Grace Home II

Type of visit: Case Management - Other

Licensing Program Manager (LPM) Laura Munoz, Licensing Program Analysts, (LPAs) Talwinder Bains and Lavinia Muscan arrived on 07/30/2026 for an unannounced inspection to follow up on substantiated allegations of neglect resulting from a complaint investigation. LPM and LPAs met with Licensee, Nelson Jacinto and Administrator, Julio Esguerra and explained the reason of the visit. On May 13, 2025, the Department concluded a complaint investigation regarding the following allegations: Facility staff did not seek timely medical attention for a resident, and resident sustained multiple falls while living at the facility due to neglect/lack of care and supervision by staff. The licensee was cited for California Code of Regulations (CCR) Title 22, § 87466 Observation of the Resident. At the time of the complaint visit on May 13, 2025, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). Continued on page 2 ... Page 2 ... The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility staff’s failure to address and update resident (R1) care plan to R1’s known fall risk, seek timely medical treatment for resident (R1), after R1 sustained multiple falls while in care, from the night of January 14, 2025, until EMS were contacted on January 16, 2025, which resulted in R1 being transported to the hospital, ICU admission, and subsequent hospitalization. Today, 07/30/2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department determines constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on May 13, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Facility Representative signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jul 30, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 7/29/26 to conduct a Case Management. LPA met with the Licensee, Nelson Jacinto and Administrator, Julio Miguel Esguerra and explained the purpose of today's visit. During today's visit, the Department checked the food supply and did a brief walk through the facility with staff. No concerns noted. Several topics were discussed. No immediate health and safety concerns were noted during this visit. No citations were issued per Title 22 Regulations from today's visit. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Jul 29, 2026

Type of visit: Required - 1 Year

On 5/7/26, CCL Staff, Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a Required- 1 Year inspection utilizing the inspection tool. CCL staff met with Licensee ,Nelson Jacinto , and explained the purpose of the visit. Administrator, Julio Esguerra came after short while and assisted CCL staff with today's visit. CCL staff toured the interior and exterior of the facility together with staff to ensure the health and safety of residents in care. Areas toured include but are not limited to: residents' bedrooms, bathrooms, common areas, maintenance room, kitchen, courtyard, and medication room. CCL staff observed required furniture, and lighting throughout the residents' bedrooms. Bathrooms are clean, sanitary, and in good repair. Toxic and cleaning supplies are locked in the maintenance room and is inaccessible to residents in care. CCL staff observed fire extinguishers, fire detectors, and carbon monoxide present at the facility. CCL staff observed food supplies of non-perishable for a minimum of one week and perishable foods for a minimum of two days. CCL staff observed medications were locked in medication carts and inaccessible to residents in care. Licensing posters are posted as required. Facility is compliant with fire drills per regulations. CCL Staff reviewed a total of four residents' files and four staff files. All four residents' files contain signed Admission Agreements, Identification Sheet, Releases, Preplacement Appraisals, and Resident's Rights and updated annual medical assessment. Staff have record of all required training , First Aid and CPR, and other various care provision including required training in medications. Medications were reviewed for four residents and no error were identified . Medications are centrally stored, locked, and appear to be given per doctor's order. CCL Staff requested to submit documents for review and records keeping by 5/31/26. Updated LIC500 Copy of liability insurance LIC610E There were no deficiencies observed or cited from today's visit per Title 22 Regulations. Exit interview conducted and copy of this report has provided.the state’s words, verbatim · CDSS document, May 7, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 3/9/26 to conduct a Case Management. LPA met with the Administrator, Nelson Jacinto and Assistant Administrator, Julio Miguel Esguerra and explained the purpose of today's visit. During today's visit, the Department checked the food supply and did a brief walk through the facility with staff. No concerns noted. Several topics were discussed. No immediate health and safety concerns were noted during this visit. No citations were issued per Title 22 Regulations from today's visit. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Mar 9, 2026

Type of visit: Case Management - Health Checks

CCLD Staff, Licensing Program Manager (LPM) Laura Munoz, Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 10/15/25 to conduct a Case Management. Department staff met with the Administrator, Nelson Jacinto and Assistant Administrator,Julio Miguel Esguerra and explained the purpose of today's visit. During today's visit, the Department checked the food supply and did a brief walk through the facility with staff. No concerns noted. Several topics were discussed. No immediate health and safety concerns were noted during this visit. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Oct 15, 2025

