Gene-Lyn Guest Home

Allegation investigated: Resident developed multiple pressure injuries due to neglect by staff Staff are not properly assisting resident with their dental needs

On 2/13/26, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to deliver complaint investigation findings. LPA Tamayo met with Licensee Magie Quirez (S1)and explained the purpose of the visit. Administrator, Grace Quirez(S2) , was not present during this visit. The following has been determined as it relates to the aforementioned allegation: Resident developed multiple pressure injuries due to neglect by staff Regarding the allegation “Resident developed multiple pressure injuries due to neglect by staff”, the investigation consisted of interviews and records review. Resident 1 (R1)’s Physicians Report (LIC 602) dated 5/23/24 it indicated R1 was non-ambulatory, had motor impairments due to right-sided weakness and they needed assistance from care staff “all the time”, they used a wheelchair, and they had mild confusion and disorientation. {Continued on 9099-C2} Substantiated {9099-C-2} The care plan for R1, written by Administrator Grace Quierez, noted that primary care staff will be instructed maintain proper medication, encourage resident for daily activities and range of motion, in addition to “Instruct facility staff and primary caregiver to observe patients’ skin during bathing and toileting”, and position pillows to prevent pressure and skin to skin contact. Per record review and interviews, a review of the Preplacement Appraisal dated 8/20/2023 for R1 indicates 2-person assist is needed for bathing, and toileting. Facility was unable to show they repositioned R1 on a regular basis and there was no plan in place to ensure residents are rotated and checked for developing pressure injuries. Medical records show R1’s wounds got worse overtime, and necessary medical attention was not obtained. R1’s primary cause of death is septic shock due to stage 4 pressure wounds. It was corroborated by S1, S3, and S4 that care staff did not notify the Licensee or Administrator when the pressure injuries were noticed nor did they activate 911. Facility did not ensure staff were properly trained in Pressure Injuries. Per interviews and record reviews, it was learned that S3 noticed R1’s pressure injuries on 08/26/2025 and attempted to clean the wounds themselves prior to notifying the Licensee on 8/28/25. S4 was also aware that R1 had developed pressure injuries prior to 8/28/25 Per, R1s Personal Rights for RCFE dated 08/26/2025, Gene-Lyn Guest Home, Inc. must provide continuous care and supervision and if there are any changes in R1’s physical, mental, emotional, and social functions, the facility must notify the resident’s family, physician, and other appropriate people. A hospital physician (W1) explained that the pressure injuries could have developed over the course of a few days, but not in a single day. This suggests that the injuries likely developed during R1’s residency at Gene-Lyn Guest Home, Inc. Interview with a Witness 2 (W2), revealed that upon R1’s hospitalization, R1 was found to have multiple pressure injuries. W2 stated that some gauze in R1’s lower back wound, they stated It “...seemed like someone was trying to clean the wound but was inexperienced”. A review of R1’s medical records obtained from the hospital confirmed the presence of multiple pressure injuries that had developed for “weeks” leading up to R1’s death on 9/1/25 and the primary cause of death was stage 4 pressure injury ulcers. Based on the above noted information, the allegation that a “Resident developed multiple pressure injuries due to neglect by staff” is substantiated. {Continued on 9099-C-3} {9099-C-3} The following has been determined as it relates to the aforementioned allegation: Staff are not properly assist residents with their dental needs Regarding the allegation “Staff are not properly assist resident with their dental needs”, the investigation consisted of interviews and records review. LPA Tamayo observed that R1’s Admission Agreement for RCFE dated 08/23/2023 indicates the facility will aid with Residents’ dental and medical care appointments and transportation for appointments. Records show Dental care visits were not provided for R1 in the last 12 months. The facility did not have records of daily dental care available for review. On 9/16/25, LPA Tamayo interviewed family member for another resident (R3), in which it was reported R3 was missing a lot of teeth, and they had more teeth at move in days prior. Per record review and interviews, the pre-admission appraisals dated 8/20/2023 indicated 1 person assist will be provided for oral care on a daily basis. Additionally, per R1's Personal Rights for RCFE dated 08/26/2025, Gene-Lyn Guest Home, Inc. must provide continuous care and supervision and if there are any changes in R1’s physical, mental, emotional, and social functions, the facility must notify the resident’s family, physician, and other appropriate people. Based on the above noted information, the allegation that staff are not properly assisting residents with their dental needs is substantiated. The care plan for R1 noted that primary care staff will be instructed to brush their teeth two times a day and maintain proper medication. Based on the above noted information, the allegation that “Staff are not properly assist resident with their dental needs” is substantiated. Based on the above noted information, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Feb 13, 2026 · control 27-AS-20250912154258

