Good Shepherd of Danville

Type of visit: Case Management - Other

On 4/22/2026 at 1:30PM, Licensing Program Analyst (LPA) A. Gomez conducted a case management visit while at the facility for Complaint 15-AS-20250825130104. LPA met with Administrator, Roche Castro and informed him the reason for visit. During visit, LPA requested S2 and S3's training records for 2025 as well as all unusual incident reports (UIRs) for R1. LPA waited for approximately 2 hours for the facility to produce/locate the requested records and they were unable to. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 22, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(c) · Plan of correction due date: May 19, 2026

(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement was not met as evidence by: Based on observation and interview the above requirement was not met by Facility not having the requested records upon demand which poses an immedite health risk to residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: By POC facility agrees to develop a filing system for all records and provide photos as well as documentation of what was implemented.

Type of visit: Required - 1 Year

On 9/5/2025 at 8:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Isigani Silvestre and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory of which 1 may be bedridden in room 2 only. LPA toured facility with Isigani Silvestre including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 5 bedrooms are occupied by the residents and 0 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 108.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last purchased on 3/28/2025. Emergency Disaster Plan was last posted on 3/1/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 6/15/2025. At 8:50 am, LPA reviewed 4 residents records. At 9:40 am/pm, LPA reviewed 2 staff records and 2 of 2 have current first aid training and 1 of 2 are associated to the facility. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: Resident records were incomplete S2 not trained and was observed providing care unsupervised Garage was converted to staff living quarters and it was not been approved/cleared LPA observed that S2 is was not associated to the facility Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 10/01/2025: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Current Administrator’s Certificate All forms to update Administrator The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 5, 2025

Type of visit: Case Management - Health Checks

On 8/26/2025 at 3:30 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 1 complaint. LPAs met with Administrator, Isigani Silvestre Morgan and explained the purpose of the visit. LPA toured facility including but not limited to bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at degrees 99.7 F in residents shared bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked in kitchen cabinet. Smoke detectors and Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last purchased on 3/28/25. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. LPA cited for Hot water temperature not being in range 105-120 F. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 26, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Aug 29, 2025

(e) Water supplies... maintained as follows:(2) Faucets...temperature ...of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not as evidence by Based on observation the above requirement was not met by the shared bathrooms hot water measuring at 99.7 degrees F which poses an immedite health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2025

Plan of correction: By POC facility agrees to adjust the hot water to be within range and notify CCLD.

Type of visit: Case Management - Other

On 8/12/2025 at 8:30AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit to deliver an Amended Report for Complaint 15-AS-20240910163010. LPA met with Administrator,Isagani Silvestre and informed him the reason for visit. During visit, LPA delivered the amended report for complaint 15-AS-20240910163010. Caregiver Cynthia Candell approved to sign todays report due to Administrator needing to leave. No deficiencies are being cited on this date. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 12, 2025

Allegation investigated: Staff not changing residents in timely manner Staff neglecting resident resulting in pressure injuries Staff not responding to resident calling for help in a timely manner Facility does not provide privacy to residents in care Staff verbally abusing resident

