Jasmin Terrace at Bakersfield

Allegation investigated: Illegal eviction

Licensing Program Anlalyst (LPA) Shawna Doucette arrvied at the facility unannounced to conduct a complaint investigation. LPA explained the purpose of the visit and was granted entry into the facility by Staff Amilyn Aguil. Staff contacted Administrator Ramona Eleco via telephone who responded to assist with the visit. LPA requested and reviewed a copy of R1's file. LPA interviewed Administrator. Based on interviews and records review, R1 was not given an eviction notice and was not accepted back to the facility. Interviews and records review revealed R1 did not have a reappraisal and did not have a change in condition. Substantiated Based on interviews and records review, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. A copy of this report with plans of corrections and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 24-AS-20260113101718

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Jan 23, 2026

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) This requirement was not met as evidenced by:Licensee sent R1 to the hospital but did not allow R1 to return to the facility without following proper eviction processes which poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: Licensee agrees to submit in writing the understanding of this regulation and how it will be met by POC due date 01/23/26

Allegation investigated: Staff did not give resident medication as prescribed

Licensing Program Anlalyst (LPA) Shawna Doucette arrvied at the facility unannounced to conduct a complaint investigation. LPA explained the purpose of the visit and was granted entry into the facility by Staff Amilyn Aguil. Staff contacted Administrator Ramona Eleco via telephone who responded to assist with the visit. LPA requested copies of R1's file. LPA reviewed medication records. LPA interviewed Administrator. Based on records review, R1 was ordered to start taking aspirin on 1/2/25. R1 did not start the medication until 1/5/25. Based on interviews, Administrator stated if a medication is missed the policy is to intial MARS log and circle the initial and write refused on the back of the MAR. LPA observed medications to be given with only the initial and no circle however on the back of the MAR it was stated refused. Records were contradicting. Substantiated Based on records review and interviews, it is undetermined whether or not the allegations occurred. 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. A copy of this report was provided to Administrator. Based on interviews and records review, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. A copy of this report with plans of corrections and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 24-AS-20260106154213

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 15, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requrement was not met as evidenced by: Licensee did not administer R1's prescribed aspirin that was prescibed on 1/2/26 until 1/5/26, which poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: Licensee agrees to conduct a medication training and will schedule the training by POC due date 01/15/26. Once training is complete Licensee will submit proof of training.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a Case Management for an incident that occurred on 12/30/25. LPA met with Administrator Ramona Eleco. Administrator stated there was a staff in the dining area getting residents coffee. Administrator stated R1 and R2 sit at tables near each other. Administrator stated R1 wheeled his wheelchair next to R2 and then swung at R2 but missed. Administrator stated R2 then swung at R1 causing R1 injury to his eye. Administrator stated the med room is next to the dining area and a resident notified the medication technician. Administrator stated staff immediately separated R1 and R2. Administrator stated the police were called but neither resident was arrested. R1 was sent to the hospital for evaluation. A copy of this report was provided with plan of correction and appeal rights.the state’s words, verbatim · CDSS document, Jan 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jan 15, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met by: Licensee did not ensure R1 was free from abuse by R2 hitting R1 causing injury to R1's eye resulting in medical attention for R1 which poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: Licensee agrees to submit a written plan to to ensure the safety of residents by POC due date 01/15/26

Allegation investigated: Staff left resident unattended for an extended period of time.

Licensing Program Analysts (LPAs) S. Doucette and J. Duarte arrived at the facility unannounced to commence a complaint investigation. LPAs were granted entry into the facility by Administrator, Ramona Eleco and LPAs explained the purpose of the visit. LPAs reivewed records and interviewed staff. Based on records review, R1's LIC602 stated R1 cannot leave the facility unassisted. The facility driver schedule has five residents scheduled for appointments on 10/10/25, with appointments indicating whether or not a staff attended the appointment with residents. R1 did not have a staff assigned listed for R1's appointment. Based on interviews, residents may be left at appointments unatteneded depending on residents cognitive ability. However, interviews revealed there are times when residents that require care and supervision Substantiated have been left unattended at appointments. Interviews revealed R1 was dropped off at an appointment on 10/10/2025 at 9:30 AM and was left in the lobby unattended until staff arrived to pick up R1 at 11:00 AM. Based on interviews, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. A copy of this report with plans of corrections and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 24-AS-20251012184241

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 3, 2025

87464 Basic Services (f)Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by licensee did not provide R1 care and supervision during a doctor visit on 10/10/25, which possess an immediate, health, safety, and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 2, 2025

Plan of correction: Licensee agrees to conduct care and supervision traning to ensure residents are provided care and supervision during appointments. Licensee agrees to submit date of training by POC due date of 12/03/2025 and will submit proof of training once training is completed.

