Garfield Villas

Allegation investigated: Staff did not meet residents' diapering care needs in a timely manner resulting in injuries.

This is an amended version of the original report created on 11/17/25. Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to conduct Resident interviews and to review Resident files. LPA met with Claudia Carrillo and discussed the purpose of today’s visit. Rosalie Sandoval arrived at approximately 9:30 A.M.. During the 11/17/25 visit, LPA obtained a copy of the resident and staff rosters, interviewed Staff #1 (S-1) through Staff #3 (S-3) and conducted a tour of this facility. During today’s visit, LPA interviewed Resident #1 (R-1) through Resident #9 (R-9) and reviewed Resident #1 (R-1) through Resident #10 (R-10) files and obtained relevant documentation. LPA was unable to interview Resident #10 (R-10) as R-10 was not present at the time of this visit. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Staff did not meet residents' diapering care needs in a timely manner resulting in injuries. It has been alleged that residents in rooms 8, 21 and 28 are not receiving incontinence care which has caused the residents to sustain rashes. Per staff interviews, there are no residents at this facility that require incontinence care and are independent in their continence needs. Interviewed staff indicated that this facility does not have room numbers 8, 21 nor 28 at this facility. Resident interviews and reviewed documentation revealed that they (residents) are independent with their toileting needs (do not require assistance nor incontinent care). Interviews and documentation do not corroborate this allegation. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report and appeal were provided to Rosalie Sandoval.the state’s words, verbatim · CDSS document, Nov 17, 2025 · control 28-AS-20251113125920

Type of visit: Annual/Random

On 06/05/25, LPA Vaid conducted partial annual at the facility due to insufficient time. Today LPA Vaid will complete the remaining domains of the CARE tool. Met with Stephanie Cordova-med aid and Administrator Rosalie Sandoval explained the reason for the visit. LPA Vaid and staff Cordova toured the facility and did not observe any health and safety concerns. The facility is licensed to serve 40 non-ambulatory residents ages 60 and over with an approved hospice waiver for 5 residents. The facility is a 2-story building located in a residential area, it has 20 shared rooms, an activity room, a dining room with kitchenette, a medication room, a cover balcony on the second floor, and a back outdoor area. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for S-1 through Staff #4 (S1-S4). Staff have their Health Screening and Tuberculosis Screening on file. First Aid /CPR Certifications and clearance are observed. Incidental M&D: The medications are centrally stored in the medication room and in bubble packs and/or original containers. Medications are administered as prescribed by the Physicians’ order. Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #4(R-4). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Functional Capabilities, ALW assessment and Resident Rights were observed. Clients with SHN: Facility does not use manual restraints at this facility. No deficiencies were noted on today’s visit. Exit interview was conducted with Rosalie Sandoval administrator and a copy of this report, were provided.the state’s words, verbatim · CDSS document, Jun 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sanjay Vaid conducted an unannounced annual visit to the facility. LPA met with Rosalie Sandoval administrator and explained the reason for the visit. Obtained copy of staff and resident rosters. Toured the facility with med-aid Stephanie Cordova. The CARE tools were used to conduct the annual investigation for the facility. The facility is licensed to serve 40 non-ambulatory residents ages 60 and over with an approved hospice waiver for 5 residents. The facility is a 2-story building located in a residential area, it has 20 shared rooms, an activity room, a dining room with kitchenette, a medication room, a cover balcony on the second floor, and a back outdoor area. Facility does not have a kitchen and per the plan of operation they receive food prepared in their sister facility for all resident meals. LPA Vaid conducted a tour of the facility with Stephanie Cordova and observed the following: Dining area is clean. Kitchenette's drawers/cabinets were observed, cleaning supplies were observed in a cabinet with a lock and inaccessible to the residents. Activity room was observed. Four (4) resident rooms were observed, room #75, 78, 79 and 86. Each room has sufficient lighting, and required furniture and bedding supplies. A bathroom was observed in each bedroom and water temperature was tested, is within the required 105-120 degrees F. Outdoor area has shaded sitting areas. Last fire inspections were conducted March 2025. Last fire drill was conducted on 04/25/2025, earthquake drills was conducted 04/2025. Two (2) fire extinguishers were observed and last checked on 6/26/2024. A copy of liability insurance was obtained expires 06/04/2026. Due to shortage of time, the following Care Tools were completed: Infection Control, Operational Requirements, Physical Plant and Environment Safety, Staffing, Residents rights- Information, Planned Activities, Food Service, and Disaster Preparedness. No deficiencies were noted on today’s visit. Exit interview was conducted with Rosalie Sandoval administrator and a copy of this report, were provided.the state’s words, verbatim · CDSS document, Jun 5, 2025