***This is an amended report*** On 8/12/25 at 8:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver amended findings for the above allegation. LPA met with Administrator, Isagani Silvestre and explained the purpose of the visit. During course of the investigation, the Department conducted interviews with facility staff and witnesses. Documents including but not limited to: R1’s medical records, care notes, photos of resident, and admission agreements were collected and reviewed. Report continues on LIC9099-C Substantiated pg 2 On the allegations Staff not changing residents in timely manner, Staff neglecting resident resulting in pressure injuries, and Staff not responding to resident calling for help in a timely manner the following information was gathered: On 9/19/2024 a subpoena was served to Ace Home Health for R1’s medical records. The records revealed that between 1/23/2024 and 9/18/2024 R1 experienced worsening pressure injuries from lack of care and infrequent diaper changes by the facility staff. A care plan dated 10/31/2023 also stated that R1 is to have a call button and requires assistance with Activities of Daily Living (ADL’s). On 7/15/2024 W1 documented “R1 is left in soiled adult diapers during the night leading to severe excoriation of the skin and worsening of pressure injuries. Staff do not consistently respond to R1’s calls for assistance in a timely manner.” W1 also documented that they previously provided detailed instructions for staff to reposition R1 every 1-2 hours and promptly change R1’s diapers after incontinence; however, staff failed to consistently follow these instructions. W1 stated “I have repeatedly told the facility staff that R1 cannot sit in a wet diaper. It exacerbates R1’s skin injuries. They (staff) tell R1 that they will “get to it” but R1 ends up sitting in their waste for hours. R1 skin was bloody and raw on multiple occasions. W1 further explained that R1’s sacral pressure injury progressed to a stage 3 due to prolonged moisture exposure. W1 also noted that R1’s condition improves when wound care staff intervene, but the facility staff revert to neglectful care shortly after. R1 stated in interviews that sometimes they ring their call bell, and no staff come for hours. R1 states that once they had to wait so long that they started crying from sitting in their own waste. R1 states that staff tell them to “stop yelling because they are not an animal” R1 reported delays in assistance occurring particularly during night shifts and further described the pain they experience from sitting in their waste. Report Continues on LIC9099-C pg 3 S1 stated that they estimate that R1’s diapers are changed about 12-18 times a day, but that staff relies on R1 to tell staff when they need to be changed, and that staff do not proactively check on R1. S1 admitted that there could be delays stating “Sometimes we(staff) are busy with other residents so there might be a delay, but we(staff) eventually get to R1.” S1 confirmed that staff were aware of R1’s need for frequent diaper changes. In the interview with S2 they denied being informed of delays in R1 being changed and the fact that R1 had pressure injuries. However, when S2 was presented with documentation of R1’s notes detailing the instructions for R1 from the wound care they stated that, “This should have not happened if proper care was provided” S2 also denied knowing of the notes left for R1’s pressure injuries S3, S4, and S5 all had similar account when it came to the frequency of changing R1 stating that they are changed on average 10 times a day but did wait for R1 to request being changed. Staff also all alluded to R1 “requiring a lot of attention” and that they were not always able to assist immediately. Based on the interviews, medical records, wound care notes and photos it was found that delays in providing incontinence care directly contributed to the progression of R1’s pressure injuries. While staff claimed to respond “eventually” the lack of proactive care and reliance on R1 to request assistance demonstrates systemic neglect. The facility failed to ensure adequate staffing or adherence to care instructions, resulting in preventable harm to R1. Therefore, the allegations of Staff not changing residents in timely manner, Staff neglecting resident resulting in pressure injuries, and Staff not responding to resident calling for help in a timely manner are Substantiated. Report Continues on LIC9099-C pg 4 Amended On the allegation "Facility does not provide privacy to residents in care" during the course of the investigation it was found during interviews when CCLD comes to visit the staff will question the residents as to what they talked about with LPA's or Investigators. It was observed during the investigation that staff went to question R1 after speaking with the Investigator and that the Investigator had to advice staff that all interviews are confidential. Based on interviews and observations the allegation "Facility does not provide privacy to residents in care" is Substantiated. On the allegation of “Staff verbally abusing resident” 3/19/2025 LPA interviewed staff S2 and S6 on 3/19/202 that stated that they do not use profanity, call residents’ names, or yell at residents. S2 admitted to sometimes raising their voice when residents are yelling at them and making accusations that they deemed untrue. S2 emphasized that they do not yell at clients but that when clients are upset their tone elevates when trying to reason with residents. Therefore the allegation “Staff verbally abusing resident” is substantiated. ****A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.**** The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22. Substantiated findings will be reviewed for possible enhanced civil penalty assessment. Exit interview conducted and a copy of this report provided. ***Caregiver, Cynthia Caudill was approved by administrator to sign todays amended report*** On the allegations Staff physically abuses residents in care, and Staff does not allow residents access to phone interviews and observations were conducted. Throughout the course of the investigation it was found that the facility has a phone that is available to residents and that it is operational with service. It was observed on 3/19/2025 that the primary phone is located in the kitchen on the table and is cordless allowing residents to take the phone throughout the facility. During the investigation the LPA did not observe any residents with bruises or scratches. LPA interviewed staff and did not find any inclination of physical abuse. LPA was unable to interview additional residents due to their cognitive abilities. Based on interviews and observations the above allegations are Unsubstantiated. 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 UNSUBSTANTIATEDthe state’s words, verbatim · CDSS document, May 28, 2025 · control 15-AS-20240910163010