Allegation investigated: Licensee is not ensuring that the safety needs for resident in care are being met. Licensee is not according dignity to resident in care.

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA was granted entry into the facility by Activiteis Director Candaleria Carrillo. LPA met with Administrator Ramona Eleco and explained the purpose of the visit. LPA interviewed Administrator. Based on resident and staff interviews, regarding the allegation Licensee is not ensuring that the safety needs for resident in care are being met, is undetermined whether or not the residents safety needs are being met. Interviews revealed R1's safety needs are being met. Based on records review it was revealed R1 has a doctors order for the lap belt for R1's wheelchair. Unsubstantiated Based on interviews, regarding the allegation Licensee is not according dignity to resident in care is undetermined if the licensee is not according dignity to the resident. Interviews reveal that R1 is being accorded dignity by staff and the Licensee. Based on records review and interviews, it is undetermined whether or not the allegations occurred. 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. A copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Sep 12, 2025 · control 24-AS-20250814123159

Allegation investigated: Staff do not ensure the facility is free of pests Staff do not ensure the facility is properly maintained Staff did not prevent residents from engaging in a physical altercation

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA was granted entry into the facility by Activiteis Director Candaleria Carrillo. LPA met with Administrator Ramona Eleco and explained the purpose of the visit. LPA interviewed staff and residents. LPA obtained a copy of the pest control service records. LPA obtained a copy of admissions agreement and LIC 602 for R1, R2 and R3. Based on observation, records review and interviews regarding the allegation Staff do not ensure the facility is free of pests, it was found facility has a pest control service and is following pest control instructions. LPA toured facility and did not observe any pests. LPA conducted interviews which revealed sometimes facility has roaches but pest control is contacted immediately to resolve issues. Pest control records show facility is being serviced indoors and outdoors. Unsubstantiated Based on observation and interviews, regarding the allegation Staff do not ensure the facility is properly maintained, it was revealed sprinkler system has been broke for about a week however facility is in the process of fixing. LPA observed grass to be wet during tour and trees to all have green leaves. During the tour, LPA observed facility staff on the room trimming tree branches. Based on interviews regarding the allegation Staff did not prevent residents from engaging in a physical altercation, it is undetermined if this allegation is valid due to conflicting statements and no visible injuries to the resident. Based on records review and interviews, it is undetermined whether or not the allegations occurred. 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. A copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Sep 12, 2025 · control 24-AS-20250908140237

Allegation investigated: Staff did not provide a safe environment for a resident in care.

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA was granted entry into the facility by Staff Amilyn Aguil. LPA met with Administrator Ramona Eleco and explained the purpose of the visit. LPA interviewed resident and staff. LPA reviewed records. Based on interviews, the allegation Staff did not provide a safe environment for a resident in care is undetermined if it is valid. Interviews with staff and resident are conflicting. Based on records review and interviews, it is undetermined whether or not the allegations occurred. 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. A copy of this report was provided to Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 23, 2025 · control 24-AS-20250528154409

Allegation investigated: Staff are not rotating bed ridden residents. Staff did not provide adequate supervision to residents in care. Staff did not dispose of resident's trash.