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 14, 2026

87411 Personnel Requirements - General (a) Facility personnel shall at all times be ... competent to provide the services necessary to meet resident needs. ... to ensure provision of personal assistance and care ... Based on Department investigation in which record review and interviews in which it was learned that R1 developed multiple pressure injuries due to neglect by staff. Licensee did not ensure R1 was seen by a physician for wounds and provided wound care at the facility. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2026

Plan of correction: POC: BY POC due date, licensee shall submit a plan to ensure 87411 is being met for all staffincluding trainings on repositioning and pressure wounds. POC shall be faxed by POC due date to 916-2634744.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Feb 14, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental careg … (1) The licensee ... assist in arranging ... medical and dental care ... This regulation was not met as evidence by: Based on Department investigation in which it was determined that staff are not properly assisting residents with theirmedical and dental needs, including ensuring R1 was seen by physician for . This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2026

Plan of correction: POC: BY POC due date, licensee shall submit a plan to ensure all residents obtain a medical and dental evaluation if they have not had one in the last 12 months or there is a need. POC shall be faxed by POC due date to 916-2634744.

Type of visit: Case Management - Deficiencies

On 2/13/26, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced for a case management deficiency visit. LPA Tamayo met with Licensee, Magie Quirez, and (S1) explained the purpose of the visit. The Administrator, Grace Quirez, was not present during this visit. Allegation: Resident did not receive timely medical attention During the course of a self reported incident, the Department found that a resident did not receive timely medical attention. Per Incident report dated 8/31/25 the Regional Office was notified that Alpha 1 was activated by the licensee on 8/28/25 for Resident 1 (R1), as they were sent to the Hospital on 8/28/25 due to swelling in the right side of R1’s face and “blisters burst the back of both legs”. A Death report for R1 was sent to the Regional Office by the Licensee on 9/4/25, in which it was indicating R1 died on 9/1/25 due to a bacterial infection. Per R1’s Death Certificate for R1, it was revealed that the primary cause of death was septic shock with Stage 4 pressure ulcers. On 9/4/25, LPA Tamayo called S1 and provided additional guidance regarding completing incident reports and death reports and requested the and the LIC 602 and LIC 624 for R1. Record review indicates that Resident 1 (R1) was not on Hospice. Hospital personnel (W1) explained that the pressure injuries could have developed over the course of a few days, but not in a single day. CONTINUED ON 809-C2 809-C2 This suggests that the injuries likely developed during R1’s residency at Gene-Lyn Guest Home, Inc. A review of R1’s medical records confirm the presence of multiple pressure injuries that had developed for “weeks” leading up to their death and the primary cause of death was stage 4 ulcers. It was also learned that gauze was found in R1’s wound located on the base of their spine. Hospital staff was interviewed, Witness 2 (W2) stated, “It seemed like someone was trying to clean the wound but was inexperienced”. Daily notes dated 8/26/25 indicate that the primary care staff (S3) noticed R1’s pressure injuries prior to obtaining medical attention for R1 on 8/28/25 and S2 attempted to clean the wounds themselves prior to notifying S1 on 8/28/25. Per staff interviews and record review it was discovered that staff were aware staff should call 911 for emergent situations but did not do so. Staff were also aware they cannot retain a resident with Stage 3 or 4 Pressure Injuries. During a facility visit on 8/21/26, LPA Tamayo provided guidance to S1 and S3 regarding the requirement for training staff to call 911 in an emergency and not delay care including not calling the administrator first. Based on information received from documentation and interviews, the following deems this allegation to be substantiated. A $500 immediate civil penalty applies. Allegation: Resident died due to severe pressure injuries sustained while in care. The Department conducted an investigation regarding the allegation “”Resident died due to severe pressure injuries sustained while in care”, the investigation consisted of record review and interviews. On 8/21/25 and 9/17/25, LPA observed administrator, Grace Quirez (S2), was not present at the facility. On 8/21/25, S1 stated that they are “always” at the facility and act as the main administrator. LPA Tamayo provided S1 and S3 with guidance around needing to call 911 and/or Hospice without any delay in the case a resident is in need of medical attention. Additionally, LPA provided S1 with guidance around needing to create an updated appraisal for residents when there is a change of condition or after 12 months from the last appraisal date, which ever comes first. CONTINUED ON 809-C3 809-C3 The care plan for R1, written by Administrator Grace Quierez, noted that primary care staff will be instructed maintain proper medication, encourage resident for daily activities and range of motion, in addition to “Instruct facility staff and primary caregiver to observe patients’ skin during bathing and toileting”, and position pillows to prevent pressure and skin to skin contact. On 8/31/2025, RO received an incident report informing R1 had right face swelling, burst blisters on “the back of both legs”. On 9/4/2025, The RO received a Death Report informing R1 passed away at the hospital from “MRSA” and “prior to death, resident has a swelling on her right face and had blisters burst in the back of both legs”; Date of death is 9/1/2025. Medical records state that R1 had a stage four Pressure Ulcer for “months” leading up to their death and the primary cause of death for R1 was septic shock with stage 4 pressure injuries. Hospital personnel, W1, explained that the pressure injuries could have developed over the course of a few days, but not in a single day. This suggests that the injuries likely developed during R1’s residency at Gene-Lyn Guest Home, Inc. Staff was aware staff should call 911 for emergent situations and the facility cannot retain a resident with Stage 3 or 4 Pressure Injuries. Based on information received from documentation and interviews, the following deems this allegation to be substantiated. A $500 immediate civil penalty applies. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. The above deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(e) · Plan of correction due date: Feb 14, 2026

