Hartnell Home Care

Type of visit: Case Management - Other

On 10/2/2025 at 3:00 pm, Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo conducted an unannounced Case Management visit to follow up on R1 status. LPAs met with care staff and Renato Tisico, explaining the purpose of the visit. LPA spoke with Administrator (ADM) Victoria Puruganan via phone and received verbal permission for care staff to sign the report. LPA toured the facility and observed that the facility do not have any resident. LPAs interviewed staff 1(S1) stated that ADM gave them until Saturday morning 10/4/25 to move out of the facility. An exit interview is conducted, and a copy of this report is provided.the state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Case Management - Health Checks

On 9/25/2025 at 3:55 pm, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Case Management visit to follow up on R1 status. LPA met with care staff and Renato Tisico, explaining the purpose of the visit. LPA spoke with Administrator (ADM) Victoria Puruganan via phone and received verbal permission for care staff to sign the report. LPA toured the facility and observed that the facility only has R1 residing at the facility. LPA tried to reach out to the R1 family multiple times and left messages. LPA spoke with ADM regrading R1 status. ADM stated that they are actively searching for facilities, however the monthly rate that R1 pay is too low. An exit interview is conducted, and a copy of this report is provided via email.the state’s words, verbatim · CDSS document, Sep 25, 2025

Type of visit: Case Management - Other

On 9/16/2025 at 1:30 pm, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Case Management visit to deliver a formal letter to the Licensee; however, LPA could not reach the licensee. LPA met with care staff and Renato Tisico, explaining the purpose of the visit. LPA spoke with Administrator (ADM) Victoria Puruganan via phone and received verbal permission for care staff to sign the report. LPA toured the facility and observed that the facility only has R1 residing at the facility. LPA tried to reach out to the R1 family multiple times and left messages. LPA provides a copy of the letter Intended to Licensee to Renato care staff. An exit interview is conducted, and a copy of this report is provided.the state’s words, verbatim · CDSS document, Sep 16, 2025

Type of visit: Case Management - Health Checks

On 9/10/2025 at 9:00 am, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Case Management visit for an health and safety checked. LPA met with care staff and Renato Tisico, explaining the purpose of the visit. LPAs spoke with Administrator (ADM) Victoria Puruganan via phone and received verbal permission for care staff to sign the report. LPA toured facility and observed that facility only have R1 residing at the facility. R1 is receiving home health services (once a week). LPA tried to reached out to R1 family multiplies times, and left messages. An exit interview is conducted copy of this report is provided.the state’s words, verbatim · CDSS document, Sep 10, 2025

Type of visit: Case Management - Health Checks

On 9/4/2025 at 9:00 am, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Case Management visit for an health and safety checked. LPA met with care staff and Renato Tisico, explaining the purpose of the visit. LPAs spoke with Administrator (ADM) Victoria Puruganan via phone and received verbal permission for care staff to sign the report. LPA toured facility and observed that facility only have R1 residing at the facility. R2 moved out on 9/3/23 and R3 moved out on 8/30/25. LPA spoke with R1 brother and provided resources and education upon facility placement. An exit interview is conducted copy of this report is provided.the state’s words, verbatim · CDSS document, Sep 4, 2025

Type of visit: Case Management - Other

On 8/25/2025 at 10:30 am, Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo conducted an unannounced POC Case Management visit. LPAs met with care staff and Renato Tisico, explaining the purpose of the visit. LPAs spoke with Administrator (ADM) Victoria Puruganan via phone and received verbal permission for care staff to sign the report. Upon reviewing R1 files, there are missing documents, including but not limited to: - Incomplete physician report - Needs and Service plan A civil penalty on today's date is assessed for $300 due to failure to correct from 8/23/25 to 8/25/25. An exit interview is conducted a copy of this report is provided with an appeal right.the state’s words, verbatim · CDSS document, Aug 25, 2025

Type of visit: Case Management - Other

On 8/25/2025 at 12:20 pm, Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo conducted an unannounced Case Management visit requesting documents from the facility. LPAs met with care staff and Renato Tisico, explaining the purpose of the visit. LPAs spoke with Administrator (ADM) Victoria Puruganan via phone and received verbal permission for care staff to sign the report. LPAs requested for complete resident(R) files of R1, R2, R3, R4, and R5. ADM will submit documents by 8/29/25. An exit interview is conducted copy of this report is provided.the state’s words, verbatim · CDSS document, Aug 25, 2025