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA was granted entry into the facility by Staff Amilyn Aguil. LPA met with Administrator Ramona Eleco and explained the purpose of the visit. LPA reviewed records and obtained copies of records. LPA interviewed staff and residents. Based on interviews and records review, the allegation Staff are not rotating bed ridden residents is undetermined if it is valid. Records review indicates there are no residents that are currently bedridden. Administrator stated there are two residents that do not get out of bed but are not bedridden. Both LIC 602's indicate both residents are non ambulatory. Based on interviews, the allegation Staff did not provide adequate supervision to residents in care is undetermined if it is valid. Based on interviews, this allegation was addressed in Complaint 24-AS-20250127090613. The resident no longer resides at the facility. Unsubstantiated Based on observation and interviews, the allegation Staff did not dispose of resident's trash is undetermined if it is valid. LPA viewed R1's room on 06/16/25 and on 07/23/25. LPA did not observe an excessive trash. Administrator stated rooms are cleaned daily. LPA observed housekeeping staff cleaning rooms during both visits. Based on records review and interviews, it is undetermined whether or not the allegations occurred. 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. A copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 24-AS-20250613153922

Allegation investigated: Facility does not meet resident’s special diet

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA was granted entry into the facility by Staff Amilyn Aguil. LPA met with Administrator Ramona Elecon and explained the purpose of the visit. LPA reivewed records. Based on records review and observation of food supplies, the allegation Facility does not meet resident’s special diet, the facility did not offer sugar free or low carb desserts for diabetic residents. R4 has an order for low carb and limit sweets. Facility menu shows pudding and ice cream is served. Facility does not have a sugar free option for diabetic residents in care. Substantiated outside. Based on records review and interviews, the allegation Staff do not ensure residents needs are met is undetermined if this allegation is valid. LPA reviewed shower and incontinence schedule showing how often residents are showering and being changed. Residents are being showered and changed regularly. Interviews indicate residents are being showered and changed regularly. Based on interviews, the allegation Staff do not ensure residents personal property is safely secured it is undetermined if this allegation is valid. Administrator does not have any reports of any property being stolen. Administrator has had issues with residents thinking a shirt is theirs because several residents have white shirts that are similar or the same. Administrator stated she started writing the name on the shirt tags to prevent confusion. Facility rooms all have locks on doors, so residents are able to lock rooms to prevent others from going in their rooms. Based on interviews, the allegation Staff do not ensure adequate care and supervision is provided resulting in resident elopement, it is undetermined if this allegation is valid. Interviews indicate facility has not had any elopements that have not been addressed. Prior to this complaint, Administrator stated the last elopement was in January 2025. Based on records review and interviews, the allegation Licensee does not ensure fire drills are conducted in the facility is undetermined if this allegation is valid. Facility records show disaster/fire drills were conducted 1/2025, 2/2025 and 5/2025. Administrator stated drills are conducted regularly. LPA obtained copies of drills with staff signatures showing completed. Based on interviews, observation and records review, the allegation Staff does not ensure sufficient activities are provided for residents in care in undetermined if the allegation is valid. LPA observed a calendar in the dining room showing daily activities. LPA observed residents playing bingo, watching movies, listening to music and doing exercises during visits at the facility. Based on records review, observation and interviews, it is undetermined whether or not the allegations occurred. 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. A copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 24-AS-20250528135847

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Jul 24, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply:(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: Licensee is not providing sugar free options for desert to meet the requirements of R4's specialized diet, which poses a potential health safety and or personal right risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2025

Plan of correction: Plan of Correction: Licensee agrees to meet this regulation by providing foods the meet the needs of the specialized diets. LPA will clear via visit. POC cleared during visit.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Sarah Hurt and Shawna Doucette conducted an unannounced facility visit to conduct a Case Management. LPA met with facility Administrator Ramona Eleca, and explained the purpose of today's visit. LPA's received an incident report documenting on 06/13/2025 facility staff reported bringing Resident 1 to his spot at the dining table at 06:30 p.m. and leaving him at the table while going to bring other residents to dining. Staff noticed at 06:45 p.m. Resident 1 was not at his seat in the dining area. All facility staff immediately looked for Resident 1 inside and outside of the facility premises. Facility staff found Resident 1 at the nearby store. The following deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with Administrator Ramona Eleca, A copy of this report along with appeals rights provided.the state’s words, verbatim · CDSS document, Jun 25, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 26, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:.(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The following requirement has not been met as evidenced by: Resident 1 eloped from the facility on 06/13/2025, which poses an immediate, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 25, 2025