Type of visit: Case Management - Health Checks

Licensing Program Manager (LPM) Laura Munoz, Licensing Program Analysts (LPA) Talwinder Bains arrived at the facility unannounced on 08/12/25 to conduct a Case Management. Department staff met with the Administrator, Nelson Jacinto and facility staff. Sacramento Behavioral Health Representative was also present during this visit. LPA toured the facility to check the health and safety of residents in care. Areas toured included but not limited to residents rooms, bathrooms, common areas and outside area. LPA toured kitchen area and observed that facility has adequate food supply of 2 days perishable and 7 days non perishable per regulation. LPA observed that facility was clean and odor free. LPA observed that staff were attentive to residents care needs during tour. From the tour, there was no immediate health and safety risks observed for the residents in care. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Aug 12, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Manager (LPM) Laura Munoz, Licensing Program Analysts (LPA) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 07/16/25 to conduct a Case Management. Department staff met with the Administrator, Nelson Jacinto and facility staff. During today's visit, Department followed up on the issues discussed during NCC meeting with administrator on 07/10/25 at our office. Based on today's visit, LPAs and LPM observed karaoke the dining area open to residents and observed water with cups and snack available to residents. LPAs and LPM met with Licensee and staff to review licensing regulations and Department expectations in regards to compliance. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Jul 16, 2025

Type of visit: Office

On 07/09/25, around 01:30 PM, Regional Manager (RM) Alycia Rayner, Licensing Program Manager (LPM) Laura Munoz, Licensing Program Analyst (LPA) Talwinder Bains, Licensing Program Analyst (LPA) Lavinia Muscan were present for a Non-compliance Conference with Licensee / Administrator Nelson Jacinto which was held in-person in the office. This conference does not in any manner excuse past problems or resolve the Department’s case against the licensee if the problems are not corrected. The Non-Compliance Conference may be the last step prior to initiating administrative action following unsuccessful attempts by the Department to gain compliance. Since last office meeting with facility on 07/31/24, the facility has been issued 9 A citations, 6 B citations, civil penalties and repeat civil penalties $4,850 were issued. Substantiated Complaints, case management visits and other visits include allegations in the following areas: - Not providing timely medical care including resident’s death, Residents Personal Rights, Issues with food services and physical plant, no activities for residents and various other areas related to residents’ health and safety The licensee shall submit the following by AUGUST 1, 2025: Develop and implement new protocols for timely medical response; supervision and fall reduction. Submit Training, policies, management oversight to ensure care staff is aware and familiar with the needs of the residents and when to call 911. Create activities based on resident's preferences. Cups should be available at water station at all times for residents. Conduct mandatory training for all staff in the above areas. Plan how food will be available to residents. Implement internal audits and increase administrative oversight. Conduct mandatory training for all staff in the above areas Licensee shall hire a qualified administrator by 08/01/25. Compliance plan documents shall be submitted to CCL by: 07/23/25 COB; Fully implement plan with documentation by 08/09/25. Provide proof of staff training completion. Submit all documents to LPA Bains via email. The licensee agreed with the drafted non-compliance plan as outlined in LIC 9111. No citations were issued today. An exit interview was conducted, and a copy of this report was provided to the licensee.the state’s words, verbatim · CDSS document, Jul 9, 2025

Type of visit: Case Management - Health Checks

On 07/08/25, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains came to facility to conduct health and safety checks. LPAs met with administrator, Nelson Jacinto and explained the purpose of today's visit. Department found multiple concerns. Deficiencies were observed and cited per Title 22, CCR Regulations as listed on LIC809-D. Civil penalties will be assessed if facility will not comply with all POC requirements as issued today. Exit interview conducted. Copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 8, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b) · Plan of correction due date: Jul 9, 2025

87555- (b) The following food service requirements shall apply: This requirement is not met as evidenced by: Based on observation, no snacks were available to residents, multiple food items were not labeled in kitchen area and the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Licensee shall send a letter of understanding of this regulation, will draft a plan on how facility will provide snacks for residents, and how all open food items will be labeled and shall conduct staff training. All POC documents are due by 07/09/25. Civil penalty of $250.00 was issued as it was a repeat citation within 12 months.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87219(a) · Plan of correction due date: Jul 15, 2025

87219- (a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: This requirement is not met as evidenced by: Based on observation, during inpection, no planned activities were available for residents as required, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Licensee shall send a letter of understanding of this regulation, and will draft a plan on how the facility shall ensure residents have planned activities per regulation, and shall conduct staff training. All POC documents are due by 07/15/25. Civil penalty of $250.00 was issued as it was a repeat citation within 12 months.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 9, 2025