87463 Reappraisals (e) The licensee shall immediately ... bring any significant change in condition ... to the attention of the appropriate licensed medical professional ... Documentation... This regulation was not met as evidence by: Based on record review and interviews, Licensee did not ensure R1 was seen by a licensed skilled professional timely. R1 did not receive timely medical attention when they developed pressure injuries prior to going into septic shock, which was their primary cause of death. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2026

Plan of correction: POC: BY POC due date, licensee shall submit a plan toensure all residents have the needed dental and medical POC shall be faxed by POC due date to 916-2634744.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87615(a)(1) · Plan of correction due date: Feb 14, 2026

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition ... shall not be admitted or retained in a residential care facility for the elderly:(1) Stage 3 and 4 pressure injuries. Based on Department investigation in which record review and interviews in which it was learned that R1 developed multiple pressure injuries due to neglect by staff. Licensee did not ensure R1 was seen by a physician for wounds and provided wound care at the facility. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2026

Plan of correction: POC: BY POC due date, licensee shall POC: BY POC due date, licensee shall submit a plan to train all staff via a third party vendor regarding pressure wounds. POC shall be faxed by POC due date to 916-2634744.

Allegation investigated: Licensee did not ensure that resident's records were readily available as necessary. Staff cannot communicate due to language barrier.

Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to complete and close up the complaint investigation for the allegations listed above. LPA Cynthia Tamayo met with facility Licensee, Magie Quirez and explained the purpose of the visit. It was alleged Licensee did not ensure that resident's records were readily available as necessary. Based on the interviews and cord reviews obtained during the investigation process, the allegations have been corroborated. On 8/13/2025, the local fire department responded to a 911 call made by Resident 1's (R1's) visiting family members (P1, P2, and P3), due to R1 "not being responsive". R1 moved into the facility on 8/10/25. When emergency personnel requested resident records, the records were not immediately available. Records were provided when licensee (S1) arrived to the facility a five to ten minutes after emergency personnel arrived, at which point the requested records were provided. Interviews with witnesses corroborate resident records were locked and the licensee (S1) provided the documents when they arrived to after Sacrament Metro Fire Department (SMFD) had arrived. Continued on 9099-D Substantiated Interviews and record review confirm R1 did not have a POLST, only an advanced directive. It was alleged Staff cannot communicate due to language barrier. Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated. LPA interviewed S2 and S3, whom where working on 8/13/25. Staff were not able to communicate fluently in English. When asked about resident history and care needs, staff where unable to provided complete and accurate responses. Witness interviews corroborate S3 and S2 were not able to give medical history, report on R1's condition, or baseline of R1 to emergency personnel. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation that Licensee did not ensure that resident's records were readily available as necessary is substantiated. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation that staff cannot communicate due to language barrier is substantiated. Two deficiencies were cited per California Code of Regulations, TITLE 22, which can be found on LIC 9099-D. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 17, 2025 · control 27-AS-20250814112509

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Sep 24, 2025

87506( (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by a delay in providing resident records to emergency personnel when requested. This poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: Licensee will review regulation and submit a statment of understanding to the department by 9/24/2025 to cynthia.tamayo@dss.ca.gov. Licensee will ensure resident records are complete upon admission and are accessible to staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Sep 24, 2025

7411 Personnel Requirements - General (a) Facility personnel shall at all times be ... competent to provide the services necessary to meet resident needs. ... to ensure provision of personal assistance and care as required in Section 87608... This requirement is not met as evidenced by staff's inability to communicate effectivly especially in emergency situations. This poses a potential health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: Licensee will review regulation and submit a statment of understanding to the department by 9/24/2025 to cynthia.atamayo@dss.ca.gov. Licensee they will train staff on communication and emergency procedures.