Plan of correction: Administrator will conduct in service training with facility staff on resident elopement and submit to LPA by POC date of 06/26/2025.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA)'s Shawna Doucette and Sarah Hurt arrived at the facility unannounced to conduct the Required Annual Inspection. LPA's met with Administrator Ramona Eleco. LPA's toured the facility. Facility was set at a temperature of 73F to 74 F on the 3 halls. Fire extinguisher was dated 3/8/25. Last fire drill was conducted 1/25 and 5/25. Smoke detectors are hard wired with a fire panel. Carbon monoxide detectors were properly operating. Facility has a sprinkler system that was serviced annually. Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. LPA's observed a large round dining room table blocking a fire exit in the dining room. LPA's took photos. Facility has alarms on exit doors. Resident rooms were furnished and clean. Resident bathrooms with clean with grab bars and skid mats. A sample of rooms water temperature was checked for each hall measuring between 108 F to 111 F. A tour of the outside was conducted. There was outdoor seating with shaded tables for the residents. LPA Doucette reviewed resident and staff records. Staff training was current. Current first aid and CPR were reviewed. LPA Hurt reviewed resident medications. LPA Hurt observed morning medications for Residents AM medications for 06/26/2025 not in bubble packs. LPA Hurt observed the medications in small pill cups taped together in a tower with residents name scribbled on each cup. LPA's reviewed Plan of Operation, and Emergency Disaster Plan (LIC610E) and facility Infection Control Plan. A copy of this report with plans of corrections and appeal rights were provided to the Administrator via email. Civil Penalties were issued for fire clearance violation.the state’s words, verbatim · CDSS document, Jun 25, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a Case Management regarding 3 incidents that occurred on 5/30/25 and 5/31/25. LPA requested copies of Hospice notes for R1 regarding R1's fall. Facility does not have any notes from Hospice regarding the visit for R1's fall. Administrator requested copies from Hospice. LPA observed R1 to have a lot of swelling above and below the left eye. Administrator advised the swelling was noticed this morning and hospice was notified and it was unrelated to R1's fall. LPA requested copy of Hospice Care plan. LPA was advised it is unknown if R2 actually fell. R2 reported to facility staff she fell and called 911. LPA requested copies of discharge paperwork for R2. Administrator advised R3 did not hit her head. LPA followed up on the incident with R3. Administrator advised R3 did not his his head. LPA will review paperwork and will return at a later date if deficiencies are warranted. A copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Jun 4, 2025

Allegation investigated: Staff not preventing resident from smoking inside facility while oxygen tank are in use by another other resident. Staff does not prevent resident from disturbing another resident when sleeping. Staff does not prevent resident from inappropriate behavior. Staff does not prevent resident from inappropriately touching another resident.

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA was granted entry into the facility by Staff Maria Vargas. LPA met with Administrator Ramona Elecon and explained the purpose of the visit. Based on interviews and observation, R1 no longer resides in the facilty. Although R1 may have smoked in the facility, facility staff redirected R1 to not smoke in the facility. Facility staff worked with R1's case manager to find R1 a more suitable facility. Based on interviews, R3 refused to speak to LPA to determine whether or not R1 was disturbing R3's sleep. Based on records review, R2 engages in inappropriate behaviors. Based on interviews, it was reported to staff by R4 that R2 engaged in an inappropriate behavior. LPA was unable to locate another resident that observed the incident. Facility staff stated R4 was the only resident to report the incident. Unsubstantiated Based on interviews, it was reported R2 was rubbing R5's arms. Based on interviews. R2 was redirected to not touch other residents. LPA was unable to interview R5 due to R5 having dementia. Based on records review and interviews, it is undetermined whether or not the allegations occurred. 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. A copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 24-AS-20250218101333

Allegation investigated: Staff neglect resulted in resident developing gangrene

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to deliver findings. LPA met with Administrator Ramona Eleco. LPA's disclosed the purpose of the inspection and was granted entry into the facility by Staff. The Department has investigated the above allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 19, 2025 · control 24-AS-20250211153913