Allegation investigated: Staff did not keep the facility free of bed bugs

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation for the allegation above. LPA met with administrator Rosalie Sandoval and the purpose of the visit was discussed. On todays visit, LPA conducted the following: LPA toured the physical plant that included resident rooms, Interviewed Staff #1-#4 (S1-S4), interviewed residents #2-5 (R2-R5) , Collected documents for pest control from the last 3 months, collected copies of documents from Resident #1 (R1s) File, and collected copies of the staff and resident roster. R1 was unavailable for interview. The investigation revealed the following: In regards to the allegation "Staff did not keep the facility free of bed bugs" it is alleged that R1's room and the facility has a bed bug issue not being addressed. (4) of (4) Staff interviewed denied the allegation. (4) of (4)... Continued on LIC 9099-C Unsubstantiated Residents interviewed could not corroborate the allegation. LPA observed rooms #86, #70, #78, #79 and #80. LPA did not observe any bed bugs. Residents interviewed stated they could not recall any issues of bed bugs in the facility. Staff interviewed stated that the facility has a contract for pest control services to be completed monthly. File review of the pest control invoices does not show any notes or observations of bed bugs in the facility. R1's file does not show any notes or documentation of having bed bugs. Based on interviews, file review, and observations conducted, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 28-AS-20241031164014

Type of visit: Annual/Random

Licensing Program Analyst(s)(LPA) Sanjay Vaid conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Rosalie Sandoval administrator and explained the reason for the visit. Licensing Program Analyst(LPA) Sanjay Vaid conducted continuation of the annual from 05/23/24. During the last visit the following care tools utilized were : Operational Requirements, Physical Plant and Environment, Staffing, Residents rights information, Planned Activities and Food Services. On todays visit the following care tools utilized were: Infection Control, Personal Records training, Resident Rec-Incident Reports, Disaster Preparedness, Resident with SHN and Accidental M&D. The facility is licensed to serve 40 non-ambulatory residents ages 60 and over with an approved hospice waiver for 5 residents. The facility is a 2-story building located in a residential area, it has 20 shared rooms, an activity room, a dining room with kitchenette, a medication room, a cover balcony in the second floor, and a back outdoor area. Facility does not have a kitchen and per the plan of operation they receive food prepared in their sister facility for all resident meals. Medication room was observed inaccessible to the residents. Medication was reviewed for 5 residents. LPA reviewed 5 resident/staff files and interviewed 5 residents and 4 staff. Last fire inspections was conducted on 4/02/24. Last fire drill was conducted on 4/10/23, earthquake drill was conducted on 04/25/24. Administrators certificate #6012456740 is in process of renewal, post mark for renewal sent is 12/14/23. No deficiencies were noted on today’s visit. Exit interview was conducted with Rosalie Sandoval administrator and a copy of this report, was provided.the state’s words, verbatim · CDSS document, May 30, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst(s)(LPA) Sanjay Vaid conducted an unannounced annual visit to the facility at 12:40 pm. LPA met with Rosalie Sandoval administrator and explained the reason for the visit. Obtained copy of staff and resident rosters. The CARE tools were used to conduct the annual investigation for the facility. The facility is licensed to serve 40 non-ambulatory residents ages 60 and over with an approved hospice waiver for 5 residents. The facility is a 2-story building located in a residential area, it has 20 shared rooms, an activity room, a dining room with kitchenette, a medication room, a cover balcony in the second floor, and a back outdoor area. Facility does not have a kitchen and per the plan of operation they receive food prepared in their sister facility for all resident meals. LPA Vaid conducted a tour of the facility with Rosalie Sandoval and observed the following: Dining area is clean. Kitchenette's drawers/cabinets were observed, cleaning supplies were observed in a cabinet with a lock and inaccessible to the residents. Activity room was observed. Five resident rooms were observed, room #70, 75, 87, 88, 89. Each room has sufficient lighting, and required furniture and bedding supplies. A bathroom was observed in each bedroom and water temperature was tested between 108.9 – 116.4 degrees F., which is within the required 105-120 degrees F. Outdoor area has shaded sitting areas. Last fire inspections were conducted on 04/02/24. Last fire drill was conducted on 04/10/24, earthquake drills was conducted on 04/25/24. Fire Extinguishers were observed and last checked on 6/30/23. Copy of Surety Bond was examined and has coverage up to $8000.00 per incident dated 01/15/2016. A copy of liability insurance was obtained expires 05/08/2025. Due to shortage of time,the staff and residents were not interviewed. The following Care Tools were completed: Operational Requirements, Physical Plant and Environment Safety, Staffing, Residents rights- Information, Planned Activities, and Food Service. No deficiencies were noted on today’s visit. Exit interview was conducted with Rosalie Sandoval administrator and a copy of this report, were provided.the state’s words, verbatim · CDSS document, May 23, 2024