Type of visit: Case Management - Other

On 8/25/2025 at 12:50 pm, Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo conducted an unannounced Case Management visit for an overdue payment of the facility license. LPAs met with care staff and Renato Tisico, explaining the purpose of the visit. LPAs spoke with Administrator (ADM) Victoria Puruganan via phone and received verbal permission for care staff to sign the report. ADM was about to show proof that ADM paid the overdue fee on 8/25/25. An exit interview is conducted copy of this report is provided.the state’s words, verbatim · CDSS document, Aug 25, 2025

Type of visit: Case Management - Other

On 8/25/2025 at 1:20 pm, Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo conducted an unannounced Case Management visit to check in with residents(R), residents' family members, and POA. LPAs met with care staff and Renato Tisico, explaining the purpose of the visit. LPAs spoke with Administrator (ADM) Victoria Puruganan via phone and received verbal permission for care staff to sign the report. An exit interview is conducted copy of this report is provided.the state’s words, verbatim · CDSS document, Aug 25, 2025

Type of visit: Case Management - Deficiencies

On 8/20/2025 at 12:30 pm, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Case Management visit. LPA met with care staff, Renato Tisico, and explained the purpose of the visit. LPA spoke with Administrator (ADM) Victoria Puruganan via phone and received verbal permission for care staff to sign the report. During the visit, LPA observed that the facility had admitted a new resident (R). LPA spoke with ADM regarding the R1 record. ADM stated that the R1 record is not complete; however, it will be complete by Friday. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted, and a copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Aug 22, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on record review and interviews by the Department, Licensee did not comply with the regulation cited above, by not having R1 complete files at the facility.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: By POC date, Administrator agrees to have R1 complete files at the facility.

Type of visit: Case Management - Other

On 8/20/2025 at 3:30 pm, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced POC Case Management visit. LPA met with care staff, Renato Tisico, and explained the purpose of the visit. LPA spoke with Administrator (ADM) Victoria Puruganan via phone and received verbal permission for care staff to sign the report. ADM was able to provide POC for liability insurance for this facility. The liability effective date for Hartnell is August 12, 2025, to August 12, 2026. LPA cleared the deficiency. An exit interview is conducted a copy of this report is provided.the state’s words, verbatim · CDSS document, Aug 20, 2025

Type of visit: Case Management - Health Checks

On 8/06/2025 at 9:00 am, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Case Management Health Check visit. LPA met with care staff, Renato Tisico, and explained the purpose of the visit. LPA spoke with Administrator (ADM) Victoria Puruganan via phone and received verbal permission for care staff to sign the report. During the health and safety check, LPA observed a total of 2 staff members assisting 2 residents at the facility. LPA toured the facility with care staff, including the bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe, and there are no imminent health/safety concerns on today's date. No deficiencies were cited during the health and safety check. An exit interview was conducted, and a copy of this report was provided via email.the state’s words, verbatim · CDSS document, Aug 6, 2025

Type of visit: Case Management - Deficiencies

On 7/31/2025 at 9:30 am, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Case Management visit. LPA met with care staff, Renato Tisico, and explained the purpose of the visit. LPA spoke with Administrator (ADM) Victoria Puruganan via phone and received verbal permission for care staff to sign the report. LPA reviewed and confirmed that the facility liability insurance expired that LPA obtained on 7/30/2025 via email; however, after the file review showed that ADM submitted the facility property insurance for the facility. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted, and a copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 31, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.605 · Plan of correction due date: Aug 7, 2025

§1569.605 Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Based on records reviewed and interviews by the Department, the Licensee did not comply with the regulation cited above by not having current liability insurance.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: By the POC date, the Administrator agrees to submit proof of active liability insurance to CCLD.