Type of visit: Required - 1 Year

On 8/21/2025, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a Required - 1 Year visit. LPA met with licensee, Magie Quirez, S1 and explained the purpose of the visit. An entrance interview was conducted. Administrator Certificate Number 7021127740 for Grace Nicole Quierez is #7021127740 and expires 12/9/2025. The facility is approved for age range 60 and over. Licensed to serve up to 6 no ambulatory residents. Hospice waiver on file for 2 residents. The current census is 5. There are currently no residents on hospice. LPA toured the physical plant was conducted with S1 to ensure residents’ health and safety and the facility is in compliance with Title 22 regulations. The following was observed: KITCHEN: Appliances and fixtures were clean and functional. The facility had ample supply of perishable and non-perishable food. Refrigerator temperature was at 45 degrees F and freezer temperature was at 0 degrees F. Knives and other sharps are locked inaccessible in a drawer. Kitchen and house cleaning supplies are stored in a locked cabinet located under the sink. Water temperature was tested and both measured at 110.4 degrees F. Resident Bennie Davenport (R1) administers their own insulin medication. LPA observed insulin medication is properly stored in a lock box in the refrigerator. Continued on 809-C COMMON AREAS: Common areas include the Living Room and Dining Room. All furniture was observed to be clean and in good condition with enough seating for six residents . There was space to accommodate both indoor and outdoor activities. LPA noted an Activity Calendar and activity storage in the entrance bulletin board. One (1) fire extinguisher was observed throughout the common area and was last serviced on 10/2024. Combination smoke detectors and carbon monoxide detectors were working and operational. EXTERIOR: Exterior passageways were clean and clear of any obstructions. Outdoor furniture observed to be in good condition. Clients are supervised at all times when they are outside. BEDROOMS: LPA inspected facility bedrooms. The facility has 5 total client bedrooms. All bedrooms were observed to contain furniture, bedding and linens within regulation. Extra linens are stored in the hallway cabinet. Client bedrooms had no visible hazards observed. Resident in room #3 stated they prefer sleeping on a recliner over a bed. S1 stated son requested recliner for R1 upon admission. There is no staff bedroom. LPA reviewed regulation with S1 regarding the requirement to have wake staff at all times. BATHROOMS: All bathrooms were observed to be clean and sanitary, and supplied with paper and hygiene products. Water temperature was tested and both measured at 110 degrees F. MEDICATION REVIEW: LPA reviewed medications which are centrally stored in a locked cabinet in the hallway. All medications were stored and administered in compliance with regulation. RECORD REVIEW: LPA reviewed five (5) resident file records. Resident records were reviewed for, but not limited to care plans, physician's report, and admissions agreement. Resident files reviewed contained all required documents. LPA reviewed three (3) staff records during today's visit. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All staff records reviewed were in compliance at the time of the visit. continued on 809-C INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility's infection control plan as well as the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are within regulation. Both documents were observed to be complete and recently updated. Personal Protection Equipment (PPE) and extra emergency supplies, including emergency food and water, are stored in the garage. LPA reviewed reporting requirements with S1. S1 stated they understood and will follow reporting requirements. The following documents were collected during this visit: (1) LIC 610E Emergency Disaster Plan (2) Proof of Current Liability Insurance (3) LIC 309 Administrator Organization As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted with S1, and a copy of these LIC 809 reports were provided to the facility.the state’s words, verbatim · CDSS document, Aug 21, 2025

Type of visit: Required - 1 Year

On 8/23/2024, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a Required - 1 Year visit. LPA met with Licensee Magie Quierez and explained the purpose of the visit. Administrator certification expires on 12/9/2025. The facility is licensed to serve up to 6 non-ambulatory residents. Hospice approved for 2. Current census is 5. LPA toured the facility with Magie Quierez. LPA toured the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 111.9*F which was within the required range of 105-120*F. The temperature inside the facility measured at 77*F which was within the required range of 68-85*F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. LPA requested resident and staff files for review. LPA reviewed (3) staff files and (3) resident files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following forms and documents were requested to be submitted within 15 days: LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Copy of Administrator Certificate, LIC 610 Emergency Disaster Plan and Proof of Current Liability Insurance. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed. An exit interview was conducted, and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Aug 23, 2024

Allegation investigated: Facility staff hit resident

Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 10/3/2023 to conclude the investigation of the above allegation and to deliver the findings. LPA met with facility staff Jennylyn Pulido and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on information obtained, it was determined that there is not a preponderance of evidence to prove that facility staff hit residents. Based on staff interviews, staff S1 and S2 denied hitting R1 or any residents. Additionally, R1’s mother stated that she believes R1 should be placed in a mental institution. Moreover, it was learned that there were no markings or bruises in the area where R1 stated they were hit. As a result of the investigation, LPA finds the allegation above to be 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 occurred. An exit interview was conducted, and a copy of the report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 3, 2023 · control 27-AS-20230921081601