87309- (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as cleaning chemicals were accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Licensee shall send a letter of understanding of this regulation and shall conduct staff training. All POC documents are due by 07/09/25. Civil penalty of $250.00 was issued as it was a repeat citation within 12 months.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains, Licensing Program Manager (LPM) Laura Munoz, and Regional Manager (RM) Alycia Rayner arrived on June 4, 2025 to conduct the annual inspection. Department met with administrator, Nelson Jacinto and explained the purpose of today's visit. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. Department reviewed five (5) residents and two (5) staff files. All required postings were observed. Department and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. Grab bars were present at the toilet and in the shower. Department checked the kitchen area for the ability to prepare and store food. Department observed the area used for medication to be locked and inaccessible to residents. Department observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguishers were last serviced on 12/5/24 and were ready for emergency use. Department found multiple concerns, therefore, deficiencies were observed and cited per Title 22, CCR Regulations as listed on LIC809-D. Civil penalties will be assessed if facility will not comply with all POC requirements as issued today. Exit interview conducted. Copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 4, 2025

Allegation investigated: Facility staff did not seek timely medical attention for resident. Resident sustained multiple falls while living at the facility due to Neglect/Lack of Care and Supervision by staff.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/13/25 to deliver the complaint findings for above allegations. LPA met with administrator Nelson Jacinto and explained the purpose of the visit. The department conducted records review ,staff and residents interviews to investigate the complaint. **Report continued on LIC9099-C** Substantiated ***Report continued from 9099.... Allegation- Neglect/Lack of Care and Supervision: facility staff failed to seek timely medical attention for resident, R1- Substantiated Department conducted record review and staff’s interviews to investigate this allegation. Record review reflected that resident, R1 showed a decline, fall of 2024 in their overall physical and cognitive abilities. R1 had several falls, failed to sleep at night, and needed a higher level of care. On 01/14/2025, R1 had a fall at day program, R1 was evaluated by day program staff and determined to not have any injuries. The following day, 01/15/2025, R1 had a change of condition and was too weak to stand up out of bed. There was inconsistent information as staff stated during investigation that staff assisted R1 into a wheelchair where they spent the day however EMT records indicated staff stated that R1 was not seen out of their room in 48 hours. On 01/16/2025, R1 still could not stand up or transfer without assistance, that was when staff called 911 and decided to transport him to the hospital. It was noted by facility staff and day program staff that R1 would constantly walk, and it was hard for staff to get them to sit still. Per R1s Medical records review, upon R1’s arrival to the hospital, R1’s temperature was 30.8 °C, blood pressure 93/61, bradycardic at 55, EKG showed sinus bradycardia, chest x-ray showed bibasilar consolidation left greater than right. CT chest abdomen pelvis shows bilateral pneumonia, aspiration possibility, air-filled esophagus, moderate to severe pancreatitis. Posterior aspect of the left temporal lobe shows moderate encephalomalacia. Moderate cortical sulcal widening. R1 passed away at hospital on 01/28/2025 due to Cardiopulmonary arrest, acute respiratory failure and multifocal pneumonia and acute respiratory distress syndrome. Staff interviews indicated that, based on R1’s care needs they needed a higher level of care. Licensee, Nelson Jacinto was aware R1 was a fall risk, however the facility failed to put a plan into place. Interviews indicated R1 should not have been in the facility due to their care needs and preemptively wrote a (60-Day Notice to Vacate) for R1 on 10/02/2024, however R1 was never served the eviction notice. Based on interviews and records review, R1 had an obvious change of condition after a fall but facility staff failed to seek medical attention in timely manner, therefore, the allegation is Substantiated. ....report continued..... .....report continued....... Allegation- Neglect/Lack of Care and Supervision: Resident, R1, sustained multiple falls while living at the facility due to Neglect/Lack of Care and Supervision by staff. -Substantiated Department conducted record review and staff’s interviews to investigate this allegation. It was noted during record review that, between 2/03/2024 to 1/14/2025, resident, R1, sustained 13 falls with a majority of the falls being from 8/2024 to 1/14/2025 (10 falls). Interviews and documents reviewed indicated the facility had no plan of action to assist in mitigating R1’s falls. R1’s care plan was not updated, and R1 was not made a fall risk. Facility staff stated they tried to have R1 use a walker or wheelchair, but R1 refused. Staff interviews stated, “they cannot force residents to do something they don’t want to.” R1 attended a Day program. Interviews with Day Program staff stated R1 was noted as a fall risk and implemented a plan resulting in R1 only utilizing a wheelchair while at the day program. Day program had no issues having R1 in a wheelchair. Grace Home II failed to implement the same fall mitigation plan for R1. Licensee/Owner, Nelson Jacinto admitted during his interview he knows there should have been a fall plan put in place and the facility failed to act. Nelson Jacinto and staff attempted to blame R1’s responsible party (RP) as RP did not give them a plan of action. Based on investigation conducted, facility staff were aware R1 was a fall risk and did not put measures in place to provide adequate care and supervision to R1 resulted in R1 sustaining multiple falls and did not seek timely medical care to address R1s health condition that contributed to R1’s death. Based on the facility failing to implement any sort of plan of action to mitigate R1s falling and staff failing to remove R1 from the facility after there were clear signs facility was aware they could no longer meet R1’s needs, the allegation is Substantiated. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met. Therefore, the above allegations are found to be SUBSTANTIATED. The citation issued today is under review and a future civil penalty may apply based on Health and Safety code §1569.49(e) H&S. In addition, civil penalties in the amount of $500.00 are assessed today for a resident, R1s death due to facility’s lack of care and supervision. Failure to correct the deficiencies may also result in civil penalties. Please see LIC9099-D for deficiencies cited today. Exit interview conducted. Appeal Rights provided. A copy of the report issued.the state’s words, verbatim · CDSS document, May 13, 2025 · control 59-AS-20250122110921

