Irene's Board & Care

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

On 8/25/2026 at 1:45pm, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management - Legal/Non-Compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 7/1/2025. As a result of the non-compliance conference, the licensee is placed on frequent monitoring for a period of two years. LPA met with staff Loreta Cabuquin and Julita Plarisan and explained the reason for the visit. Licensee/Administrator Angelita Maravilla was not at the facility, LPA spoke with them over the phone and they stated they would return to the facility to meet with the LPA, they arrived at 2:45pm. LPA and staff toured the facility for health and safety concerns. During today's visit the forecast temperature in Paso Robles is 99°F, the indoor facility temperature was 75°F per the thermostat located on the second floor; the second floor is not accessible to residents. The temperature on the first floor felt comfortable and residents stated they were comfortable. LPA observed upon arriving to the facility one resident was putting a puzzle together, another was watching TV with a cup of water within arms reach, and staff stated the third resident was out of the facility with family. LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. The facility had no obstructions in hallways, doorways or exits. LPA reviewed staff medication training and found three (3) of three (3) staff have not received all eight (8) hours of medication training in the last twelve (12) months. Licensee stated they and the two staff present during today's visit assist with medication administration and have not completed all required hours. Exit interview conducted, deficiency cited on LIC809-D page, report signed, appeal rights and report provided to the Licensee.the state’s words, verbatim · CDSS document, Aug 25, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(b) · Plan of correction due date: Sep 8, 2026

(b) Each employee who received training and passed the examination... and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not ensure all three staff that assist with medication administration recieved their annual medication training, which poses a potential Health, Safety, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: Licensee states they will ensure they and the other two staff recieve the required hours and email the completed training documents to the LPA on or before 9/8/2026.

Allegation investigated: Staff do not provide adequate supervision resulting in a resident eloping from the facility. Staff do not follow reporting requirements. Staff do not provide activities.

On 6/16/2026 at 9:10am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to further investigate the allegations of this complaint and deliver final findings. LPA met with Licensee/Administrator Angelita Maravillas and explained the purpose of the visit. During a visit on 3/11/2026 LPA conducted interviews, toured the facility, and obtained relevant documents. On the allegation, staff do not provide adequate supervision resulting in a resident eloping from the facility and staff do not follow reporting requirements; it was alleged that Resident #1 (R1) is not able to leave the facility unassisted and that they have left the facility unattended three times. It is alleged that in September 2025 R1 left the facility unattended and was found by police; and on a day in March 2026 R1 left the facility unattended, walked two blocks, staff drove to find R1, brought them back to the facility, and told them not to tell anyone about the incident. (Continued on LIC9099-C) Substantiated LPA review of R1’s records revealed that R1’s medical assessment (LIC602A) dated 6/11/2025 states R1 is able to leave the facility unsupervised (considering physical and cognitive abilities). Interviews and police incident report reveal that on 9/12/2025 an employee of a commercial business approximately 0.7 mile from this facility called police when R1 entered the business and appeared confused. Police took R1 to a facility they previously lived at, the facility was able to assist police in contacting R1’s family, and R1’s family returned them to this facility the same day. Interviews revealed that on a day in March 2026 R1 left the facility unattended, when staff noticed R1 missing from the facility they went looking for them and found R1 on the sidewalk east of the facility approximately two houses down. Interviews revealed no knowledge of a third incident where R1 left the facility unattended. A review of reports received from the facility by Community Care Licensing (CCL) revealed the facility has not submitted reports for either of the two listed incidents. The Licensee states they have not documented either of these incidents. An appraisal/needs and services plan for R1 dated 6/20/2025 does not mention any risks, non-risks or interest to R1 in leaving the facility unsupervised. A reappraisal dated 12/25/2025 states R1 is ambulatory and very independent; that all staff are to orient R1 to time, place and situation; and that all staff are to take R1 for a short walk. Staff interviews revealed that they do not think R1 is able to find their way back to the facility if they leave and the reason R1 needs to be oriented to time, place, and situation is because are confused at times. The Licensee states that R1’s primary care physician was made aware by family of the incident that happened on 9/12/2025, but that no staff notified the physician or requested an updated medical assessment. The Licensee states the physician has not been made aware of the incident that occurred in March 2026 and they do not know why they have not updated the appraisal/needs and services plan to reflect R1’s interest in leaving the facility unassisted and risk of elopement. During the initial LPA visit on 3/11/2026 LPA requested the Licensee obtain an updated medical assessment from the physician and update R1's reappraisal. As of today's visit the Licensee has an updated medical assessment dated 4/30/2026 indicating that R1 is not able to leave the facility unsupervised and needs safety assistance. R1's reappraisal was updated with a date of 3/13/2026 stating staff are expected to increase visual checks of R1 and report increased wandering to the physician. (Continued on LIC9099-C) Based on all interviews conducted and documents obtained, although R1’s medical assessment dated 6/11/2025 states they may leave the facility unsupervised the facility did not report to R1’s primary care physician the incidents that have occurred, did not seek an updated medical assessment, and did not conduct a reappraisal addressing changes in condition until the LPA requested they be addressed on 3/11/2026. At this time the above allegations were found to be substantiated, there is a preponderance of the evidence to prove that the alleged violations occurred. On the allegation, staff do not provide activities; it was alleged that R1 is not provided any activities and just sits in front of the television all day. LPA reviewed an activity calendar dated March 2026 with most activities scheduled daily at 10,130, and 500, Licensee states these times are 10:00am, 1:30pm and 5:00pm. The general activities held at 10:00am are exercise or outdoor sitting; at 1:30pm movie or western show; at 5:00pm current events, ice cream social, or music; with ten days in March 2026 listing 11:00am pet therapy and five days with 1:30pm table games. During LPAs recent visits LPA has observed residents watching TV in the living room or spending time in their private rooms. Staff interviews reveal that they walk with R1 outside the facility once or twice a day and that R1 will sometimes play games like Scrabble with them or put together a puzzle. Staff stated R1’s family also takes them out of the facility multiple times each week and also walk around the neighborhood with them. Staff state pet therapy has not happened for months and that they have heard residents say they are bored. Resident interviews revealed that the facility does not provide activities, they are not aware there is an activity calendar, and have not seen a pet in the facility for pet therapy. Resident’s also state they are not allowed to go outside on the back patio and that staff do not do activities outside, like outdoor sitting. Residents state they are not encouraged to contribute to the planning of activities. Based on observation, all interviews conducted, and documents obtained, at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, deficiencies cited on LIC809-D pages, report signed, appeal rights and report provided to Licensee. Staff stated that they have always put the phone on speaker mode for R1 due to their hearing loss and R1 has never asked for it to not be on speaker or to have privacy during phone calls. They state if she wants privacy they would direct R1 to their private room and help them turn the speaker mode off. Interviews also revealed R1 has a personal cell phone that they can also take private calls on. LPA review of R1’s preadmission appraisal and medical assessment (LIC602A) revealed that R1 does have hearing loss. R1 stated that they can take calls privately and are hard of hearing. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated there is not a preponderance of the evidence to prove that the alleged violation occurred. On the allegation, staff are unable to communicate with residents due to a language barrier; it was alleged that most of the staff do not speak English and it’s very difficult for residents to communicate with them. LPA noted there are two additional staff that work at this facility in addition to the Licensee. The primary language of these two staff is Visayan, a dialect in the Philippines. The Licensee also speaks the dialect. During recent visits, LPA observed staff were able to communicate in English sufficiently to complete tasks and respond to simple questions. At times, their responses were brief or required repetition, and there were moments when it was unclear whether they fully understood verbal instructions. However, staff consistently demonstrated understanding through their actions. Residents reported that they are able to communicate with staff with occasional difficulty understanding stating it could be due to their own hearing loss. LPA reviewed with the Licensee the personnel requirements in Title 22 stating staff are required to have training on the skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. Based on observation, all interviews conducted, and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. (Continued on LIC9099-C) On the allegations, staff do not ensure that bathrooms have towels and facility is malodorous; it was alleged that sometime in November 2025 there were no paper towels in the bathroom and that the bathroom smelled like urine. This facility has two public restrooms. During LPA visit on 3/11/2026 and today Licensee showed LPA a supply of paper towels and toilet paper kept at the facility, both bathrooms had paper supplies and LPA did not note a urine smell during either visit. During a recent visit LPA noted the paper towel dispenser in the public bathroom closest to the resident bedrooms to be located high up on the wall and asked that it be moved lower for easier access. The Licensee has since moved the dispenser lower. Residents state they cannot think of a time when there were no paper products, maybe a small quantity once, and they have not noted strong urine smells in the facility. Based on observation, all interviews conducted, and documents obtained, at this time the above allegations were found to be unsubstantiated, meaning that the allegations may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. On the allegation, staff do not ensure resident's hygiene needs are being met; it was alleged that sometime in November 2025 R1 was wearing dirty clothes, smelled, and their hair looked greasy and dirty. R1’s medical assessment states that they do not require assistance to bath, dress and groom. Staff state the residents bath 1-2 times a week and if they want to more often they can. Staff state R1 is able to dress independently but they usually assist with that task, as well as, bathing because they do not want R1 to fall and R1 has mobility limitations. They state R1 does get frustrated sometimes and try to refuse their help. Residents state staff assist them with bathing and grooming if they need it. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. (Continued on LIC9099-C) On the allegation, staff do not ensure resident is receiving medication as prescribed; it was alleged that R1 is diabetic and is not able to administer their own medication. It is also alleged that the Administrator is a nurse, but is not at the facility everyday to assist R1 with medication administration. Review of R1’s records reveal they are prescribed insulin injections; the medical assessment dated 6/11/2025 states that R1 is able to administer their own injections, is prescribed a diabetic/low carb diet, and the appraisal/needs and services plan dated 12/25/2025 states R1 is able to self-administer their insulin injections. R1 has a continuous glucose meter that continuously checks their blood glucose level, with external display that has an audible alert when their insulin is outside the designated range. Interviews revealed one of R1’s local family members is a nurse who assists R1 in replacing the sensor every 15 days. During two separate visits, including the visit on 3/11/2026, LPA observed R1 self-administer their injections. R1 states the food served at the facility follows their diet. Staff state and record review reveal R1 is on a diabetic/low carb diet and they do provide foods that meet R1’s needs. Staff stated due to tremors they sometimes assist by stabilizing R1’s hand as R1 administers the insulin, they also assist R1 by preparing the insulin pen with needle, and set the insulin pen dial per physician order. The Licensee was able to provide documented staff training on diabetes. As of today's visit the California Board of Registered Nursing (BRN) shows the Licensee/Administrator of this facility has a registered nursing license with a status of “retired”, as of 12/31/2023. According to the BRN website, a retired status means the registered nurse (RN) shall not engage in the practice of nursing. Meaning the Licensee/Administrator is not allowed to administer injections to R1, or any resident, per California Title 22 regulations for residential care facilities for the elderly. Additionally, any other staff at this facility who are not appropriately skilled professionals may not administer injections. Licensee states they recently paid to bring their RN license current. Based on observation, all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, report signed, and report provided to the Licensee.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 29-AS-20260303110830