Allegation investigated: Staff are not meeting resident medical needs

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA identified herself and explained the purpose of the visit with Activities Director Candaleria Carrillo. Administrator Ramona Eleco responded to the facility to assist with the visit. LPA interviewed staff and reviewed records. LPA met with R1 and observed the surgery to be completed. Based on records review, Facility staff contacted doctor to get a referral for R1 to see a specialist on 11/22/24, 11/27/24, and 12/2/24. After not receiving the referral and approval from insurance facility staff sent R1 to the hospital on 12/5/24. On 12/12/24 R1 went to the specialist and scheduled surgery for 12/26/24. On 1/30/25 R1 was sent to the hospital to remove bandage. R1's surgery was complete and R1 is scheduled to see the specialist on 2/10/25 and 2/13/25 for follow up. Unsubstantiated Based on records review and interviews, it is undetermined whether or not the allegation occurred. 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. A copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 24-AS-20241204104029

Allegation investigated: Staff do not prevent resident from smoking in the facility

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA identified herself and explained the purpose of the visit with Activities Director Candaleria Carrillo. Administrator Ramona Eleco responded to the facility to assist with the visit. LPA Interviewed staff and residents. Based on interviews, R1 does smoke in the facility. Staff attempt to redirct R1. R1 is failing to comply with house rules, which poses a danger to residents who require oxygen. Facility does not have any documentation on how they are trying to prevent R1 from smoking in the facility. Substantiated Based on interviews, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. A copy of this report with plans of corrections and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 24-AS-20250127090613

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 7, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by R1 continues to smoke in the facility, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 6, 2025

Plan of correction: Licensee agrees to submit a plan on how this regulation will be met by POC due date 02/07/25

Allegation investigated: Staff do not ensure bed ridden residents are repositioned in a timely manner Staff do not ensure residents receive feeding assistance Staff do not prevent resident from having a physical altercations with other residents Staff do not ensure residents personal property is safe guarded

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA identified herself and explained the purpose of the visit with Staff Darlene Ruano. LPA met with Activities Director Candaleria Carrillo and Administrator Ramona Eleco. LPA interviewed staff and residents. LPA toured the facility. Based on interviews, the facility does not currently have any bedridden residents residing in the facility, therefore respositioning is not necessary. Based on interviews and reviewing records, R4 and R5 can feed themselves however facility staff have to follow up to ensure residents ate their food. Per R4 and R5's LIC 602 both residents are able to feed themselves. Based on interviews, facility was not made aware a resident was hitting another resident until the Residents's Unsubstantiated Council meeting on 8/28/24. Facility has taken precautions and advised R1 to let staff know if R6 enters the room. R1 is able to lock the door at night, which has resolved the issue. Although this may have happened, facility staff took precautions once staff was made aware. After conducting interviews, it was found facility provide residents with a wheelchair or walker if needed until the residents insurance approves the wheelchair or walker. Once the new walker or wheelchair arrive, residents get the wheelchair or walker that was provided by their insurance. Based on records review and interviews, it is undetermined whether or not the allegation occurred. 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. A copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 24-AS-20240826133935

Allegation investigated: Staff spoke to resident in an inappropriate manner. Staff did not treat resident with respect.

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation and deliver findings. LPA identified herself and explained the purpose of the visit with Administrator Ramona Eleco. LPA conducted interviews with staff and residents. Based on interviews, Staff spoke to resident in an inappropriate manner and Staff did not treat resident with respect. After conducting interviews, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. A copy of this report was provided with appeal rights and plans of correction. Substantiatedthe state’s words, verbatim · CDSS document, Aug 22, 2024 · control 24-AS-20240528092313

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 23, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by Licensee did not ensure Administrator spoke to R1 appropriately and respectfully which poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Licensee agrees to conduct a staff training on personal rights by POC due date 09/15/24

Allegation investigated: Staff are not providing residents with adequate towels

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation and deliver findings. LPA identified herself and explained the purpose of the visit with Administrator Ramona Eleco. LPA toured the facility. LPA chedked the linen closet where clean towels are stored. LPA located a towel with a large hole in it. LPA took photos. Based on observation, Staff are not providing residents with adequate towels. Based on observation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. A copy of this report was provided with appeal rights and plans of correction. Substantiated Based on interviews and records review, incontinence log shows residents are being checked every two hours. Based on interviews, staff are disclosing the name of medications given to residents. Based on observation and interviews, staff are providing adequate food. LPA observed orange juice, pineapple juice, cranberry juice and apple juice. LPA checked the menu and took photos. Residents had French toast with syrup, pineapple juice, breakfast meat and cornflakes. LPA observed residents have oven fried chicken, pilaf, spinach and a roll for lunch. Based on interviews, observation and records review, it is undetermined whether or not the allegations occurred. 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. A copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Aug 22, 2024 · control 24-AS-20240603090548

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(3)(C) · Plan of correction due date: Aug 30, 2024

(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement was not met as evidenced by: Licensee had towels with large holes in the linen closet which poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Plan of Correction Licensee agrees to remove and replace all towels/linens with holes. Licensee agrees to conduct a staff training on appropriate linen supplies by POC due date 08/30/24.