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 14, 2025

87466-Observation of the Resident- licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs……. This requirement is not as evidence by…. Based on record review and interviews, it has been concluded that facility did not reassess R1 for unmet needs despite multiple falls incidents from 08/2024 till 01/15/25, which poses immediate health and safety risks for residents in care.the state’s words, verbatim · CDSS document, May 13, 2025

Plan of correction: Licensee will make sure that Observation of for any resident per their health care needs/changes will be done in timely manner so residents care needs can be met per RCFE regulation 87466. Licensee shall submit letter of understanding of this regulation to CCL by POC date-05/14/25. resident’s who are identified as a fall risk. Additionally, the facility shall develop a plan on how the facility will address resident’s who are identified as a fall risk. Immediate civil penalty of $500.00 was assessed during today’s visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: May 14, 2025

87463(a) Reappraisals- The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months......... This requirement is not as evidence by… Based on record review and interviews, it has been concluded that facility did not provide proper care and supervision for R1 which resulted R1s fall and death on 01/28/25 which poses an immediate health and safety risks for residents in care.the state’s words, verbatim · CDSS document, May 13, 2025

Plan of correction: Licensee will make sure that Reappraisals requirements all residents can be met per RCFE regulation 87463. Licensee shall submit letter of understanding of this regulation to CCL by POC date-05/14/25. Additionally, the facility shall submit an addendum to the facility plan of operation regarding reappraisals addressing regulation requirements.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 12/12/24 to do a health and safety check. LPA met with Administrator, Nelson Jacinto and explained the purpose of the visit. During today's visit, the Department checked the food supply and did a brief walk through the facility with administrator. No concerns noted. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Dec 12, 2024

Allegation investigated: Client wandered away from the facility due to lack of care or supervision from staff .

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 09/10/24 to do the complaint investiagtion for above allegation. LPA met with administrator Nelson Jacinto and explained the purpose of the visit. LTCO, Byron Toliver was also present during this visit. From record review, administartor and resident (R1) interviews, it has been concluded that R1 AWOL from facility on 09/05/24 sometime after 11AM and was located at El Hogar Clinic, 630,Bercut Drive, Suite # C, Sacramento,CA,95811 (19 miles away from facility) and El Hogar staff notified facility regarding R1s presence at the clinic around 1PM. It was indicated that R1 was very thirsty and clammy when Clinic staff found R1. R1 was transferred to local hospital to get medical care and discharge to facility on 09/05/24 around 10PM. R1s LIC602 ,dated- 01/17/24 signed by thier physician disclosed that R1 cannot leave facility unassisted. From all gathered information, it has been conlcuded that R1 had AWOL from facility unassisted and unsupervised on 09/05/24 due to lack and care from facility. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is cited.Exit interview was conducted .Copy of the report and appeal rights were left provided. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today. Substantiatedthe state’s words, verbatim · CDSS document, Sep 10, 2024 · control 59-AS-20240906162443

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80078(a) · Plan of correction due date: Sep 11, 2024

80078(a) Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by: Based off of observation and record reviews ,it has been concluded that resident, R1 AWOL'd from the facility on 09/05/24 due to lack of care and supervision of staff which presents an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: Facility agrees to hold a training on the AWOL procedure with all staff and send a copy of topics covered and a list of attendees name/date/signature by POC date, 09/11/24 and provide staffing as necessary to meet residents needs. Facility agrees to revisit AWOL procedure and to submit in a written AWOL procedure to CCL within 15 days.