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jun 30, 2026

The licensee shall ensure that residents are regularly observed for changes in physical, mental... When changes... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not report R1's changes in condition to their physician until the LPA requested they do so which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: Licensee states they will create a policy on reporting and documenting changes in condition and train the staff on the policy. Licensee will email the policy and staff training tot he LPA on or before 6/30/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(b) · Plan of correction due date: Jun 30, 2026

87219(b) Planned Activities (b) Residents served shall be encouraged to contribute to the planning, preparation, conduct, clean-up and critique of the planned activities. This requirement was not met as evidenced by: Based on observation, interview, and record review, the licensee did not involve resident in planning activites and provide the activities listed on their calendar which poses an potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: Licensee states they will get resident input prior to creating each months calendar. Licensee will email LPA the July activity calendar and a letter of understanding on the importance of involving residents in activity planning on or before 6/30/2026.

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

On 6/16/2026 at 9:10am, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management - Legal/Non-Compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 7/1/2025. As a result of the non-compliance conference, the licensee is placed on frequent monitoring for a period of two years. LPA met with Licensee/Administrator Angelita Maravillas and explained the reason for the visit. LPA and Licensee toured the facility for health and safety concerns. LPA tested the hot water at 109.8°F, within regulation temperatures 105-120°F. LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility had no obstructions in hallways, doorways or exits. LPA and Licensee conducted a medication audit and reviewed the facilities Centrally Stored Medication and Destruction Records(CSMDRs). At 10:16am LPA observed a physician order dated 3/30/2026 for Resident #1 (R1) that stated memantine hcl 10MG take one tablet by mouth daily. The facilities medication administration record(MAR), CSMDR, and the medication bottle for R1 all state memantine hcl 5mg take one tablet by mouth daily. The Licensee states they over looked the dosage of 10mg on the physician order and that they have been giving R1 one 5mg tablet once daily. The Licensee called the physician for clarification and received an updated order during the visit. At 10:55am the LPA noted a physician order for Resident #2 (R2) stating seroquel 25mg take 1-2 tablets by mouth at bedtime as needed for agitation/sleep disturbances. R2's MAR for June 2026 indicates R2 has received seroquel 25mg twice daily at 8:00am and 4:00pm. The Licensee states R2 typically goes to bed between 6:00pm - 7:00pm. (Continued on LIC809-C) The Licensee also stated that R2's physician is aware they are receiving the medication twice daily routinely and not at bedtime. The Licensee states they do not have a physician order stating this but that they have requested one and so has R1's family, from the physician. R2's record reveals there is no physician order stating if R2 can determine their need for a PRN medication or if they can communicate their symptoms. During LPA visit conducted on 3/11/2026 Licensee was cited for not following physician orders, they submitted their plan of correction by the due date. Today's visit revealed the Licensee continues to not follow physician orders. LPA and Licensee reviewed staff training noting required documentation and hours. Exit interview conducted, deficiencies cited on LIC809-D page, an immediate civil penalty in the amount of $250 for a repeat violation within twelve months is being assessed on the attached LIC421FC, reports signed, and reports provided to Licensee.the state’s words, verbatim · CDSS document, Jun 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 17, 2026

