Executive Director Shaun McGuirk indicated that R1 refused to have their diapers or bedding changed. It was also advised that R1 constantly refused showers and change of clothes. Information obtained from additional staff members corroborated the information that R1 refuses to shower or allow staff to change their bedding. It was advised that staff document R1’s refusals on a log. Staff did stated that R1’s room has an odor due to the refusal of assistance, but staff clean and sanitize the room once a week and more frequently as on a need for service basis. Unsubstantiated Information obtained from interview with R1 corroborated that they refuse to be showered and allow staff to change their bedding. R1 denied that there are odors coming from their room. It was further advised that R1 does not have any issues or concerns. Information from additional witness corroborated the information that they are aware of R1’s refusals to be showered and change their bedding. During a visit, LPA conducted a room tour of R1’s room and observed and no issues were observed. LPA also observed R1’s refusals on logs dated from the month of November 2023, December 2023 and January 2024 . Based on information obtained through interviews, review of documents, and observation, this agency has investigated the complaint alleging facility staff left residents in soiled clothing and facility staff do not keep the facility free of odors. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was discussed with and provided to Sales Director, Carline Callaghan.the state’s words, verbatim · CDSS document, Feb 13, 2025 · control 18-AS-20240123164701

Allegation investigated: Residents incontinence care needs are not being met Staff chemically restrained resident Facility has an infestation of bed bugs

On 2/6/2025, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to the facility to deliver complaint investigation findings regarding the allegations listed above. LPA met with Executive Director (ED), Shaun McGuirk who was informed of the purpose of the visit. Regarding the allegation, “Residents incontinence care needs are not being met” it was alleged facility staff are double briefing Resident 1 (R1), Resident 2 (R2) and Resident 3 (R3) and it is not safe. R1 was interviewed and reported they experience bladder leakage and a medical professional recommended they add an incontinent pad to their brief to protect them against any leaks. R1 reported they have since requested for staff to place an incontinent pad inside their brief to protect them against leaks. R1 reported they have not experienced skin breakdown or any negative effects by adding a pad to their brief. R2 was interviewed and reported they receive incontinent care in a timely manner. R2 was unable to recall if staff have double briefed them but reported not having knowledge staff are double briefing any of the residents. Unsubstantiated R3 declined to be interviewed. Three (3) staff were interviewed, and all reported they have never observed residents wear two (2) briefs at a time and had knowledge some residents request to add an incontinent pad to their brief. A witness interview was conducted with R1 and R2’s physician who reported they have never observed any residents at the facility wear two (2) briefs or report they are forced/encouraged to double brief. R1 and R2’s physician added they are not aware double briefing causes any medical issues or increases the risk of skin breakdown. R1 and R2’s physician reported for the past five (5) years they have never observed or suspected any of their patients residing in the facility to be neglected by facility staff. Regarding the allegation, “Staff chemically restrained resident” it was alleged on an unknown date, facility staff chemically restrained Resident 4 (R4) by administering a specific supplement after breakfast. R4 declined to be interviewed. LPA reviewed R4’s Physician's Report (LIC 602A) dated 5/23/22 noting R4 has the capacity to communicate their needs and administer their own Pro-Re-Nata medications. LPA also reviewed R4’s Medication Administration Record (MAR) for December 2023, which listed the supplement in question to be administered as needed at bedtime. One (1) of three (3) staff interviewed reported being authorized to dispense medications, refuted the allegation, and reported the supplement in question is only dispensed at night and at the request of R4. Two (2) of three (3) staff interviewed reported they have never suspected facility staff are over medicating residents or not following medication orders. Regarding the allegation, “Facility has an infestation of bed bugs” it was alleged there is a bed bug infestation in R1’s room and the facility has not obtained professional pest control services. It was further alleged the facility attempted to treat the affected areas themselves but has been unsuccessful. R1 was interviewed and reported in the past, they experienced bed bugs in their room. R1 added they reported sights of bed bugs to the executive director who resolved the issue. R1 reported their room underwent treatment twice and the facility worked diligently to eliminate the bed bugs. The facility reported Western Exterminator Company (WEC) completed an initial inspection of the building on 7/27/2023. An agreement was signed between the facility and WEC on 8/4/2023 and WEC began ongoing treatments on 8/15/2023. LPA reviewed the facility’s Heat Treatments log which noted R1’s room received a heat treatment on 8/22/23, 11/13/23, and 11/27/23. LPA reviewed a proposal dated 12/8/2023, prepared by the Western Exterminator Company (WEC) addressed to the facility. The service specifications noted bed bug heat treatment to various infested resident rooms including R1’s. An interview with Maintenance Director (MD), Roy Hayes revealed the facility owns a heater to treat bed bugs and will immediately treat any areas reported to have bed bug activity in addition to canine bed bug inspections and chemical spray/heat treatments provided by WEC. MD Hayes also added the facility purchased new mattresses and protectors to replace the ones with bed bugs. LPA also reviewed receipts from Amazon (dated 12/5/2023) and Mattress Firm (dated 12/8/2023) noting the purchase of 14 mattresses and mattress protectors. ED McGuirk was interviewed and reported the facility purchased the same exact bed bug heater WEC uses, which allows the facility to immediately treat the affected areas while waiting for Western to become available to conduct an on-site inspection. Although the facility has experienced issues with bed bugs, they are taking appropriate steps to help mitigate the problem. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was reviewe and provided to ED McGuirk.the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 18-AS-20231206091208