Type of visit: POC

On 07/31/2025 at 2:00 PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a POC visit. LPA spoke with Administrator (ADM) Victoria Puruganan and explained the purpose of the visit via phone. ADM gave verbal permission for the Care staff, Renato L. Tisico, to sign the report. The administrator failed to provide POC during the POC visit. - 87623 Indwelling Urinary Catheter - §1569.625 Staff training ***An immediate $200.00 civil penalty will be assessed on today's date for failure to correct *** Exit interview conducted. A copy of the LIC421FC, this report, and appeal rights are provided.the state’s words, verbatim · CDSS document, Jul 31, 2025

Type of visit: Case Management - Other

On 7/30/2025 at 10 am, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Case Management visit to review residents’ (R) files. LPA informed Administrator, Victoria Puruganan, of the purpose of the visit. Victoria Puruganan arrived approximately 1 hour later. LPA obtained R1, R2, and R3 physician reports, identification, and emergency information. LPA obtained facility liability documentation. There is no deficiency during this visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 30, 2025

Allegation investigated: Facility does not ensure adequate staffing during the night shifts

On July 17, 2025, at 3 pm, Licensing Program Analysts (LPAs) K. Nguyen and L. Alexander arrived unannounced to deliver findings on the above allegation. LPAs met with care staff Renato L. Tisico and explained the visit. Administrators were notified and gave verbal for care staff to sign the report. Allegation: Facility does not ensure adequate staffing during the night shifts- Unsubstantiated Report continues on LIC 9099c... Unsubstantiated During the investigation, LPAs reviewed the staff schedule (LIC500). LPAs reviewed the Residents' files. LPAs interviewed Resident 1 (R1), Resident 3 (R3), Administrator (ADM), Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), Staff 4 (S4), Staff 5 (S5), and Staff 6 (S6). R1 and R3 stated that there are always staff at the facility. R1 stated R1 heard from R1 room that staff are redirecting R3 back to R3 room, because R3 tends to yell and open other residents' rooms. R1 states “There are night staff at all times”. R3 states, “The facility does not have an issue with staff at night”. S1 and S2 are live-in care staff, and S1 is the main care staff for the night shift. LPAs interviewed S3, S4, S5, and S6 via phone; all stated that they are S1 and S2 staff relieved on their days off. Based on interviews, the facility is ensuring adequate staffing during the night shifts. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. An exit interview is conducted, and a copy of this report is provided.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 15-AS-20250715161132

Type of visit: Case Management - Deficiencies

On 07/17/2025 at 5:30 PM, Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a case management visit. LPAs met with Administrator, Victoria Puruganan, and explained the purpose for the visit. While LPA L. Alexander was at the facility for a complaint investigation (#15-AS-20250715161132), the following deficiency was observed. After reviewing Guardian system, LPA L. Alexander observed staff (S) S1, S2 and S3 was fingerprint cleared, but not associated to the facility. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report, LIC421BG, and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jul 18, 2025

87355 (e) (3) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Criminal Record Clearance. All individuals subject to a criminal record review ...Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not associating S1, S2 and S3 to the facility which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Administrator agreed to send LIC9182 and US Issued ID for S1, S2 and S3 to CCLD to be associated to facility through Guardian. Civil Penalties of $1500.00 assessed today.

Type of visit: POC

On 07/17/2025 at 4:30 PM, Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a Plan of Correction (POC) visit. LPAs met with caregivers, Renato & Zenaida Tisico and explained the purpose of the visit. Zenaida phoned Administrator, Victoria Puruganan to inform. Victoria Puruganan arrived approximately 1 hour later. On 07/16/2025, LPAs conducted an Annual Inspection visit in which deficiencies were cited. The POC due date was 07/17/2025. Administrator failed to submit the POC by the due date and this is why LPAs came to make a POC visit. Deficiency not cleared: CCR 87202(a)(2) Fire Clearance: for having Resident, R2, in a bedroom without fire clearance for bedridden. Administrator will send LIC 200 and facility sketch to CCLD. Immediate Civil Penalties in the total amount of $500.00 is assessed today for failure to meet POC date for deficiency 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. A copy of this report, appeal rights provided and LIC421IM provided.the state’s words, verbatim · CDSS document, Jul 17, 2025