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4)The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on observation, interview and record review, the licensee is not providing residents their medications as prescribed, which poses an immediate Health, Safety, Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: Licensee obtained an updated physician order for the memantine during the LPA visit and is working to obtain the updated seroquel order by tomorrow. Licensee will email LPA the updated seroquel order when received and a statement of understanding of this regulation by 6/17/2026.

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

On March 11, 2025 at 9:50am, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management - Legal/Non-Compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on July 1, 2025. As a result of the non-compliance conference, the licensee is placed on frequent monitoring for a period of two years. LPA met with Licensee/Administrator Angelita Maravillas and explained the reason for the visit. The LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At 10:05am, LPA and Licensee conducted a walk through of the facilities first floor where residents reside, the second floor is only accessed by facility staff. In bedroom #2 LPA noted two electrical outlets with no faceplates, leaving wires accessible. LPA and Licensee conducted a review of the facilities Centrally Stored Medications and Destruction Records (CSMDR) and the centrally stored medications for all three residents in care. During the review LPA and Licensee noted Resident #1 (R1) has a tube of triamcinolone 0.1% cream not logged on R1's CSMDR. Resident #2 (R2) with a bottle of quetiapine 25mg, pharmacy label states quantity thirty (30), instructions take one tablet by mouth every day, a physician order dated 11/12/25 states take one tablet by mouth twice daily and the CSMDR states this bottle was started November 2025 with no day noted. Had the medication been given as prescribed the medication from this bottle would have run out in fifteen days but a count of the pills in the bottle revealed eighty-six (86) pills, Licensee stated the reason there were more pills in the bottle (Contniued on LIC809-C) than the label stated was because they did not have enough pills and they took pills they had left over from a former resident and poured them into this bottle. A second bottle of quetiapine 25mg for R2 contained ninety (90) pills matching the quantity on the pharmacy label, the CSMDR for this medication states started on 3/8/2026. A review of Resident #3's (R3's) medication and CSMDR revealed a bottle of levothyroxine 75mcg with instructions to take one tablet by mouth every morning, a quantity of ninety (90) pills and start date of October 30, 2025; a count of the medications in the bottle revealed twenty-nine (29) dark blue pills with a stamp P3 indicating the pill dosage of 75mcg and three (3) light blue pills with a stamp P4 indicating 88mcg; Licensee stated R3's order changed from 88mcg to 75mcg and they must have combined the medications into this bottle; with a start date of October 30, 2025 at a quantity of ninety (90) this would be a ninety day supply. R3 also has a bottle of lisinopril 10mg with instructions take one tablet by mouth daily, and started on October 30, 2025; a count of the bottle revealed six (6) pills of the medication and a seventh pill with stamp of U25 matching R3's quetiapine 25mg bottle. Administrator stated they would destroy the medications that are mixed in bottles, stop using medications prescribed for other people, and ensure residents are receiving medications as prescribed. Exit interview conducted, deficiencies cited on LIC809-D pages, reports signed, and reports provided to Licensee.the state’s words, verbatim · CDSS document, Mar 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 12, 2026

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4)The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by: Based on observation, interview and record review, the licensee is not providing reisdents their medications as prescribed, which poses an immediate Health, Safety, Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Licensee removed and will destroy the mixed medications and they will write a procedure on using one bottle at a time and properly documenting start dates, email this to LPA by 3/12/2026. Additional Licensee will sign up for vendored medication training and email LPA confirmation for all three staff.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(5) · Plan of correction due date: Mar 12, 2026

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement was not met as evidenced by: Based on observation, interview, and record review, the licensee tansffered medications into three different medication bottles which poses an immediate Health, Safety, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Licensee states they will no longer mix medication and will incldue this in the procedure for the above plan of correction and email to LPA by 3/12/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 25, 2026

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidenced by: Based on observation, the licensee did not ensure two electrical outlets were covered with faceplates which poses a potential Health and Safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Licensee will have the outlets covered with faceplates and email LPA pictures by 3/25/2026.

Type of visit: Case Management - Other

On February 9th, 2026, at 9:30am, Licensing Program Analysts (LPAs) Haner-Tomasko conducted a Case Management - Other visit to the facility for the purpose of issuing Immediate Exclusion orders. LPA met with staff Loreta Cabuquin. LPA explained the reason for today's visit. During today's visit LPA conducted a physical tour of the facility and checked the wellness of the resident's in care. On January 8th, 2026 LPA conducted a Case Management – Other visit to the facility to review the Accusation for License Revocation, Revocation / Forfeiture of Administrator Certificate, and Exclusion Action documents with the Licensee and the backup administrator Kevin Schaefer. An Order of Licensee/Facility of Immediate Exclusion from Facility was issued on January 21st, 2026, in reference to facility backup administrator Kevin Schaefer. This Decision and Order became effective on February 2, 2026. On January 26th, 2026, LPA spoke with Licensee Angelita Maravilla over the phone regarding this exclusion order and the Licensee stated they were aware of the order and Kevin Shaefer’s last day in the facility was January 22nd, 2026. The Order regarding Exclusion from Facility indicates that Kevin Schaefer is not allowed to have contact with residents, be an Administrator, or be present at this facility or any facility licensed by the California Department of Social Services. During today’s visit LPA noted that Kevin Schaefer was not present in the facility. The Licensee could not be present during today’s visit, LPA reviewed the report with the Licensee over the phone and they gave permission for staff Loreta Cabaquin to sign the report. Exit interview conducted, report signed and a copy of this report was provided to lead staff Loreta Cabuquin.the state’s words, verbatim · CDSS document, Feb 9, 2026