Allegation investigated: Staff did not ensure the facility was free from mold

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA identified herself and explained the purpose of the visit with Administrator Ramona Eleco. LPA toured the facility. LPA cited during annual inspection on 06/11/2024. LPA's took photos during ths visit on 6/11/24. Based on interviews and observation, Staff did not ensure the facility was free from mold. Based on interviews and observation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Refer to annual inspection for citation. Substantiatedthe state’s words, verbatim · CDSS document, Jun 26, 2024 · control 24-AS-20240429145710

Allegation investigated: Staff do not prevent residents from smoking in prohibited smoking areas at the facility

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA identified herself and explained the purpose of the visit with Administrator Ramona Eleco. LPA toured the facility. LPA interviewed Staff and Residents. LPA obtained copies of R1's assigned rooms. After conducting interviews, R1 was in a room with R2, who has oxygen and R1 would sometimes smoke in the room. Based on interviews, R1 was smoking in other parts of the facility. Based on interviews, Staff do not prevent residents from smoking in prohibited smoking areas at the facility Based on interviews, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. Substantiated An exit interview was conducted with Administrator Ramona Eleco and a copy of this report along with appeal rights and plan of correction were provided.the state’s words, verbatim · CDSS document, Jun 26, 2024 · control 24-AS-20240429123951

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(2) · Plan of correction due date: Jun 27, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Licensee did not ensure R1 did not smoke inside of the facility which poses an immediate health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 26, 2024

Plan of correction: POC Licensee agrees to submit a plan in writing on how this regulation will be met by POC due date.

Allegation investigated: Facility staff denied resident's visitor access to the resident during normal visiting hours

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation and deliver findings. LPA identified herself and explained the purpose of the visit with Administrator Ramona Eleco. LPA obtained a copy of the visitor policy. Based on interviews it is undetermined whether or not Facility staff denied resident's visitor access to the resident during normal visiting hours. Based on records review and interviews, it is undetermined whether or not the allegation occurred. 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 26, 2024 · control 24-AS-20240620141603

Type of visit: Case Management - Incident

On 6/18/2024 Licensing Program Analysts (LPAs) B. Miranda & S. Doucette arrived to the facility unannounced. During the visit LPAs spoke with various residents at the facility. R1 had a black eye. When LPA asked how R1 got the black eye they stated they fell. Administrator stated R1 fell on 6/17/24, facility was informed there is still time to report. R2 had injuries to their legs. R2 stated they crashed into the vending machine about a week and a half ago. Administrator stated the incident happened about 1-2 weeks ago. LPA S. Doucette conducted interviews and was informed R3 was placed in the Geri Chair after eloping from the facility. Administrator was asked about the elopement and stated R3 followed their son out of the facility, and the son and had to bring R3 back to the facility. Facility had their own incident report, but the incident was not provided to the Dept. The facility's report states the resident was found at a neighbor's house. LIC602 indicated the R3 cannot leave the facility unattended. Copy of facility report was provided to LPA. Citation and civil penalty will be issued. LPA asked Administrator if they knew which exit R3 left the facility, Administrator stated they believe through the front door, the front door does not have an auditory device. LPA S. Doucette cited for no auditory device on the front door for the annual inspection. While touring the facility LPAs observed R4 to have long and black/brown toe nails. The nails on the big toes are longer than the tip of the big toe (pictures were taken). Administrator was asked why R4's toe nails were so long, Administrator stated maybe because of their diabetic shoes. LPA asked if R4 sees a podiatrist, Administrator stated when needed. LPA showed Administrator the picture, administrator had no comment. Citations were issued under Title 22, Division 6, & Chapter 8 on LIC809D & civil penalties were issued. Exit interview was conducted and a copy of this report was provided to Administrator Ramona Eleco.the state’s words, verbatim · CDSS document, Jun 18, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 28, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee failed to report 3 incidents to the Dept that occurred in the facility. R3 eloped from the facility and it was not reported to the Dept.the state’s words, verbatim · CDSS document, Jun 18, 2024