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: May 28, 2025

(b)In addition … the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry … from incontinence This requirement was not met as evidence by: Based on interviews and record review the facility did not comply with the section cited above by not keeping R1 clean and dry from incontinence which posed a potential health , and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment. Also facility agrees to maintain a log of all incotinence care provided with times and dates.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jun 4, 2025

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on interviews the facility did not comply with the section cited above by not having adequete staff to respond to residents needs in a timely manner which posed a potential health, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment. Facility also hired additional staff and agrees to send CCLD an updated staff schedule.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Jun 4, 2025

(a)In addition … residents …shall have all of the following personal rights:(1)To have …personal privacy in… communications…and meetings of resident and family groups. This requirement was not met as evidence by: Based on interviews and observation the facility did not comply with the section cited above by not providing privacy to residents which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jun 4, 2025

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, … This requirement was not met as evidence by: Based on interviews the facility did not comply with the section cited above by speaking inappropriately to residents which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Jun 4, 2025

(a) Residents... have all of the following rights: (6) To care, ...that meet their individual needs ... by staff that are...competency to meet their needs. This requirement was not met as evidence by: Based on interviews, record reviews, and observations the facility did not comply with the section cited above by not providing resident with competent care which resulted in pressure injuries which posed an immediate health, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment. Resident was sent out to hospital and returned once injuries got better.

Type of visit: Case Management - Other

On 05/28/2025 at 12:00 PM Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a Case Management visit while delivering findings for complaint 15-AS-20240910163010. LPA met with Backup Administrator, Merdith Castro and explained the reason for the visit. Upon arrival to the facility LPA observed S1 yelling at R1 in their room and LPA heard S1 state "thats not my job". S1 stopped yelling at R1 once R1 started yelling back and LPA announced themself. LPA then interviewed R1. During the course of the case management LPA reviewed the care plan for R1, interviewed S1, S2, S3, R1, and R2. LPA observed R1s careplan and found that it is not being followed. LPA found that S1 has previously spoken to residents inappropriately and it has not been reported to CCLD. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: Staff talking to resident inappropriately Staff not reporting incidents as required Staff not following residents care plan The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, May 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 4, 2025

(a) Each licensee shall furnish... reports...to, the following:(1)A written report shall be submitted ...within seven days(D)Any incident which threatens the welfare,... of any resident. This requirement was not met as evidence by: Based on interviews, and record reviews, the facility did not comply with the section cited above by not reporting incidents to CCLD as required ehich posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(1) · Plan of correction due date: Jun 4, 2025

(a)Residents of residential care facilities for the elderly shall have all of the following rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: Based on interviews, and observation, the staff did not comply with the section cited above by speaking inappropriately to residents which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment. Backup Administrator also states that they will start documenting and providing disciplinary action to staff as needed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jun 4, 2025

(f) Basic services shall at a minimum include:(4)Personal assistance.. as indicated in the pre-admission appraisal, with ...bathing ... This requirement was not met as evidence by: Based on interviews, and record reviews, the facility did not comply with the section cited above by not providing resident with bathing as specified in their care plan which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment.

Allegation investigated: Staff do not keep the facility clean, sanitary or free of trash Staff do not keep the facility free of rodents

On 11/06/24 at 10:30 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA spoke with Meridith Castro, Administrator via cell phone and met with Isagani Silvestre, Administrator present at the facility and explained the purpose of the visit. During the investigation LPA toured the facility and interviewed S1. S1 stated that she is working with the Sanitation Company to secure larger trash bins for the facility to ensure that the trash is managed properly. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Upon inspection LPA observed the facility to be neat, clean, tidy, and free of rodents and odors. Trash bins are located behind the fence along the side of the facility. LPA did not observe any exposed waste or feces, the trash was neatly stored in the bins. There was no excess waste observed. This agency has investigated the complaint alleging staff do not keep the facility clean, sanitary or free of trash and staff do not keep the facility free of rodents. We have found that the complaint was unsubstantiated. 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 allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 6, 2024 · control 15-AS-20241031123214