Type of visit: Case Management - Other

On 1/8/2025, at 9:40am Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced case management – other visit at the facility to ensure the health and safety of the residents in care. LPA met with backup administrator Kevin Schaefer announced who he was and the reason for the visit. Licensee Angelita Maravillas was not able to meet at the facility but LPA and backup administrator called Angelita over the phone. LPA reviewed the documents, laws and regulations listed below with both Angelita and Kevin. LPA recently conducted the facilities annual visit on 12/12/2025 and during today’s visit LPA conducted a physical plant tour with the Licensee. LPA observed all four residents in care. On 12/11/2025, Accusation for License Revocation, Revocation / Forfeiture of Administrator Certificate, and Exclusion Action was sent to the Licensee of Irene’s Board and Care. LPA asked Licensee over phone call if they received the Accusation filed and dated on 12/10/2025. Licensee stated that they received the documents and have submitted an appeal. LPA and the Licensee reviewed the Accusation documents together. LPA reminded the Licensee that the Accusation needs to be shared with residents, residents’ responsible persons, the local Long-Term Care Ombudsman (LTCO), and is required to be posted in the facility in a prominent place. LPA shared and discussed the Health and Safety Code §1569.38 Posting of licensing reports; disclosure to new residents with the Licensee and the Licensee acknowledged understanding of the requirement. Per Health and Safety Code §1569.38(g), A licensee who fails to comply with the requirements of subdivision (b) or (c) shall be liable for civil penalties in the amount of one hundred dollars ($100) for each day of the failure to provide notification as required in this section. (Continued on LIC809-C) The total civil penalty for each day shall not exceed one hundred dollars ($100) regardless of the number of notices that the licensee fails to send that day. The total civil penalty for a continuous violation of subdivision (b) or (c) shall not exceed five thousand dollars ($5,000). Today at approximately 10:30am LPA observed accusation posted in a prominent place on the cork board near the dining room with other postings. Angelita gave permission over the phone for Kevin to sign the report. Exit interview conducted, report signed, and report provided to the backup administrator.the state’s words, verbatim · CDSS document, Jan 8, 2026

Type of visit: Required - 1 Year

At 9:20am, on 12/12/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Licensee/Administrator Angelita Maravillas, announced who he was and the reason for the visit. Licensee and LPA conducted a full tour of the facility. This facility is a two story residential home. LPA noted only staff have access to the second floor where there are live-in staff bedrooms and bathrooms; all resident bedrooms and bathrooms are on the first floor. This facility has four resident bedrooms (two are dual occupancy), two shared half bathrooms, and separate shower room for resident use. There is a family room, living room with dining space, and a kitchen. A room for staff to take a rest break is located under the stairs. Access to the laundry room and garage is through locked doors for resident safety. LPA noted that the back patio has seating and shade for residents and visitors. The facility has battery operated smoke detectors in each room that are working, the carbon monoxide detector is in the family room above one of the doorways leading to the hallway with resident bedrooms and is functioning normally. LPA observed multiple fire extinguishers throughout the facility that are in the green compression range, purchased on 9/1/2025. LPA tested facility hot water at 108*(f), within regulation temperatures 105*-120* (f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. During today's visit LPA noted no obstructions in hallways, doorways or exits. During the tour at approximately 10:00am, LPA observed Staff #1 (S1) and Staff #2 (S2) providing care to Resident #1 (R1) with the bedroom door fully open not providing R1 with privacy and Resident #2 (R2) walked by R1's open door during the care to access the half bathroom at the end of the hallway. (Continued on LIC809-C) Medications are locked in a cabinet near the dining area. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records(CSMR), finding nine resident medications not documented on the CSMR and five expired medications. LPA conducted a staff and resident file review. LPA observed 4 of 4 resident reappraisals are not up to date or complete. LPA and Licensee conducted a review of the annual care tool modules. Exit interview conducted, deficiencies cited on LIC809-D pages, reports signed, and reports provided to Licensee.the state’s words, verbatim · CDSS document, Dec 12, 2025

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff does not ensure sharp items are inaccessible to residents. Staff does not ensure cleaning products are locked away.

At 9:15am, on 9/25/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to investigate the allegations of this complaint. LPA met with Caregiver - Julita Plarisan, announced who he was and the reason for the visit. The Licensee/Administrator Angelita Maravillas was not at the facility, LPA attempted to contact her by mobile phone with no answer, the staff contacted her via facebook messanger audio. LPA explained the reason for the visit to the Licensee and they gave permission for Caregiver Julita Plarisan to sign this report. During the visit the LPA conducted interviews with residents, staff, the licensee, and collected relevant documentation. On the allegations, staff does not ensure sharp items are inaccessible to residents and staff does not ensure cleaning products are locked away. It was alleged by a reliable source that toward the beginning of this week (Continued on LIC9099-C) Substantiated On allegation, facility did not have an adequate amount of fruit and vegetables. It was alleged by a reliable source that there was limited to no fruit and vegetables on hand for the residents in care toward the beginning of this week in September 2025. During todays visit LPA observed approximately two ripe bananas, five oranges, nine apples, a full bag of purple grapes, four small tomatoes, five heads of lettuce, a half a bag of cut broccoli and an unopened 5 lb bag of mixed frozen vegetables which is an acceptable amount of perishable foods for 4 residents, for two days. LPA noted that there are more than a dozen canned fruits and vegetables in the pantry. LPA interviewed Licensee, who stated, they go shopping at least once a week or twice a week if needed. Residents stated to LPA during interview that they get enough fruits and vegetables. One resident stated they really like vegetables and usually get extra and another stated the staff meet their low carbohydrate diet needs. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted over the phone with Licensee and the Caregiver present at the facility, report signed, and report provided to the Caregiver. in September 2025 that the laundry room door and bathroom door across from the laundry room were left open leaving disinfectants, cleaning solutions, and laundry detergent unattended and accessible to residents in care. Additionally, at about the same time the kitchen knife drawer was left unlocked, a knife and pair of scissors were left on the kitchen counter unattended and accessible to residents in care. During today's visit LPA toured the facility and noted the laundry room door was closed, but unlocked. LPA observed the staff working in and around the laundry room at the time not leaving it unattended. LPA did not observe any cleaning solutions left unlocked in the bathroom across from the laundry room. The knife drawer was locked and no knives or scissors were left out unattended. LPA interviewed Licensee regarding the specific incident in the allegation and the Licensee admitted that at the time of the alleged incident the staff were caring for a resident in the resident's private room leaving all of the items listed in the allegation unattended by staff and accessible to the other 3 residents in care. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred. The facility was previously cited for disinfectants and cleaning solutions being left out, unattended, and accessible to residents in care on a Case Management - Legal/Non-Compliance visit dated 8/12/2025. Exit interview conducted over the phone with Licensee and the Caregiver present at the facility, deficiencies cited on LIC809-D pages, a civil penalty in the amount of $250 for a repeat violation is being assessed on the LIC421FC, report signed, report and appeal rights provided to the Caregiver.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 29-AS-20250922190818

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 26, 2025

Storage Space and Access (a) ...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives,...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 was not met as evidenced by: Based on observation, the licensee did not follow this regulation when they left disinfectants, cleaning solutions, knives, and sharp objects out and accessible to residents in care which poses an immediate Health and Safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: Licensee states they will re-train the staff on this regulation and create log sheets to record the date, time and reason for every time staff unlock and lock any locked cabinets containing disinfectants, cleaning solutions, poisonous substances, knives, and sharp objects. Licensee will email LPA training documents and signed staff roster on or before 9/26/2025 and the log on or before 10/03/2025.