Allegation investigated: Staff are prohibiting resident from having visitors indoors.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit regarding the above allegation. LPA met with Naylet Velazquez, Supervisor and explained the reason for the visit. Shortly after, the Administrator, Rosalie Sandoval arrived and assisted LPA with the visit. During the initial visit conducted on 02/01/2023, LPA Pena obtained copies of the Resident & Staff Rosters, reviewed Resident #1 (R1's) files such as: Face sheet, Admission's Agreement, Physician's Report, and Appraisal, incident reports, police report which involved S2 and W2 (PR# 23000396 / dated 01/02/2023), interviewed Staff #1 (S1) - Staff #4 (S4), and Resident #1 (R1) - Resident #2 (R2). During today’s visit, LPA Pena obtained copies of the Resident & Staff Rosters, House Rules, Visitation Policy, Facility’s Visitation Practices and Incident Report (SIR/dated 01/05/2023). LPA reviewed Resident #1 (R1's) files such as: Face sheet, Admission's Agreement, Physician's Report, and Appraisal/Needs and Services Plan. LPA also reviewed PIN 22-28.1-ASC (issued 11/29/2022), interviewed Resident #3 (R3) - Resident #10 (R10) and re-interviewed Staff #1 (S1) - Staff #3 (S3). *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: “Staff are prohibiting resident from having visitors indoors.” It is alleged that a resident is not allowed to have visitors inside the facility. Interviews conducted with the staff denied the allegation and stated that they are aware of resident rights regarding visitation. Staff interviewed stated that facility allows indoor visits however, visitors are required to go through covid screening and wear a mask upon entering to protect the residents in the facility. Staff interviewed indicated that they did not restrict visitors of any residents nor require an appointment to visit. (4) of (4) staff interviewed indicated that R1’s family members refused to be screened nor follow the facility's visitation policy. Staff stated they still allowed R1's family members to come in and just asked them to follow covid guidelines. S1 stated that the visiting requirements were explained to R1. (9) out of (10) residents interviewed stated that they are allowed to have visitors indoors during visiting hours and the facility does not restrict their visitation rights. Residents indicated that the staff conducted covid screening, signing in and checking temperatures before letting visitors in. LPA observed the visiting policy posted on the door and is accessible to residents and families. LPA did not observe any documents or evidence in R1's file indicating that the facility is restricting visitation from certain individuals or family members. LPA reviewed documents such as facility's best practices for visitation and CCLD Provider Information Notice (PIN 22-28.1-ASC), issued on Nov 29, 2022 regarding best practices for visitation. Documents reviewed stated that licensees should follow the strictest requirements, encourage shorter indoor visits and longer outdoor visits and recommended screening for COVID-19 signs, symptoms, and exposure for visitors. Additionally, a well-fitting face mask was required for visitors at all times in indoor settings, regardless of vaccination status. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview and a copy of this report was provided to Rosalie Sandoval, Administrator.the state’s words, verbatim · CDSS document, Feb 8, 2024 · control 28-AS-20230126151309