Plan of correction: Procedure will be put into place to make sure all incidents are reported to the Dept within the proper time limit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(a)(1) · Plan of correction due date: Jun 28, 2024

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee failed to arrange or assist R4 with proper foot care.the state’s words, verbatim · CDSS document, Jun 18, 2024

Plan of correction: Frequent body check on R4. Administrator will make arrangement with R4's doctor.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 19, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement is not met as evidenced by: Based on observation, interview, and record review the licensee failed to follow physician orders by allowing the resident to elope from the facility unassisted. Facility did not know R3 left until R3's family arrived and was unable to locate R3 at the facility. This poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2024

Plan of correction: R3 has been placed on special monitoring. Statement will be sent to LPA.

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPA)'s Shawna Doucette and Brianna Miranda arrived at the facility unannounced to conduct the Required Annual Inspection. LPAs were granted entry by Staff Darlene Ruano. Staff contacted the Administrator who responded to the facility to assist with the visit. LPAs met with Administrator Ramona Eleco. LPAs toured the facility. LPAs smelled a strong odor of urine and the bathroom counter to be dirty in Room 30. LPAs observed a bed with only the bottom sheet with a brown substance on the bottom sheet of Room 49. LPAs observed the community shower to be dirty with a trash can and a broom inside the shower. LPAs observed Room 50 to have an unknown liquid substance on the floor. LPAs observed cleaning supplies on the bed in Room 51. LPAs observed the foot and head of the bed in Room 53 to be slanting. LPA's observed a dirty diaper on the floor in Room 17. LPAs observed urine on the floor and the hoyer lift in Room 33. Room 67 had a dirty floor. LPAs took photos. LPAs observed R1 in the geri chair for majority of the day. LPA Doucette spoke to R1's family who advised R1 awoled awhile back. LPA's could not locate an awol report submitted to licensing. LPA Miranda did a case management for reporting requirements and incidental and medical. At 6:45 PM LPA's observed R1 in his geri chair unsupervised in the medication room while the medication technician opened the front door in reaching distance of medications. LPAs toured of the outside of the facility where LPAs observed torn screens and the fascia board to be rotting. The dining exit door to the courtyard is broken. LPAs took photos. Facility has outdoor seating for residents. LPAs reviewed resident's medication and files. LPAs interviewed staff and residents and found staff are administering injections to residents. R7's physicians report states R7 is unable to administer own injections or check glucose. LPA obtained a copy of R7's LIC602. This was addressed with Administrator on 8/22/23 per inspection notes. LPAs found medication errors for R7 and R8. Facility staff are crushing medications without a physician order and putting it in R9's coffee. R8's PRN was not administered or logged properly showing out 90 pills records indicated only 26 were administered however there were only 8 pills left. LPA took photos. Facility does not have hospice or home health care plans or do not have current or accurate care plans for residents on hospice or home health. Facility does not have RCFE (602A) for majority of residents to indicate whether or not a resident has dementia. Administrator was not able to provide verification of Hoyer Lift training, training for caring for bedridden residents, or current training for staff. Fire extinguisher was serviced 5/30/24. Refer to 809D. Civil penalties were issued for repeat violations. Refer to Case Management for additional citations during visit. A copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 18, 2024