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

At 9:28am, on 8/12/2025, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management - Legal/Non-Compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 07/01/2025. As a result of the non-compliance conference, the licensee is placed on frequent monitoring for a period of two years. LPA met with Lead Staff Kevin Schaefer and explained the reason for the visit. The LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At 9:35am, LPA and Lead Staff Kevin Schaefer conducted a walk through of the facilities first floor where residents reside, the second floor is only accessed by facility staff. LPA observed four (4) residents were in chairs in the family room watching TV and the fifth resident was in bed in their room. Resident rooms were observed to be furnished appropriately with sufficient lighting. Resident bathrooms were sufficiently stocked with supplies and paper towels. At 9:48am LPA observed an aerosol can of Raid bug spray and a can of Pledge furniture cleaner sitting out on bookshelves in the family room accessible to residents and at 9:52am an aerosol can of Favor furniture cleaner and Clorox disinfectant mist left out in the living room next to the TV accessible to residents in care. This facility fire clearance allows for a bedridden resident in bedroom #3. LPA interview revealed Resident #1 (R1) requires assistance from staff with turning or repositioning, meaning R1 meets the bedridden definition in Title 22 Regulations for this facility type and R1 does not reside in bedroom #3. The facility has battery operated smoke detectors in each bedroom and the hallway leading to bedrooms that are all working, the carbon monoxide detector is in the hallway and functioning normally. (Continued on LIC809-C) LPA observed multiple fire extinguishers throughout the facility in the green compression range, Kevin stated none of them have been serviced or purchased in the last year. Fire clearance violations were cited. At 10:16am LPA tested facility hot water in the resident shower which reached a maximum of 97.9*(f), not within regulation temperatures of 105*-120*(f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted a previous deficiency on 11/18/2024 when the Licensee was unable to show documentation of emergency drills conducted. The Licensee submitted documentation clearing the plan of correction for that deficiency on 12/04/2024. As of todays visit staff interview revealed an emergency drill has not been conducted this year. LPA spoke with the Licensee over the phone as they could not be at the facility in person. Exit interview, deficiencies cited on LIC809-D pages, a civil penalty in the amount of $500 for fire clearance violations is being assessed on the LIC421IM, a civil penalty in the amount of $250 for a repeat violation is being assessed on the LIC421FC, report signed, report and appeal rights provided to Backup Administrator.the state’s words, verbatim · CDSS document, Aug 12, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Aug 13, 2025

Fire Clearance(a)...Prior to...retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city,...fire department,...or the State Fire Marshal. (2)Bedridden persons. This requirement was not met as evidenced by: Based on observation and interview, the licensee did not follow their fire clearance a bedridden resident, R1, resides in a non bedridden room and fire extinguisher not serviced annually which poses an immediate Health and Safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: Licensee will submit an LIC200, LIC9054, and the facility sketch to the LPA by 8/13/2025 to see if the fire marshal will update the fire clearance to meet the needs of the resident in care. Provide LPA with proof of fire extinguisher service or purchase by 8/26/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Aug 13, 2025

Storage Space and Access (a) ...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances,... 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 was not met as evidenced by: Based on observation, the licensee did not follow this regulation when they left bug spray and cleaning solutions out and accessible to residents in care which poses an immediate Health and Safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: Backup Administrator removed and locked up the items at time of LPA observation. Licensee will email LPA a statement of understanding on this regulation by 8/13/2025. Licensee will conduct staff training on this regulation and email LPA documentation of the training on or before 8/26/2025.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Aug 26, 2025

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. ... This requirement is not met as evidenced by: Based on interview and not being able to produce evidence of quarterly drills, the licensee did not comply with the section cited above during the facility visit which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: Licensee will conduct an emergency disaster drill on each shift and show proof to LPA by 08/26/2025 via email. Licensee will also create a written plan to ensure the required drills are conducted quarterly and email the plan to LPA on or before 8/26/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(e)(2) · Plan of correction due date: Aug 26, 2025

(e) Water supplies and plumbing fixtures shall be maintained as follows:(2)...Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F... This requirement is not met as evidenced by: Based on observation the licensee did not meet this regulation when LPA tested the resident shower temp reaching a maximum of 97.9 degree F which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: Licensee will adjust water heater to meet the regulation and create a written plan to ensure the water temperature at all resident used faucets deliver water within regulation. Licensee will email the plan to LPA on or before 8/26/2025.

Allegation investigated: Licensee does not ensure door exits in residents rooms are kept free of obstructions.

At 7:20am on 12/12/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the initial investigation visit to the allegation to this complaint. LPA met with Licensee/Administrator, Angelita O. Maravillas, announced who he is and the reason for the visit. LPA conducted a tour of all resident rooms, conducted interviews, and issued final findings to the allegation to this complaint. As to the allegation of, “Licensee does not ensure door exits in residents’ rooms are kept free of obstructions.” It was alleged that on 11/27/2024 a Reliable Witness 1 (W1) observed several obstacles blocking the resident room exit doors. It was discovered through interviews, and observations that on 11/08/2024 at 8:04am LPA Jeffries interviewed by phone Reliable Witness 2 (W2), who stated that facility had a Hoyer lift blocking the exit door in Resident Room #2. Additionally, on 11/18/2024 during the annual inspection LPA Jeffries had observed a 3-drawer nightstand dresser and boxes blocking the CONTINUED on LIC9099-C Substantiated exit door to Resident Room #1.At the time Resident Room #1 had no residents currently occupying Resident Room #1. During that annual visit, on 11/18/2024 LPA verbally addressed the blocking of exits doors being a fire hazard (CCL 87203 State Fire Marshal, Chapter 10 CFC 1032.3 Required exits access, exits and exit discharges shall be continuously maintained and free of obstructions.[egress]) with the Licensee/Administrator, Angelita O. Maravillas, who acknowledge the fire hazard dangers, and moved items blocking Resident Room #1 exit doors. On 11/27/2024, W1 observed “numerous” items including, assistive medical devices/equipment, tray tables, large rolling garment racks, and stand-up assistance devices blocking sliding door exits. On 12/12/2024 at 7:45am LPA Jeffries conducted a facility tour observing Resident Rooms #2 with a Sara Steady lift partially blocking the exit door and Resident Room #4 with a chaise lounge couch partially blocking exit in room #4, LPA instructed Licensee/Administrator to permanently move both obstacles. At this time there is sufficient evidence to the allegation of, “Licensee does not ensure door exits in residents’ rooms are kept free of obstructions.” and is substantiated at this time. Exit interview, report read, citation issued, appeal rights and report provided.the state’s words, verbatim · CDSS document, Dec 11, 2024 · control 29-AS-20241205160726