Type of visit: Required - 1 Year

On 07/16/2025 at 9:30 am, Licensing Program Analysts (LPAs) K. Nguyen and L. Alexander conducted an unannounced 1-Year Required inspection. LPAs met with Zenaide Tisico, the caregiver, and explained the purpose of the visit. Victoria Puruganan, Administrator, arrived at 11:00 am. The Administrator currently holds a certificate (#7005844740) that expires on October 24, 2026. The facility’s fire clearance was approved for six (6) non-ambulatory residents. Hospice waiver approved for two (2) residents. LPAs toured the facility with the caregiver, including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and backyard. The facility consists of five (5) total bedrooms which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPAs observed that lighting in all rooms is adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 123 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide detectors were in operating condition during the visit. Fire extinguishers were last serviced on 12/20/2024. The Emergency Disaster Plan was posted. The first aid kit was observed to be complete. Report continues on LIC 809c... LPA reviewed three (3) residents' files and reviewed seven (7) staff files. LPAs observed the following deficiencies: At 10:54am paneling from appliances, book shelf and electronics located outside garage At 10:54am three (3) ladders, mattress, chair, bags of charcoal, wood located rear back yard At 10:57am one (1) resident laying in bedroom #3 with a urinary catheter laying on the floor LPA requested the following documents to be submitted to CCLD by 7/25/2025. · Resident Roster · LIC 308 Designation of Administrative Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report (updated) · LIC 610E Emergency Disaster Plan (9 pages) · Liability Insurance 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 right providedthe state’s words, verbatim · CDSS document, Jul 16, 2025

Type of visit: Case Management - Deficiencies

On 5/7/2025 while conducting a Case Management Licensing Program Analysts (LPA) K. Nguyen reviewed resident files and interviewed staffs, shows that prior to hospitalization R1 have a wound located on the left side of R1 hip. 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 right provided.the state’s words, verbatim · CDSS document, May 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87612(a)(11) · Plan of correction due date: May 9, 2025

87612 Restricted Health Conditions (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (11) Wound care as specified in Section 87631. This requirement was not met as evidenced by: Based on files review and interviews conducted administrator did not comply with the section cited above by R1 having a wound prior to hospitalization, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Administrator will inform licensing, and submit all require documents regarding wound care and updates reports any wound residents developing, or return back to facility upon wound care. Review the citied regulation with a self-certification understanding regulation, fax all documents to CCL by POC date.

Type of visit: Case Management - Other

On 5/7/2025 while conducting a Case Management Licensing Program Analysts (LPA) K. Nguyen reviewed residents files, shows R1 and R2 files are incomplete. 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 right provided.the state’s words, verbatim · CDSS document, May 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b) · Plan of correction due date: May 23, 2025

87506 Resident Records (b) Each resident’s record shall contain at least the following information: This requirement was not met as evidenced by: Based on files review and interviews conducted administrator did not comply with the section cited above by not having a complete files for R1, and R2, which poses an immediate health and safety risk to persons.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Administrator will complete R1, and R2 files. Review the citied regulation with a self-certification understanding regulation, fax all documents to CCL by POC date.

Type of visit: Case Management - Deficiencies

On 5/7/2025 at 11am Licensing Program Analysts (LPA) K. Nguyen conducted an unannounced Case Management visit because on 5/6/25 LPA received information by the Regional Office upon the Administrator did not report or submit a death report to licensing. LPA were greeted by care staff Evangeline Fernadez and explained the purpose of the visit. LPA asked to contact Administrator (ADM), Victoria Puruganan via telephone. ADM was not able to meet LPA and asked for Jezrael Pascual to assist LPA and sign the report. LPA confirmed with ADM at around 1:34pm R1 passed away on 3/29/2025 under hospice care, but did not report to licensing because ADM stated that she thought that if the resident is under hospice care, then she doesn’t need to report. ***An immediate $250.00 civil penalty will be assessed on today's date for reported violation within 12month*** Exit interview conducted. A copy of the LIC421FC, this report and appeal rights provided.the state’s words, verbatim · CDSS document, May 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: May 23, 2025

87211(a) REPORTING REQUIREMENTS Each licensee shall furnish to the licensing agency such reports as the Department may require.. This requirement was not met as evidenced by: Based on files review and interviews conducted administrator did not comply with the section cited above by not following reporting requirements which poses an immediate health and safety risk to persons in care. R1 pass away on 3/29/25 and was no being reported to licensing.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Administrator will reach out to vendor certify by DSS to conduct an in service training on Reporting Requirements and fax a copy of attending staff to CCL by POC date. ***An immediate $250.00 civil penalty will be assessed on today's date for reported violation within 12month***

Allegation investigated: Facility staff are not providing food to residents in the quantity needed Facility staff are not providing assistance to residents when needed