Type of visit: Case Management - Health Checks

On 9/12/2024 at 4:30 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Caregiver, Rommel Dimzon and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 110.5 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies on a weekly basis. Resident's medications were kept locked in the med room. Smoke detectors were observed. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last purchased on 4/8/2024. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 12, 2024

Type of visit: POC

On 9/12/2024, at 4:45PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Administrator, Merdith Castro, and explained the purpose of the visit. LPA conducted an annual inspection on 8/28/2024 and cited for the following deficiencies that has not been corrected. 87202(a)(2)- LPA observed resident in room 5 is still designated as bedridden and is not on hospice. Only room 2 is cleared for bedridden and facility is only cleared for 1 bedridden resident. ***Civil Penalty 100 day X 7 days= $700 Civil Penalties in the total amount of $700.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiencies are corrected. Exit interview conducted. A copy of this report, LIC421FC, and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Sep 16, 2024

(a) All facilities shall maintain a fire clearance approved by the city, county, ..., or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in having two bedridden residents and one of the residents is in room 5 that is not cleared for bedridden which poses an immediate health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 12, 2024

Plan of correction: Administrator agrees to put resident on hospice or find new placement for resident.

Type of visit: Required - 1 Year

On 8/28/2024 at 9:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with On-Call Nurse, Merdith Castro and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory of which 1 may be bedridden in room 2 only. Facility currently has 2 bedridden residents at the facility that are not in hospice. LPA toured facility with Caregiver, Rommel Dimzon including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 112.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last purchased on 4/08/2024. Emergency Disaster Plan was not posted or available for review. First aid kit was observed to be complete. Emergency disaster drill was last conducted in February but facility does not have any record. At 1:00pm, LPA reviewed 6 of 6 residents records. At 2:20pm, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 10:37AM LPA observed that medicine cabinet was unlocked and unsupervised. staff locked cabinet. At 10:77AM LPA observed that sharps drawer with knives and scissors was unlocked and unsupervised. staff locked cabinet. At 10:38AM LPA observed a bottle of Oil Eater on the clients bathroom counter. Staff removed solution. At 10:56AM LPA observed an individual who is not currently fingerprint cleared and has previously been marked "NOT ELIGIBLE" working at the facility unsupervised. Individual left facility. (Civil Penalty $100) At 1:13PM LPA observed R1 to be designated as BEDRIDDEN and in room 5. (Civil Penalty $500) At 3:20PM The facility did not have an Emergency Disaster plan available for review At 3:25PM The facility did not have disaster drill logs available for review but said they did a drill in February. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 9/10/2024: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Current Administrator’s Certificate ****Total Civil Penalties Assessed $600**** The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 28, 2024

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 8/13/2024 at 3:14 PM Licensing Program analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit relating to the complaint investigation done on 8/8/2024. LPA met with Caregiver, Rommel Dimzon and explained the purpose of the visit. On 8/1/2024 LPA came to the facility to conduct an initial 10-day complaint investigation and deliver findings. LPA met with Administrator, Maria Arceo. At the time of the visit LPA did not put who they met with on the top of the report. LPA amended the incorrect report and provided the facility with a copy of the amended report. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 13, 2024

Allegation investigated: Illegal eviction Staff did not provide adequate food service

On 8/1/2024 at 12:00 PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced deliver findings in regards to the allegations above. LPA met with Administrator, Maria Arceo and explained the purpose of the visit. During the investigation LPA obtained a copy of an eveiction letter that was issued illegaly. LPA also conducted interviews in regards to what residents eat at meals and found that meals were not adequate. Based on LPAs observations and interviews which were conducted and record reviews, 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. Substantiatedthe state’s words, verbatim · CDSS document, Aug 1, 2024 · control 15-AS-20240411112652

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Aug 2, 2024

(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) This requirement is not met as evidence by: Based on record review and interview the licensee did not comply with the regulation above by issuing an eviction letter because the resident was unhappy with the service which posed a personal rights violation to person in care.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: By POC date administrator agrees to review the regulation and notify CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(3) · Plan of correction due date: Aug 2, 2024

(f) Basic services shall at a minimum include:(3)Three nutritionally well-balanced meals...General Food Service Requirements. This requirement is not met as evidence by: Based on interviews and record review the licensee did not comply with the regulation above by not providing 3 balanced meals daily which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: Administrator has retrained staff on what a balanced meal is.