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87203 · Plan of correction due date: Dec 25, 2024

87203 Fire Safety, All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met by evidence of W1, W2, and LPA observing Resident Room's exits being blocked by obstacles, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Licensee/Administrator, Angelita O. Maravillas, agrees to provided 2 hours of Fire Safety training from a CCLD authorized vendor to all staff by 12/27/2024 and email proof of training to LPA by 12/27/2024.

Type of visit: Required - 1 Year

At 9:00am on 11/18/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual facility inspection. LPA met with Licensee Angelita Maravillas, announced who he was and the reason for the visit being the annual facility inspection. At 9;30am Licensee and LPA conducted a full physical tour of the facility. The facility has 3 double occupancy resident rooms and one shared bathroom downstairs, upstairs, which is not licensed is for staff live-in, with 3 bedrooms, and 2 bathrooms one being an on suite bathroom, all for staff. On the first floor there are two living room areas, one room serves as a visitation room and the other living room serves as the general living room for residents in care. There is a kitchen an dining room area adjacent to the main living room. There is a laundry room where chemicals are located which is locked at all time. Centrally Stored Medications are located in a locked cabinet between the main living room and dinning area. There is a full first aide kit located in this locked cabinet. LPA noted that the stove was in need of cleaning and the staff began cleaning stove and finished before LPA finished annual inspection. LPA noted that there is at least 2 days of perishable foods and at least 7 days of non perishable foods on hand in the facility for residents and staff. LPA observed emergency water supply. LPA noted that the resident bedrooms had required chair, lighting, drawers, and bedding. LPA noted that there is liquid soap and paper towels in the residents bathroom. LPA observed back porch is elevated and has seating, table, with umbrella for shade for outdoor visitation. LPA noted that no doors or exits were blocked and all free and clear of obstruction. LPA viewed two fire extinguishers in the green, working smoke detectors in all resident rooms and two working carbon monoxide detectors tested by LPA. LPA reviewed all staff and resident files and confirmed all staff are cleared to be working in facility. LPA Reviewed Emergency Evacuation plan and Infection control plan and noted that both were reviewed and singed by licensee within the past 12 months. LPA noted that facility posting were on the wall adjacent to the 3 resident rooms and advised licensee for a more obvious centrally located location for facility posting. Continued on LIC809-C Licensee and LPA conducted a full review and the annual care tools modules. LPA noted that there was one violation pertaining to documentation of emergency quarterly drills. LPA noted that there were no other violations or citations as a result of the full annual care tools review. LPA issued citation for one violation during this annual inspection. LPA conducted interviews with 3 residents and 3 staff. Exit interview, report read, appeal rights and report provided.the state’s words, verbatim · CDSS document, Nov 18, 2024

Allegation investigated: Staff are not following infection control practices. Staff are not properly trained. Staff are unable to communicate with residents due to language barrier. Staff did not provide adequate food service. Staff did not meet residents’ medical needs. Staff did not accommodate resident for appointments. Staff did not meet resident’s dietary needs.