On 12/17/2024 at 10:00am Licensing Program Analysts (LPAs) K. Nguyen and L. Alexander arrived unannounced to conduct investigation of the above allegations. LPAs met with House Manager, Jezrael Pascual informed the purpose of LPA's visit and requested to call to Administrator (ADM), Victoria Puruganan. ADM was not available during the time of investigation. ADM gave permission to Jezrael to sign the report. Allegation: Facility staff are not providing food to residents in the quantity needed- Unsubstantiated During the course of investigation, LPAs reviewed files and conducted interviews with residents/ staffs. LPAs observed three residents and three staffs at the facility. It was alleged that facility staff are not providing food to residents in the quantity needed. LPAs interviews two residents and attempted to interview the third resident. Two out of two residents’ states that the food is in good quantity. Two out of two residents’ states that they received three meals a day and snack. Report continued on LIC 9099c… Unsubstantiated Allegation: Facility staff are not providing assistance to residents when needed- Unsubstantiated During the course of investigation, LPAs reviewed files and conducted interviews with residents/ staffs. LPAs observed three residents and three staffs at the facility. It was alleged Facility staff are not providing assistance to residents when needed, however LPAs interviewed residents two out of two indicated that staff are providing them with assistance they need, and when they needed. LPAs interviewed three staff 3 out of 3 stated they assisted residents with, bathing, changing, cooking, laundry, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview is conducted and a copy of this report is provided.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 15-AS-20241213161313

Type of visit: Case Management - Deficiencies

During a complaint investigation (15-AS-20241213161313) on 12/17/24. During staff interview Program Analysts (LPAs) K. Nguyen and L. Alexander discovered Administrator (ADM) Victoria Puruganan is not at the facility a minimum of 20 hours a week according to Administrator qualification. LPAs reviewed LIC 500 indicates ADM are present at the facility from Monday- 9am-3pm, Tuesday- 8am-2pm, Wed 9am-2pm, and as needed. Staffs stated within the month of November ADM showed up a maximum of three time. ADM gave permission for Jezrael to sign the report from the beginning of the visit. *An immediate $250.00 civil penalty will be assessed on today's date for reported violation within 12month. * Exit interview conducted. A copy of the LIC421FC, this report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Dec 24, 2024

87405 Administrator - Qualifications and Duties All facilities shall have a qualified and currently certified administrator... The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section... This requirement is not as evidenced by: Based on inteviews, the licensee did not comply with the section cited above by not having the administrator at the facility for a sufficient number of hours which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 17, 2024

Plan of correction: Licensee/ Administrator agrees to have a set hour dedicated at the facility to handle daily administrator daily operation. Licensee/ Administrator agree to have a record of time in and out sign along with staff signature witness ADM at the facility according to the ADM set time submit on a weekly basic starting 12/23/24 CCLD by POC date. *An immediate $250.00 civil penalty will be assessed on today's date for reported violation within 12month. *

Type of visit: Case Management - Deficiencies

During an complaint investigation (15-AS-20241213161313) on 12/17/24. While doing files reviewed Licensing Program Analysts (LPAs) K. Nguyen and L. Alexander discovered R1 had a fall back in October 17, 2024 that led R1 to the emergency room, which facility failed to report to CCLD. LPAs tried to contact Administrator, but was not able due to phone went to voicemail. ADM gave permission for Jezrael to sign the report. *An immediate $250.00 civil penalty will be assessed on today's date for reported violation within 12month. * Exit interview conducted. A copy of the LIC421FC, this report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Dec 27, 2024

87211(a) REPORTING REQUIREMENTS Each licensee shall furnish to the licensing agency such reports as the Department may require.. This requirement was not met as evidenced by: Based on intervews conducted licensee/adminisrator did not comply with the section cited above by not not follow reporting requirements which poses an immediate health and safety risk to persons in carethe state’s words, verbatim · CDSS document, Dec 17, 2024

Plan of correction: Administrator will review and conduct an in service training on Reporting Requirements and fax a copy of the training agenda to CCL by POC date. *An immediate $250.00 civil penalty will be assessed on today's date for reported violation within 12month. *