Allegation investigated: Illegal eviction

On 11/25/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation noted above. LPA met with Cherryrose Gajo, Resident Services Director,and Shaun McGuirk, Executive Director. where LPA explained the purpose of the visit and the elements of the allegations. The allegation was investigated and the investigation consisted of observations, interviews and records review. On 4/6/23 Community Care Licensing received a complaint alleging an illegal eviction of Resident #1 (R1). It was alleged that a text message was sent on 04/02/23 stating that R1 needed to be moved out by the end of the week due to R1 no longer being safe or appropriate for assisted living. LPA conducted a records review of narrative charting which revealed that R1 began to exhibit a change of condition on or around 03/19/23. Further review revealed that on 03/21/23 R1s responsible party was contacted and informed that R1 “should be in a secure environment and that currently memory care was full”. On 04/02/24 after facility staff consulted with a doctor it was recommended for R1 to be seen at the emergency room for an evaluation due Unsubstantiated to increased behaviors of wandering and confusion, the narrative charting revealed that the recommendation was not followed. LPA conducted interviews, per the interviews conducted with the Resident Services Director, Cherryrose Gajo, the facility implemented a 1:1 Caregiver for R1 and for their safety. Per a records review conducted, revealed that alternative placement was being looked into in or around March 2023 for R1. Per an additional records review (text message), conducted the facility suggested a resource to assist with relocating R1. R1 was unable to be interviewed as they moved out of the facility on 04/17/23. Based on interviews and records review the allegation of illegal eviction is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted and a copy of this report, LIC811-Confidential names list was provided to Cherryrose Gajo, Resident Services Director, and Shaun McGuirk, Executive Director.the state’s words, verbatim · CDSS document, Nov 25, 2024 · control 18-AS-20230406105616

Type of visit: Required - 1 Year

On November 06, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Shaun McGuirk. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for (143) Elderly Adults and is currently operating at a capacity of (113) Elderly Adults (740). LPA Mixson toured the facility along with the Administrator and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. Additionally, there were no bodies of water on the premises. The facility is a multi-level building located at 1351 E. Washington Ave Escondido, CA. 92027. Physical Plant: The facility phone number is (760) 741-3055 and it is operable. LPA Mixson observed a sampling of the residents’ living units, and each was equipped with required furniture as per Title 22. LPA Mixson inspected a sample of the facility restrooms, and the hot water temperature tested within regulations. The restrooms sampled were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the PUB 475. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit. Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility heating system and other appliances were operable currently at the time of this visit. Administrator informed LPA there were safety lights for night throughout the facility. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. Care & Supervision/Administration: Adequate staff are present for the supervision of resident in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses a current administrator’s certificate with an expiration date of 12/23/2024. Records Reviewed and Resident/Staff Files: LPA reviewed five staff files and reviewed the facility's staff schedule. The staff files reviewed have criminal clearance and updated First Aid Certification. Five resident files were reviewed and possessed required paperwork. Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards. Drills are conducted quarterly and one per shift. Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures. There were deficiencies observed and/or cited per Title 22, Division 6 of the California Code of Regulations at this time. An exit interview was conducted where a copy of this report was discussed and given to Administrator, Shaun McGuirk.the state’s words, verbatim · CDSS document, Nov 6, 2024

Allegation investigated: Resident eloped from facility due to lack of supervision.