At 0:00 am on 10/10/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct a new complaint investigation visit, and issue final finding on two separate older complaints. LPA met with Licensee/Administrator, Angelita Maravillas, announced who he is and the reasons for the visit. Staff are not following infection control practices. As to the allegation of, “Staff are not following infection control practices.” I was alleged that facility staff do not utilize Personal Protective Equipment (PPE) or proper infection control, nor proper food handling, and isolation in the event of outbreaks. It was discovered through observations, and interviews on 02/02/2024, LPA Jeffries observed ample supply of PPE on hand in the facility living room cabinet and facility garage storage area. On 02/02/2024, LPA Jeffries conducted interviews of Staff 1 (S1) and (S2), who both stated they had been trained in infection control within the past year. S1 and S2 both stated that they understood infection control and COIVD+ isolation practices. CONTINUED on LIC9099-C Unsubstantiated On 02/02/2024 LPA Jeffries observed lunch meal preparation and service and noted staff meeting infection control practices and regulation requirements (87555) pertaining to food preparation. LPA noted that the facility has had a total of one COIVD+ outbreak, on 08/18/2022 with no issues and followed all COVID+ recommend precautions during that outbreak, including contact and communications with local Public Health Officials. LPA Jeffries observed infection control training documentation for S1 on dates annual for 4 years including last training on 07/28/2023, and S2 for the same dates, 4 years including last training on 07/28/2023. LPA also noted that Facility Administrator is a currently licensed Register Nurse, with current training for infection control practices. At this time there is not enough evidence to support the allegation of, “Staff are not following infection control practices.” and is unsubstantiated at this time. As to the allegation of, “Staff are not properly trained.” It was alleged that staff do not have proper training for lifting, assisting non-ambulatory residents, dementia care. It was discovered through documentation, observations, and interviews, on 02/02/2024, LPA conducted interviews with S1 and S2 who both stated that they are current on 20 or more hours of annual training, including 8 hours of dementia specific training. On 03/08/2024, LPA observed training records for in-service Hoyer Lift Training for S1 on 11/01/2016, and S2 on 12/02/2018. S1 stated that they have more than 10 years’ experience in caregiving with this population, and S2 stated they have more than 25 years’ experience in caregiving with this population. On 02/02/2024, LPA Jeffries observed Residents 1-2 being assisted from living room by S2 with no issues. On 02/02/2024, LPA conducted an interview with Administrator, Angelita Maravillas, who is currently a licensed Registered Nurse, who conducts in-house training for all staff, who stated all staff are experienced and trained. At this time there in not enough evidence to support the allegation of, “Staff are not properly trained.” and is unsubstantiated at this time. As to the allegation of, “Staff are unable to communicate with residents due to language barrier.” It was alleged that; Residents and their families do not have access to staff that fluently speak English. It was discovered through interviews on 02/02/2024 LPA Jeffries conducted interviews with S1, S2, and Administrator. LPA noted that all interviews were conducted in English. LPA noted that Administrator and S2 have a primary language of Tagalog, and a secondary language of English in which both are proficient. S1 has a primary language of English and only understands Tagalog however does not speak Tagalog. Both Administrator and S1 reside as live-in caregivers at the facility and one or both are available at all times. At this time there is not enough evidence to support the allegation of, “Staff are unable to communicate with residents due to language barrier.” and is unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegations of, “Staff did not provide adequate food service.”, and “Staff did not meet resident’s dietary needs.” It was alleged that, 15 hours are to pass between dinner and breakfast and meals provided are repetitive and lack diversity which often consist of frozen dinners, sandwiches, canned fruits/vegetables. It was discovered through interviews, observations, and documentation that on 02/02/2024, LPA Jeffries conducted interviews with Residents 1-4 (R1, R2, R3, and R4). R1 stated that they normally eat dinner between 4:30pm and 6:30pm. R1 stated that the facility meals are good. R1 stated that the facility provides breakfast in the morning shortly after they get out of bed between 7:00am and as late as 9:00pm. R1-R4 all stated they have no issues with the food service at the facility and can get snacks as requested. On 03/08/2024, LPA Jeffries conducted a visit and noted that the dinner service had not yet been started at 4:00pm when LPA left the facility. On 02/02/2024, LPA conducted an interview with S1, who stated the current residents are provided meals in the morning when they get up and its not always at the same time. S1 stated the times vary between 6:00am and 9:00am for breakfast. S1 stated that dinner is planned to be prepared at 5:00pm but staff will prepare it earlier depending on Residents requests and needs. LPA Jeffries noted that facility meets food regulation requirements on 02/02/2024 and all past Licensing inspections for the last 4 years. LPA reviewed R1-R5’s LIC602’s (Physicians Reports) and noted that no resident (R1-R5) had any noted dietary restrictions. At this time there is not enough evidence to support the allegations of, “Staff did not provide adequate food service.” and“Staff did not meet resident’s dietary needs.” and both are unsubstantiated at this time. As to the allegation of, “Staff did not accommodate resident for appointments.” It was alleged that on approximately, 01/27/2024, R5 was not provided proper and timely medical care, on 01/27/2024, at 4:30pm being observed slumping in recliner as well as verbally non-responsive and mostly unaware of his surroundings. It was discovered through interviews and documentation that on 02/02/2024, LPA Jeffries interviewed Staff 1 (S1) who stated that on the day in question (01/27/2024) R5 had taken an “as needed” (Pro re nata or PRN) medication for agitation and that particular medication makes R5 very lethargic. On 02/02/2024 LPA Jeffries collected facility documentation of Narcotic Distribution Record which indicated that R5 had taken narcotic medication at 2:00pm on 01/27/2024 which also noted that the medication was “effective”. LPA observed facility Centrally Stored Medication Record which showed the PRN medication in question, was prescribed by Physician per regulations. LPA also observed facility Visitor Log In which did not show that R5 had any visitors on this day. LPA Jeffries noted that the visitation log for 01/27/2024, showed the individuals that visited the day of 01/27/2024 would have no knowledge of R5 medical conditions as well as when and what medications R5 were present and not knowing that the condition of R5 on 01/27/2024 did not require medical attention or appointments. At this time there is not enough evidence to support the allegation of, “Staff did not accommodate resident for appointments.” and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 29-AS-20240129103742

Allegation investigated: Staff inappropriately restrained resident in care.

At 7:00 am on 10/10/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct a new complaint investigation visit, and issue final finding on two separate older complaints. LPA met with Licensee/Administrator, Angelita Maravillas, announced who he is and the reasons for the visit. LPA Jeffries conducted a cursory tour of the facility, conducted interviews, took photographs and video, reviewed, collected, and requested documentation. LPA Jeffries issued final findings to the allegations to this complaint as follows: As to the allegation of, “Staff inappropriately restrained resident in care.” It was alleged that; resident was restrained by sheets that were tied down to the bed. It was discovered through interviews and admission that, On 10/07/2024, LPA Jeffries conducted a phone interview with Reliable Witness 1 (a person with license or credentials indicating expertise training and/or experience) RW1, who stated, when I arrived at the facility to assist my patient [Resident 1 (R1)], R1 was under the covers and there were sheets tied to the bed post that were restricting my patient (R1).” CONTINUED on LIC9099-C Substantiated RW1 stated that they untied sheet tied to the bed rails and called the staff into the room and asked why they were tied to the bed.” Staff 3 (S3) responded, “resident plays with their finesse.” RW1 told S3 that it was illegal to tie up and restrict residents and untied the remaining sheets from the bed. On 10/07/2024, LPA Jeffries conducted a phone interview with Reliable Witness 2 (a person with license or credentials indicating expertise training and/or experience) RW2 stated that, while visiting the facility on 10/04/2024, they interviewed Staff 1 (S1) who when asked about residents being tied to the bed by sheets, S1 stated, “they do that because (the resident) will dig in their fesses.” When S1 was asked by RW2, as a former Administrator at this facility, how could you let this happen? S1 stated “What’s the point? I just work here. It’s my aunt’s business. And they are going to do what they are going to do.” RW2 stated that S1 never disclosed staff which staff tied residents to their bed with sheets. On 10/10/2024 LPA Jeffries arrived at the facility and conducted interviews of Licensee/Administrator, Angelita Maravillas, who stated the R1 had stage 1 to 2 wounds on their buttocks, lower back, and ankles. Licensee/Administrator stated that she “knew it was wrong” but tied R1 down with the bed with sheet so R1 would not dig into their wounds on the buttocks and back. Administrator stated only she and S2 tied R1 down to the bed with bedsheet and no other staff participated in the restraint process with tying the R1 with a bed sheet to the bed rails. LPA Jeffries interviewed 4 of 4 residents. LPA noted that only 1 of 4 Residents were capable of a full cognitive conversation. At 9:02am on 10/10/2024, LPA Jeffries attempted to interview R1, when asked if they have ever been restrained by anyone in this facility, R1 replied, “I don’t know.” When asked if they had even been tied down in the bed at this facility R1 stated, “I don’t know.” At 9:13am on 10/10/2024 LPA Jeffries interviewed R2. R2 stated that they feel safe in the facility and has never been restrained and no personal rights issues have ever been violated in this facility by staff. At this time there is enough evidence by admission to the allegation of, “Staff inappropriately restrained resident in care.” And is substantiated at this time. Exit interview, report read, citation issued, appeal rights and report provided.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 29-AS-20241004082045

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(1)(a)(10) · Plan of correction due date: Oct 10, 2024

Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons.(10) To be free from neglect, ... punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. Based admission the licensee did not comply with the section cited above by tying and allowoing S2 to tie R1 to the bed with a sheet, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Licensee agrees to have all facility employees take 4 hours of Personal Rights, and Mandated Reporting Training conducted by and authorized vender of CCLD. Licensee must identify vender by 10/11/2024 and communicate with LPA in a timely manor as completion of all staff for all 4 hours of training required by this POC.