Type of visit: Case Management - Other

On 12/17/2024 at 10:20 AM Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a Case Management visit. LPAs met with Caregivers, Paciencia, Winnie and Cesar. House Manager, Jezrael Pascual, arrived approximately, 1 hour later. Administrator, Victoria Puruganan was not available. While LPA L. Alexander and K. Nguyen was conducting a complaint investigation(15-AS-20241213161313) on 12/17/2024. During record review LPAs observed Resident (R) R1 and R2 did not have a current annual medical assessment and Appraisal Needs and Services (ANS) within the last year. Staff stated that R1 was admitted to hospice care on 12/10/2024 and there were no updated ANS documenting change of conditions. LPAs observed that R3 who has a diagnosis of Dementia does not have an updated ANS on file. LPAs obtained the following documents: admission agreement and hospice care admission for R1 and Physician's Report for R4. 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, Dec 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jan 14, 2025

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidence by: Based on record review and observation, Licensee did not comply with the section cited above by not completing an annual ANS for R3 which poses an immediate health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Dec 17, 2024

Plan of correction: Administrator agreed to self-certify that they read, understand and will comply with the regulation. In addition, send a copy of updated ANS for R3 to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463 · Plan of correction due date: Jan 14, 2025

87463 Reappraisals -This requirement is not met as evidenced by Based on record review and observation, Licensee did not comply with the section cited above by not having an updated annual medical assessments and ANS for R1 and R2 in addition R1 was admitted to hospice care dated 12/11/24 without any ANS that documents change of condition for hospice services which poses an immediate health and safety risk and personal rights to persons in care.the state’s words, verbatim · CDSS document, Dec 17, 2024

Plan of correction: Administrator agreed to self-certify that they read, understand and will comply with the regulation. In addition, send a copy of updated medical assessments (LIC602A) and ANS for R1 and R2 to CCLD by POC due date.

Type of visit: Case Management - Other

On 12/17/2024 at 10:20 AM Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a Case Management visit. LPAs met with Caregivers, Paciencia, Winnie and Cesar. House Manager, Jezrael Pascual, arrived approximately, 1 hour later. Administrator, Victoria Puruganan was not available. While LPA L. Alexander and K. Nguyen was conducting a complaint investigation(15-AS-20241213161313) on 12/17/2024. During investigation LPAs observed a chain lock attached to the inside door. LPAs advised caregivers that a chain lock can't not be attached and hooked on the doors in preventing residents from leaving out the door. 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, Dec 17, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Dec 18, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly... 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.... This does not prohibit a with permission from the Department. This requirement is not met as evidence by: This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the section cited above by having a door chain latch at front door which poses an immediate health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Dec 17, 2024

Plan of correction: Administrator agreed to remove the chain latch from front door. During visit, chain was removed. Deficiency cleared. An immediate civil penalty of $500 is assessed today.

Type of visit: Case Management - Other

During an complaint investigation (15-AS-20241213161313) LPAs K. Nguyen and L. Alexander observed that facility do not have a minimum of one week non- perishables food supply. LPAs tried to contact Administrator, but was not able due to phone went to voicemail. ADM gave permission for Jezrael to sign the report. LPAs requested Administrator to submit on weekly basic of groceries receipt and photo of all food supplies to CCLD starting from the week 12/23/24: No deficiency were cited at this time. Exit interview is conducted and a copy of this report is provided.the state’s words, verbatim · CDSS document, Dec 17, 2024

Type of visit: Required - 1 Year

On 07/24/2024 at 9:45am, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced 1-Year required inspection. LPA met with Nelai Punzalan, Caregiver, and explained the purpose of the visit. Victoria Puruganan, Administrator was not available during the inspection. Jezrael Pascual, Facility Manager later arrived at 12:10pm. The Administrator currently holds a certificate (#6019519740) that expires on 10/24/2024. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA got verbal permission for Facility Manager to sign the report. LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) total bedrooms which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguishers were last serviced on 08/16/2023. Emergency Disaster Plan was posted. First aid kit was observed to be complete. LPA reviewed five (2) residents file and four (2) staff files the files reviewed were complete. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 24, 2024

Type of visit: Case Management - Other

LPA K. Nguyen conducted an unannounced case management visit to serve an immediate exclusion order to staff S1. LPA K. Nguyen first spoke privately with Administrator/ Licensee, Victoria Puruganan to explain the situation - providing her with a copy of the Order to Executive Director of Immediate Exclusion. According to Administrator/ Licensee S1 never came back in the facility from the time that he was involved in some illegal cases sometime in 2014. Administrator/ Licensee never seen S1 since 2014. LPA K. Nguyen reviewed this report with Administrator/ Licensee, and a copy of this report is provided via email.the state’s words, verbatim · CDSS document, Jun 17, 2024