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced complaint investigation visit. LPA Silveira introduced themselves, met with Resident Services Director Cherryrose Gajo and disclosed the purpose of the visit. The purpose of the visit was to deliver complaint findings for the above-mentioned allegation. The Department’s investigation consisted of interviews with staff and outside sources, as well as a facility records review. On 06/14/21 it was alleged that Resident #1 (R1) eloped from the facility due to lack of supervision. A review of R1’s Physician’s Report dated 05/14/21 revealed that R1 was diagnosed with a major neurocognitive impairment and was not able to leave the facility unassisted. An interview with the Executive Director (ED) on 06/21/21 revealed that R1 had left the facility without staff knowledge. The ED personally searched for R1, found them at a store nearby and brought them back to the facility. (CONTINUED ON LIC 809-C) Substantiated (CONTINUED FROM LIC 809) An interview with an outside source also revealed that R1 eloped from the facility a second time, approximately one week after the first elopement, found by law enforcement, confused and lost in a different city. Based on interviews and records review, the allegation that a resident eloped from the facility due to lack of supervision was determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Pursuant to the California Code of Regulations, Title 22, Division 6, a deficiency is cited on the attached LIC 9099-D. An exit interview was conducted and a copy of this report, along with the Licensee Rights (LIC 9058 03/22) were provided to Cherryrose, whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Aug 28, 2024 · control 08-AS-20210614164509

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(D) · Plan of correction due date: Sep 28, 2024

HSC 1569.312(d) Basic services requirements: Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure supervision was provided to 1 out of 101 residents [R1], which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Resident Services Director will initiate an in-service elopment training will all staff by POC Due Date.

Type of visit: Required - 1 Year

On 12/12/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene met with Executive Director, Shaun McGuirk who was informed of the purpose of visit. LPA toured the Assisted Living and Memory Care Unit with Shaun McGuirk. The following was observed, reviewed, and inspected: The physical plant, in general, was in good repair and clean. The facility is operating in the capacity approved by Community Care Licensing (CCL). The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. LPA inspected a sample of resident bedrooms in the Assisted Living & Memory Care Unit. Resident bedrooms have the required bedding and furniture; such as clean mattresses, night stands, storage space, and sufficient lighting. Room temperatures were comfortable for residents in care. LPA inspected a sample of resident bathrooms; the bathroom appliances were operating in safe and sanitary conditions. LPA measured the hot water temperature in the sampled bathrooms, in which all bathroom sinks measured within regulation. Sampled bathrooms were equipped with non-skid surfaces and grab bars. Each resident is given a pendant to notify staff of any emergencies. LPA toured the kitchen and dining area. The facility was stocked with a 2-day supply of perishable and 7-day supply of non-perishable food items that were labeled appropriately. The facility had a menu posted and available for review. Dishes, glasses, and utensils were in good condition and stored in a healthful manner. LPA inspected the common areas. LPA observed several carbon monoxide alarms throughout the facility. Carbon monoxide & smoke detector were tested and functioning properly. Continue on LIC809-C Continued from LIC809. There was a locked and centralized storage area for medications, including refrigerated medications. Medications appeared to be dispensed and documented appropriately. The facility had a designated area for resident files and staff files. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There was adequate seating in the common areas and several activity rooms. LPA observed several activity posters. The facility was also equipped with a complete first aid kit as well as the first aid manual. LPA inspected the outdoor area of the facility. There was shaded area with seating. Overall, the facility was clean, in good repair, and operating in safe conditions for residents in care. All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Three #3 staff and #3 residents' records were reviewed. Three #3 staff and #3 residents were interviewed. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and a copy was provided to Shaun McGuirk.the state’s words, verbatim · CDSS document, Dec 12, 2023