Allegation investigated: Staff do not provide a comfortable temperature for the residents. Staff do not know to operate a Hoyer lift. Staff forced the residents to remain in recliners while in care. Staff did not address a resident's change in medical condition. Staff are limiting the residents’ activities. Staff are being forceful with residents.

At 7:00 am on 10/10/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct a new complaint investigation visit, and issue final finding on two separate older complaints. LPA met with Licensee/Administrator, Angelita Maravillas, announced who he is and the reasons for the visit. As to the allegation of, “Staff do not provide a comfortable temperature for the residents.” It was alleged that residents have complained about being cold in their rooms; It was discovered by observations and interviews that Facilities temperature reading on 03/01/2024 at 2:15pm was 73 degrees Fahrenheit, and on 02/20/2019 at 11:10AM read at 71 degrees Fahrenheit and on 01/16/2019 at 10:30AM temperature read 76 degrees Fahrenheit. On 03/01/2024, LPA Jeffries interviewed Resident 1(R1) who indicated that the facility temperatures is “just fine” and has never a problem with facility temperature. On 03/01/2024 LPA Jeffries interviewed R2, and R3, who both stated that they didn’t have any problems with temperature at the facility. On 03/08/2024. CONTINUED on LIC9099-C Unsubstantiated LPA Jeffries conducted interview with S1, who stated that the heater and Air Conditioner are both in good working order, and staff will adjust thermostat per Residents requests. At this time, there is not enough evidence to support the allegation of, “Staff do not provide a comfortable temperature for residents.” and is unsubstantiated at this time. As to the allegations of, “Staff do not know how to operate a Hoyer Lift.” And “Staff are being forceful with residents.” It was alleged that, on 02/29/2024 resident 1 (R1) was incorrectly positioned in the harness when being lifted and forceful feeding and drinking. It was discovered through documentation, observations, and interviews, on 02/02/2024, LPA conducted interviews with S1 and S2 who both stated that they are current on 20 or more hours of annual training, including 8 hours of dementia specific training. On 03/08/2024, LPA observed training records for in-service Hoyer Lift Training for S1 on 11/01/2016, and S2 on 12/02/2018. S1 stated that they have more than 10 years’ experience in care giving with this population, and S2 stated they have more than 25 years’ experience in care giving with this population. On 03/08/2024, LPA Jeffries attempted to interview R1, R2, R3, and R4 all were unable to cognitively answer questions about staff care and staff assisted transfers. On 02/02/2024, LPA Jeffries observed Residents 1-2 being assisted from living room by S2 with no issues. On 02/02/2024, LPA conducted an interview with Administrator, Angelita Maravillas, who is currently a licensed Registered Nurse, who conducts in-house training for all staff, who stated all staff are experienced and trained. At this time there in not enough evidence to support the allegations of, “Staff are not properly trained.” and.” And “Staff are being forceful with residents.” both are unsubstantiated at this time. As to the allegation of, “Staff did not address a resident's change in medical condition.” It was alleged that, unidentified male Resident showed signs of being depressed and was not communicated to family. It was discovered through documentation and interviews that on 03/08/2024, LPA Jeffries interviewed R1 and R4 both males that are currently residing at the facility; Both R1 and R4 were able to provide very basic answers to questions, due to cognitive impairments. Both R1 and R4 stated that the facility temperature was comfortable with no issues but could not state if they were happy or depressed. On 03/08/2024 LPA conducted interview with Administrator, who stated due to their diagnosis and medication, both R1 and R4 show decreasing abilities in Activities of Daily Living (ADL’s), Administrator stated that both their Physicians and Family Member are aware of declining. On 03/08/2024, LPA Jeffries reviewed R1 and R4 Physician Report (LIC602) and Centrally Stored Medication Records (CSMR) and verified Administrators interview. At this time there is not enough evidence to support the allegation of, “Staff did not address a resident’s change in condition.” And is unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegations of, “Staff are limiting the residents’ activities.” and “Staff forced the residents to remain in recliners while in care.” It was alleged that, there were multiple instances of staff forcing residents to remain in their recliners, and staff turning off residents’ televisions without consent. It was discovered through interviews. On 03/08/2024, LPA Jeffries conducted interviews with 4 of 6 Residents. R1, R3, and R4 were not able to answer questions pertaining to activities and television schedules. R1, R2, R3, and R4 all stated “yes” when asked if they could move to their rooms if they wanted, and only R2 stated that staff will sometimes turn the television off in their room before they fall asleep. On 02/02/2024, LPA Jeffries observed Residents 1-2 being assisted from living room by S2 with no issues. 03/08/2024, LPA conducted interview with S1, who stated that they will leave the television on in the resident’s room until the resident falls asleep or at their request. LPA noted that R2 occupies a double occupancy room. At this time there in not enough evidence to support the allegation of, “Staff are limiting the residents’ activities.” and “Staff forced the residents to remain in recliners while in care.” and both are unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 29-AS-20240301111042

Type of visit: Required - 1 Year

At 10:00am on 12/07/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual facility inspection. LPA met with Licensee Angelita Maravillas, announced who he was and the reason for the visit. LPA toured facility with Licensee. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning throughout the facility. Fire extinguishers were fully charged. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 70 degrees F. Hot water temperature tested and read within regulation parameters of 105-120*(f). Residents’ rooms are appropriately furnished with adequate lighting. LPA observed more than two days of perishable and more than seven days of non-perishable food. Food is stored in proper containers in the refrigerator and freezer. A written disaster and mass casualty plan is readily available located on the facility hallway cabinet. Licensee and LPA conducted a sample medication audit and reviewed the centrally stored medication record (CSMR) and found no major issues. Licensee and LPA conducted the a full review of the annual inspection control modules. LPA noted that one Technical Violation was issued on liability insurance receipt not reflecting correct amount of aggregate coverage. Licensee to rectify with their insurance company by 12/21/2023 and email LPA proof of corrected liability insurance receipt. Exit interview, report read, one technical violation issued, and report provided.the state’s words, verbatim · CDSS document, Dec 7, 2023

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.