Allegation investigated: Staff does not ensure bathrooms are kept in good repair. Staff does not ensure residents dietary needs are being met.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 08/13/24 to deliver the complaint findings for above allegations. LPA met with administrator Nelson Jacinto and explained the purpose of the visit. The department conducted records review ,facility observations ,staff and residents interviews to investigate the complaint. **Report continued on LIC9099-C** Substantiated ***Report continued from 9099.... Allegation- Staff does not ensure bathrooms are kept in good repair.-Substantiated The Department conducted record review, facility’s observations, three (3) staff and four (4) residents interviews to investigate complaint allegation. During facility visits on 06/20/24 and 07/09/24, Department observed that residents bathroom in Room #9 was not operable and repairs were needed. The shower had a leak and was inoperable. The toilet was leaking and did not flush properly. The ceiling and wall of the bathroom has what appears to be water damage. 2nd building resident's bathroom's mirror was found to be broken and not safe for resident's use. Residents who resided in Room # 9 indicated that facility was aware about their bathroom issues not failed to address the issue until the Department was involved. Based on gathered information, this allegation was found to be Substantiated. Allegation -Staff does not ensure residents dietary needs are being met. Substantiated The Department conducted record review, facility’s observations, three (3) staff and four (4) residents interviews to investigate complaint allegation. During Department visit to facility on 06/20/24, LPA Bains found multiple food items with expired dates in kitchen area. Resident (R1) was interviewed and indicated that facility was not following their dietary preference request and not serving the food which was of good quality. Based on gathered information, this allegation was found to be Substantiated. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is observed but not being cited today as it has been cited on 07/09/24 during case management visit. Exit interview was conducted and copy of the report left at the facility. Report continued from 9099-A...... Allegation- Staff does not speak to residents in an appropriate manner. Staff do not ensure residents are accorded personal privacy.-Unsubstantiated. The Department conducted record review, facility’s observations, three (3) staff and four (4) residents interviews to investigate complaint allegation. Based on the interviews conducted with the administrator, residents and staff members, it has been determined that there is no evidence of staff being inappropriate or disrespectful towards the residents. The administrator mentioned that staff may speak loudly to residents who are hard of hearing in order to effectively communicate with them. However, this does not indicate any misconduct or disrespect. The residents' interviews revealed that the staff provide care and assistance in a professional manner, and they denied experiencing any disrespect or misconduct from any staff member at the facility. Residents’ interviews indicated that staff were providing privacy while providing care to them. During the department's visits to the facility as part of the complaint investigation on 06/20/24, it was observed that the facility staff were attentive to the residents' care needs. The residents indicated that the staff were providing satisfactory care. Based on these findings, there is no substantiated evidence of staff being disrespectful or engaging in any misconduct towards the residents therefore, this allegation is UNSUBSTANTIATED. Allegation- Staff did not ensure residents personal belongings were secured. Unsubstantiated. The Department conducted record review, facility’s observations, three (3) staff and four (4) residents interviews to investigate complaint allegation. From the record review, it has been revealed that facility has record of all personal belongings for R1 in resident’s facility file per Title 22 regulations. Staff and residents interviewed indicated that facility was trying their best to safeguard all residents belongings but some residents have behavior to hide their belongings in other resident’s closets or in other areas in facility. Resident’s interviews did not indicate any concerns about their personal belongings not secured at the facility. Furthermore, during department visit on 06/20/24, it has been observed that R1 has their personal belongings in their closet and by their bedside as listed in R1’s personal belongings form. Based on all this information, this allegation is found to be Unsubstantiated. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted and a copy of this report has been provided to facility. ***Report continued from 9099-A..... Allegation- Staff does not ensure facility is kept free from pests.-Unfounded The Department conducted record review, facility’s observations, three (3) staff and four (4) residents interviews to investigate complaint allegation. LPA obtained documents relevant to the allegation as well as interviewed staff regarding the allegation. It was stated that the Pest Control company just visited the facility a prior to the department’s visit on 06/20/2024. Pest Control sprayed the exterior and interior of the building including residents rooms. During facility tour of the facility on 06/20/24, LPA Bains did not observe any pests at the facility. The facility provided documentation of continued frequent visits from a pest control agency. Residents interviews indicated that they were not aware about any pests issues at the facility. Based on this information, this allegation is found to be Unfounded. Allegation- Staff does not ensure residents are provided with clean linens. Unfounded The Department conducted record review, facility’s observations, three (3) staff and four (4) residents interviews to investigate complaint allegation. During Department visit on 06/20/24, LPA Bains observed that facility has adequate linen supplies for all residents. Staff interviews indicated that there was no linen shortage at the facility and things were fine with linen supplies and usage. Residents interviews did not indicate any concerns in this area and expressed their satisfaction with clean linen supplies. Based on this information, this allegation was found to be Unfounded. Based on the investigation,the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted and a copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Aug 13, 2024 · control 59-AS-20240613135559