Allegation investigated: Facility is in disrepair Staff restrained resident in their bed

On 8/01/2024 at 12:00 a.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Administrator, Maria Arceo and explained the purpose of the visit. Census is 6. Administrator was unavailable to resign and Caregiver, Rommel Dimzon signed report. During the visit LPA obtained copies of the physicians reports/orders for R1, and R2. LPA also toured the facility and observed dryer in disrepair with out of order sign. Staff currently dries clothes outside on line. LPA received photos of R1 improperly restrained in bed with a red white and blue strap that was tied on bed bars. Based on LPAs observations and interviews which were conducted and record reviews, 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. Substantiatedthe state’s words, verbatim · CDSS document, Aug 1, 2024 · control 15-AS-20240723151436

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(2) · Plan of correction due date: Aug 2, 2024

(a) Based on the individual's preadmission appraisal,... Postural supports may be used under the following conditions.(2) Postural supports shall... permits quick release by the resident. This regulation is not met as evidence by: Based on interview and photos R1 was restrained in bed by a strap that was tied to bedrails which posed a potential health and personal rights risk to person in care.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: Administrator has requested the correct support from the doctor and has stopped using the improper restraint.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 9, 2024

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulation is not met as evidence by: Based on observation the dryer has an out of order sign and does not properly work. Staff has been hang drying clothes outside which poses a potental personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: By POC date administrator agrees to purchase a new dryer and notify CCLD.

Type of visit: Case Management - Health Checks

On 5/14/2024 at 9:25 AM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of an unusual incident report received 5/9/2024. LPA met with Caregiver, Hope Veneracion and explained the purpose of the visit. Administrator later arrived. On 5/9/2024 CCLD received an unusual incident report stating that a resident (R1) left the facility unassisted and was not found in their bedroom at approximately 8:30AM when facility staff went to get them ready for the day. Danville Police department was notified and a search for R1 was conducted. Administrator stated that resident disabled the door alarm and exited through kitchen door. Administrator also stated that facility staff (S2) saw the resident last at approximately 3:45AM when the resident went to the bathroom. On 5/13/2024 resident was located and transferred to Contra Costa Regional Center. Resident is reported to have been located without any physical injuries. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 111 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked in the kitchen. Smoke detectors and carbon monoxide detectors were observe. First-aid kit was complete. Fire extinguisher was purchased on 4/08/2024. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. Door alarms were observed and were in working order during visit. Report continues on LIC809-C LPA interviewed S1, S2, Administrator, and R2. LPA also spoke with R1's regional social worker over the phone as well as a Danville police officer. LPA obtained copies of R1's needs and services plan, as well as the police report number associated with he incident. Administrator is to fax over staff training's for review. During interview S1 stated that the kitchen door alarm was set at the end of their shift and they are unsure as to how it got turned off. S2 states that they also remember going over all door alarms with S1 and that they were set. S1 and S2 state that they are unsure if R1 would be able to reach the door alarm to disable it but that R1 observes staff closely and has attempted before to unlock other locks such as the medicine cabinet. S2 also states that they saw R1 go to the bathroom around 3:45am. During interview with R2 they stated that they did not hear R1 on the morning of elopement. R2 states that R1 has attempted to exit facility before and frequently walks around at night checking to see what doors are unlocked. R2 states that they did not hear any alarm go off on the day of elopement. During phone interview with R1's regional social worker LPA was informed that R1 has a history of elopement. Social worker states that R1 has "sneaky" behavior and has in the past been know to observe staff and use that as a means to elope or do other dangerous behaviors. Social worker stated that R1 has had psych evaluations that show that R1 is high functioning but lacks the cognitive abilities to think out the consequences of their actions. Report continues on LIC809-C During phone interview with Danville police officer LPA learned that it is estimated that R1 eloped from the facility around 6:00-7:00AM. R1 is suspected to have left in this time frame based on eye witnesses as well as an estimated walk time from facility to local bus stop. Officer advised LPA that R1 called their son who reported the call to police. Police then located R1 in Antioch and transferred R1 to a local hospital. R1 was observed to be lucid and without injury. The following Deficiencies will be cited: Adequate staffing/plan was not available to ensure that resident with elopement tendencies was properly addressed. Staff training's are not readily available for review at facility The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, May 14, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 21, 2024