Allegation investigated: Administrator is not at the facility a sufficient amount of time to manage the daily operations Staff do not follow reporting requirements

On this day at around 8:45 am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct investigation on the above allegations. LPA met with facility manager Jezrael Pascual and explained the purpose of visit. LPA informed Administrator (AD), Victoria Puruganan the purpose of visit over the phone. Administrator was unavailable and gave verbal permission to facility staff to sign the report. Allegation: Administrator is not at the facility a sufficient amount of time to manage the daily operations: Substantiated During the course of investigation, LPA interviewed S1, and S2 indicated Administrator is not at the facility a sufficient amount of time to manage daily operations. S1 stated that AD gave full trust to an individual staff that AD was assuming that everything was under control; therefore, AD do not need to come often. S2 admitted that S2 was not as the facility as often were S2 supposed to be to handle daily operation. Report continue on LIC 9099c... Substantiated Allegation: Staff do not follow reporting requirements: Substantiated Based on interview conducted S1 and S2 indicated that some reports are no being reported to CCLD, due to S2 assuming that the Individual staff are doing the reporting. According to S1 times that incident happened but the staff that are put in charge did not report, and AD is assuming that the report had been made. Based on LPA interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22. Deficiencies are being cited on the attached LIC 9099D. LPA discuss plan of correction to AD, and AD agree to the finding of the allegation over the phone. Exit interview was conducted with facility manager. A report and appeal rights was provided via email.the state’s words, verbatim · CDSS document, Jun 6, 2024 · control 15-AS-20240531103645

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jun 14, 2024

87405 Administrator - Qualifications and Duties All facilities shall have a qualified and currently certified administrator... The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section... This requirement is not Based on inteviews, the licensee did not comply with the section cited above by not having the administrator at the facility for a sufficient number of hours which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 6, 2024

Plan of correction: Licensee/ Administrator agrees to have a set hour dedicated at the facility to handle daily administrator daily operation. Licensee/ Administrator agrees to review the regulation under Administrator qualification and submitted a self-certified letter confirm that licensee/ administrator understanding of the regulation and fax it to CCLD by POC date. Administrator will review and conduct an in service training on Reporting Requirements and fax a copy of the training agenda to CCL by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Jun 14, 2024

87211(a) REPORTING REQUIREMENTS Each licensee shall furnish to the licensing agency such reports as the Department may require.. This requirement was not met as evidenced by: Based on intervews conducted licensee/adminisrator did not comply with the section cited above by not not follow reporting requirements which poses an immediate health and safety risk to persons in carethe state’s words, verbatim · CDSS document, Jun 6, 2024

Type of visit: Required - 1 Year

On 01/16/2024 at 10:00am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Evangeline Fernandez, Caregiver, and explained the purpose of the visit. Victoria Puruganan, Administrator arrived at 11:40am. The Administrator currently holds a certificate (#6019519740) that expires on 10/24/2024. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) total bedrooms which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 75 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 146.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguishers were last serviced on 08/16/2023. Emergency Disaster Plan was posted. First aid kit was observed to be complete. LPA reviewed five (5) residents file and four (4) staff files the files reviewed were complete. Continued on LIC809C. Continue from LIC 809 LPA observed the following deficiencies: · At 10:05am, LPA observed freezer burnt meat stored in thin produce bags. · At 10:07am, LPA observed medication in an unlocked drawer in the dining room and kitchen. · At 10:10am, LPA observed WD-40, a hammer, screw drivers, scissors in an unlocked drawer. · At 10:13am, LPA observed medication in the water temperature in the bathroom 146.8. · At 10:15am, LPA observed a resident restrained in a bedroom. · At 10:20am, LPA observed box spring, ladder, paint, wood planks, microwave, weights, nets, bricks and a unlocked storage cabinet. · At 10:23am, LPA observed a pad lock on the gate. LPA requested the following documents to be submitted to CCLD by 1/23/2024. · Resident Roster · LIC 308 Designation of Administrative Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report (updated) · LIC 610E Emergency Disaster Plan (9 pages) · Liability Insurance Continued on LIC809C. Continued from LIC809C. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. *An immediate $500.00 civil penalty will be assessed on today's date for locked gate.* Exit interview conducted. A copy of the LIC421BG, this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 16, 2024

The state marks this report as 12 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.