Type of visit: Office

On 07/31/2024 at 10:00AM, an informal conference was conducted at Sacramento Regional Office. The purpose of this informal conference meeting is to discuss the deficiencies observed within last 3 years and to address current issues at facility. Present in the meeting were, Licensing Program Manager (LPM) Laura Munoz and Troy Ordonoz, Licensing Program Analysts (LPAs) Talwinder Bains and Graham Gunby, and licensee/administrator, Nelson Jacinto. The informal conference process was explained during this meeting. Issues discussed during the meeting were: - Resident’s care and supervision - Dietary services - Resident’s Personal Rights - Facility’s Operation and Maintenance - Residents Activities Services - Multiple civil penalties assessed within last 3 months for Failure to comply with POC Requirements The facility has stated they will do the following to achieve continued and substantial compliance: • Submit a letter of understanding of Title 22 by 08/15/24 • Reach out to Community Care Licensing Division (CCLD) as a resource. Technical Support Program (TSP) was offered and accepted. Deficiencies were cited per Title 22 Regulations. Exit interview conducted. Informal meeting concluded,Appeal Rights and a copy of report was provided.the state’s words, verbatim · CDSS document, Jul 31, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405 · Plan of correction due date: Sep 15, 2024

87405-Administrator - Qualifications and Duties- (d) The administrator shall have the qualifications .......If the licensee is also the administrator, all requirements for an administrator shall apply.(1) Knowledge of the requirements ......(2)Knowledge of and ability to conform to the applicable laws, rules and regulations……this requirement is not met as evidence by; Based on facility's observations and staff's interviews, facility does not have a qualified Administrator which poses health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jul 31, 2024

Plan of correction: Licensee shall hire a qualified administrator and shall notify Department when hired. All POC documents are due by POC date-09/15/24.

Type of visit: POC

On 07/23/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a Plan of Correction (POC) case management and met with Administrator, Nelson Jacinto . LPA toured the facility and observed that Resident Room #9 bathroom still was in disrepair as the shower has a leak and is inoperable.The ceiling and wall of the bathroom has what appears to be water damage. On 06/20/2024 ,07/09/24 and 07/16/24 , LPA Bains spoke to the licensee who stated the facility would ensure the bathroom would be fixed. As of this date, there might be follow up but restroom is still inoperable. Due to this issue, On 07/09/24, LPA cited the facility on CCR regulation, 87303(a)- Maintenance and Operation- and facility should have submitted all required documents to clear POC by POC Due Date of 07/10/24. Licensee/administrator did not ensure that the POC was corrected upon Due Date of 07/10/24. LPA conducted POC visit to facility on 07/16/24 and Civil Penalty was assessed of $ 100/day from 07/10/24 -07/16/24 but facility did not comply with POC requirements till date, therefore,on today's date, LPA will be assessing a Civil Penalty of $100/day from 07/17/24- 07/23/24 ,total of $700 for this violation and will continue to accrue until POC is corrected. LPA informed administrator that Department is inviting administrator for Informal Department Meeting which will be held at 9835 ,Goethe Road #100, Sacramento, CA,95827 on 07/31/24 at 10AM and attendance is Mandatory to discuss on going issues with facility and administrator stated that they understood and accepted the meeting invite. Civil Penalties were assessed during this visit for failure to correct the above violation by POC Due Date. Exit Interview was conducted, Appeal rights were provided, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 23, 2024