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...require such additional staff for the provision of adequate services. This requirement is not met as evidence by: Based on report of resident with previous elopement behavior eloping from facility the staff were not competent in how to address the behavior and prevent the resident from being missing for days.the state’s words, verbatim · CDSS document, May 14, 2024

Plan of correction: By POC date administrator has agreed to install cameras to help monitor residents and will provide additional dementia training and submit proof of training's in accordance with regulations to CCLD

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(g) · Plan of correction due date: May 21, 2024

All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidence by: Administrator did not have training records readily available for review upon LPA's requestthe state’s words, verbatim · CDSS document, May 14, 2024

Plan of correction: By POC date administrator has agreed to provide all trainings and keep the training logs available at facility to meet regulation standards and notify CCLD

Type of visit: Case Management - Other

On 4/16/2024 at 12:50PM Licensing Program Analyst (LPA) A Gomez conducted a case management as a result of information received during a complaint visit. LPA spoke with Administrator, Merdith Castro and informed them of the nature of the Case Management. During interviews for a complaint received 4/11/2024 R1 stated that on 4/15/2024 there was not staff on schedule available to assist them with going to sleep from 9:00pm to 11:00pm. R1 stated that an off duty staff was at the facility cooking themself dinner and that when R1 asked for assistance the staff told them that they would need to wait for the next caregiver to be on duty. LPA reviewed the staff schedule and spoke with S1 and S2 over the phone who both stated that there was no gap in the schedule. The facility does not have a sign in sheet for staff. Administrator also provided LPA with a copy of the staff schedule that showed full coverage for the night. LPA was unable to determine if there was a gap in coverage for 4/15/2024. LPA went over the importance of having staff readily available and discussed the facility possibly implementing a sign in and out sheet for staff on duty. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 16, 2024

Type of visit: Case Management - Health Checks

On 04/0/92024 at 3:50 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of CCLD receiving notification of Residents being relocated to facility due to a fire at another facility. LPA met with Caregiver, Hope Veneracion and explained the purpose of the visit. Administrator was unavailable. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 110.2 degrees F in the bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked. Smoke detectors are interconnected with the sprinkler system. A comfortable temperature was maintained at 77 degrees F. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was purchased on 4/08/2024. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. LPA spoke with R1 and R2 to see how they are adjusting to the facility. R1 and R2 have dementia and were unable to give coherent answers. Administrator has residents files at the facility and medications at the facility No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 9, 2024

Type of visit: Prelicensing

On 10/4/2023 at 4:00pm,, Licensing Program Analyst (LPA)L. Hall arrived unannounced to conduct a pre-licensing inspection. LPA met with Meredith Castro, designee and explained the purpose of the visit. The facility has an approved fire safety clearance for five (5) non-ambulatory and one (1) bedridden resident. LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage and back yard. The facility has a total of five (5) bedrooms, two (2) bathrooms. There were no bodies of water present during inspection. There is sufficient lighting around the facility. Residents rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with grab bars. Passageways and hallways are free of obstruction. Locked cabinets available to store medications and toxins. Locked cabinet to store sharps. Hot water temperature is measured at 114.3 degrees Fahrenheit. Fire extinguisher was last serviced on 12/1/2022. Carbon monoxide and smoke detectors present. First-Aid kit was observed complete. Licensing Program Manager (LPM), H. Humpal gave approval to waive Comp III. No issues were noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.the state’s words, verbatim · CDSS document, Oct 4, 2023