Type of visit: POC

On 07/16/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a Plan of Correction (POC) case management and met with Administrator, Nelson Jacinto . LPA met with administrator in the parking lot as administrator was leaving with a resident for their doctor's appointment. LPA explained the purpose of the visit. Administrator stated that they were aware that facility did not comply with POC requirements from 07/09/24 visit as things were really busy with them and facility. Administrator stated that facility will send all required POC documents but did not provide any time frame. Administrator stated that Staff ,Maria Segarra (Cory) will assist LPA with today's visit and can sign today's report's documents. On 07/09/24, LPA cited the facility on CCR regulation, 87468.1 (a)(6) -Personal Rights of Residents in All Facilities -and facility should have submitted all required documents to clear POC by POC Due Date of 07/10/24. Licensee/administrator did not ensure that the POC was corrected upon Due Date of 07/10/24. On today's date, LPA will be assessing a Civil Penalty of $100/day from 07/10/24- 07/16/24 for this violation and will continue to accrue until POC is corrected. On 07/09/24, LPA cited the facility on CCR regulation, 87468(a)(13)- Personal Rights of Residents in All Facilities- and facility should have submitted all required documents to clear POC by POC Due Date of 07/10/24. Licensee/administrator did not ensure that the POC was corrected upon Due Date of 07/10/24. On today's date, LPA will be assessing a Civil Penalty of $100/day from 07/11/24- 07/16/24 for this violation and will continue to accrue until POC is corrected. On 07/09/24, LPA cited the facility on CCR regulation, 87303(a)- Maintenance and Operation-and facility should have submitted all required documents to clear POC by POC Due Date of 07/10/24. Licensee/administrator did not ensure that the POC was corrected upon Due Date of 07/10/24. On today's date, LPA will be assessing a Civil Penalty of $100/day from 07/11/24- 07/16/24 for this violation and will continue to accrue until POC is corrected. Civil Penalties were assessed during this visit for failure to correct the above violations by POC Due Date. Exit Interview was conducted, Appeal rights were provided, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 16, 2024

Type of visit: Case Management - Health Checks

On 07/09/24, CCL Staff, Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Talwinder Bains arrived to do a health and safety check. LPM and LPA met with Administrator, Nelson Jacinto (S1) and explained the purpose of today's visit.Upon arriving at the facility LPA, LPM and S1 toured the facility for areas but not limited to residents rooms, bathrooms, common areas, kitchen and outside areas. Following issues were observed during tour: CCL staff observed the exterior gate of the facility had 3 points of entry. It was observed that 2 of the 3 gates had key pad locks and one gate with the key pad lock locked to another part of the gate. Licensee indicated the gates are locked so residents cannot AWOL from the facility. The facility is restricting resident's from entering and exiting the facility which was not allowed per Title 22 Regulations. Civil Penalties are being assessed today in the amount of $500. Upon enter the facility, CCL staff observed there were no activity scheduled for residents and there were no activities calendar for residents. Additionally, the facility does not have a designated activities personnel per Title 22 regulations. During the facility tour is was observed that numerous resident's personal closets were found to be locked. Licensee indicated that only staff have access to the keys to the locks resulting in resident not having access to their personal belongings. Resident Room #9 bathroom found to be in disrepair. The shower has a leak and is inoperable. The toilet is leaking and does not flush properly. The ceiling and wall of the bathroom has what appears to be water damage. On 06/20/2024, LPA Bains spoke to the licensee who stated the facility would ensure the bathroom would be fixed. As of this date, there were no follow up and the restroom is still inoperable. 2nd building resident's bathroom's mirror was found to be broken and not safe for resident's use. During today's conversation with Licensee, the Licensee agrees to engage with the Department's Technical Support Program. The Department will submit a referral to TSP. Deficiencies issued are noted on the LIC809D per Title 22 Regulations. The Licensee has been reminded that failure to correct the deficiencies may also result in civil penalties. Exit interview conducted. Appeal rights were provided and copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Jul 10, 2024

87468.1 -Personal Rights of Residents in All Facilities -(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents....this requirement is not as evidenced by; CCL staff observed that facility has locked front entry doors with padlocks which pose a immediate health and safety risks for residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2024

Plan of correction: Administrator shall submit a letter of understanding of this regulation and will train staff as well. Administrator shall ensure that all exits are accessible to residents at all times. All POC documents are due by 07/10/24. Administrator removed all padlocks from front entrance doors while CCL staff were present. Civil Penalties assess in the amount $500.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87219(e) · Plan of correction due date: Aug 10, 2024

87219(e)-Planned Activities -In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, shall have primary responsibility for the organization, conduct and evaluation of planned activities. ....this requiement is not met as evidenced by; CCL staff observed that there were no schdueld activties for residents and there was no staff assigned to do activities as required per this regulation which poses a potential health and safety risks for residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2024

Plan of correction: Administrator shall submit a letter of understanding of this regulation to CCL and will appoint staff to do activities for residents by POC due date- 08/10/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468(a)(13) · Plan of correction due date: Jul 10, 2024

87468(a)(13)- Personal Rights of Residents in All Facilities- (13)To have access to individual storage space for private use....this requirement is not met as evidenced by; CCL staff observed that residents personal belongings were locked in thier closet(s) and were inaccessible to residents which poses immediate health and safety risks for residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2024

Plan of correction: Administartor shall submit a plan on how all resident's will be given full access to thier belongings at all times. Additionally, the Administrator shall submit a plan on how the facility will ensure resident's belongings are safeguarded. All POC documents are due by 07/10/24. **Administrator will provide all resident's who have locks on thier closets either the key to the locks or remove the lock, which ever the resident's request.**

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a) · Plan of correction due date: Jul 10, 2024

87303(a)- Maintenance and Operation-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 requiement is not as evidenced by; CCL staff observed that resident room # 9 bathroom was not operating well and 2nd building resident's bathroom has broken mirror which poses immediate health and safety risks for residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2024

Plan of correction: Administrator shall submit a work order and/or any documentations regarding the repair to bathroom #9. Administrator shall provide the Department with a timeframe of when work will be completed. Plan shall be submitted by 07/10/2024 and will send proof to CCL upon completetion.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 06/20/24 to do case management visit. LPA met with Administrator, Nelson Jacinto and explained the purpose of the visit. During complaint investigation (59-AS-20240613135559), while doing facility tour, LPA observed multiple food items in the kitchen area ( in pantry room ) which poses a potential health and safety risks to residents in care. Immediate Civil penalties of $250.00 were assessed on LIC421FC today due to repeat violations of the same regulations within 12 months for Regulation 87555. Deficiencies issued are noted on the LIC809D per Title 22 Regulations. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted. Appeal rights were provided and copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 20, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Jun 27, 2024

87555-(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained....This requirement is not met as evidenced by: During visit, LPA observed food supply with multiple expired items, and food items without date or label, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 20, 2024

Plan of correction: Administrator shall submit a letter of understanding and shall do staff training regarding this regulation and ensure that facility shall not any expired food items and food shall be labeled and dated per requiement. All POC documents are due by 06/27/24. Immediate Civil penalties of $250.00 were assessed on LIC421FC today due to repeat violations of the same regulations within 12 months for Regulation 87555.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Talwinder Bains arrived on 05/13/24 to conduct the annual inspection. LPA met with administrator, Nelson Jacinto and explained the purpose of today's visit. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed medications of five (5) residents comparing with physician orders and find no errors. LPA reviewed five (5) residents and two (2) staff files and found all required documents. Facility was clean and well organized. All required postings were observed. LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguishers were last serviced on 11/17/23 and were ready for emergency use. Hot water temperature was observed to be between 112-119 degrees F, which is within the regulation range of 105-120 degree. Inside temperature was 72 degree F. LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 05/31/24. LPA found multiple food items with expired dates in kitchen storage room during inspection, therefore, deficiencies were cited per Title 22, CCR Regulations as listed on 809-D. Exit interview conducted. Copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 13, 2024

Type of visit: Case Management - Health Checks

On 10/26/23, Licensing Program Analyst (LPA) Talwinder Bains arrived to conduct a case management and perform a health and safety check on residents in care. LPA met with administrator Nelson Jacinto and explained the purpose of todays' visit. LPA toured the facility with Administrator to check the health and safety of residents in care. Areas toured included but not limited to residents rooms, bathrooms, common areas and outside area. LPA toured kitchen area and observed that facility has adequate food supply of 2 days perishable and 7 days non perishable per regulation. LPA observed some residents were outside area and some were in their rooms. LPA observed that facility was clean and odor free. LPA observed that staff were attentive to residents care needs during tour. From the tour, there was no immediate health and safety risks observed for the residents in care. LPA and administrator discussed recent visit for resident, R1 to hospital (10/24/23 to 10/26/23) regarding R1s hip pain which was related to R1s hip surgery which was conducted in Sep. 2023 and R1 still experience lot of pain in their hip. Interview and record review indicated that R1 has been prescribed new pain medication and therapy upon discharge on 10/26/23 to address hip pain. LPA and administrator discussed the plan of relocating one of current resident, R2 to another facility since R2 was constant exit seeker and facility was working with R2s social worker to find another facility. LPA interviewed 3 residents and 3 staff during today's visit and concluded no immediate health or safety concerns for residents as of today. As a result of today’s visit, no deficiencies were observed or cited. The report was reviewed, and a copy was left at the facility.the state’s words, verbatim · CDSS document, Oct 26, 2023