The state marks this report as 34 pages; the online copy we transcribed has 20. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA)'s Shawna Doucette and Brianna Miranda arrived at the facility unannounced to conduct the Required Annual Inspection. LPA's were granted entry by Staff Darlene Ruano. Staff contacted the Administrator who responded to the facility to assist with the visit. LPA's met with Administrator Ramona Eleco. A tour of the facility was conducted with the Administrator. Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Facility does not have menus for special/modified diets for residents who require a modified diet. Facility does not have documentation of a dietician/nutritionist preparing facility menus. LPA's observed the community bathroom to be dirty with a loofah in the community shower. LPA's observed mold under the bathroom sink. LPA's took photos. A tour of the outside was conducted by LPA Miranda who observed the south side fence to be broken and tree branches on the ground. There was outdoor seating for the residents. Resident and staff records were reviewed. Current first aid and CPR were reviewed. Facility does not have hoyer lift training for staff on PM shift. Facility does not have training for restricted health care condition for R3. R4 does not have correct LIC602, and does not specify if the resident has dementia. R6 diagnosis from hospice does not match LIC602 diagnosis. Reappraisal was not completed for R6. No staff training for bedridden residents for PM shift staff. LPA obtained a copy of staff schedule. Due to time constraints, LPA's will return at a later date to complete the annual inspection. A copy of this report was provided to the Administrator via email.the state’s words, verbatim · CDSS document, Jun 11, 2024

Allegation investigated: Staff failed to seek timely medical attention after a resident’s fall Facility staff did not inform resident's authorized person about resident's injury Staff did not safeguard resident's personal items

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation and deliver findings. LPA identified herself and explained the purpose of the visit with Administrator Ramona Eleco. Based on interviews and records review staff did not immediately call 911 when R1 fell and hit her head on the floor. Based on records review and interview, facility staff did not notify R1's authorized person about R1's injury. Based on records review and interviews, facility staff was notified of R1's missing property and property was not replaced. Based on observation, interviews and records review, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. An exit interview was conducted with Administrator Ramona Eleco and a copy of this report along with appeal rights and plan of correction were provided. Substantiated Based on observation, interviews and records review, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. An exit interview was conducted with Administrator Ramona Eleco and a copy of this report along with appeal rights and plan of correction were provided.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 24-AS-20240112085412

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: May 3, 2024

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by Licensee did not call 911 when R1 fell and hit head on floor, which poses an immediate health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Plan of Correction Licensee agrees to conduct a staff training on when to contact emergency services by POC due date 5/3/24. LIcensee agrees to submit training agenda and certificates of trained staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 10, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by Licensee did not contact R1's authorized representative to inform R1's authorized representative R1 was hospitalized which poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Plan of Correction POC Licensee agrees to provide staff training on reporting procedures by POC due date 5/3/24. Licensee agrees to submit an agenda and certificates of trained staff by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: May 10, 2024

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement was not met as evidenced by Licensee did not safegaurd R1's property which poses a potential health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Plan of Correction POC Licensee agrees to train staff on safeguarding residents property and procedures for when staff are notified property is missing by POC due5/10/24. Licensee agrees to submit agenda of training and certificates of staff trained

Allegation investigated: Staff did not provide resident with water Staff do not respond to resident’s calls for assistance

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA identified herself and explained the purpose of the visit with Administrator Ramona Eleco. LPA toured the faciltiy. Based on tour of facility, LPA observed a cup of water with a straw and puree food next to R1's bed. R2 is able to get out of bed to get water. LPA observed water by R3's bed. Based on observation, LPA was able to observe the call light to be working. The call light was beeping while at the facilty. Facility does not have documentation on how long it takes for staff to respond. During the course of the visit, LPA observed other deficiencies. Unsubstantiated Based on records review and interviews, it is undetermined whether or not the allegations occurred. 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. A copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Apr 4, 2024 · control 24-AS-20240122155513

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. During the course of the complaint investigation other deficiencies were observed. LPA identified herself and explained the purpose of the visit with Administrator Ramona Eleco. Facility does not have a care plan for R1 and R2. Facility does not have training from Hospice on turning residents that are bedridden. Facility does not have documentation of the stage of R2's wound. Refer to 809d.the state’s words, verbatim · CDSS document, Apr 4, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(4) · Plan of correction due date: Apr 5, 2024

87633 Hospice Care of Terminally Ill Residents(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement was not met as evidenced by R1 and R2 not having a Hospice Care Plan outling the responsibilities of the facility staff which poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 4, 2024

Plan of correction: Plan of Correction POC Licensee agrees to submit corrected Hospice care plans for R1 and R2. Licensee agrees to submit a written understanding of this regulation by POC due date 04/5/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(A) · Plan of correction due date: Apr 25, 2024

(6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee’s responsibilities for implementation of the hospice care plan. (A) The training shall include but not be limited to typical needs of hospice patients, such as turning and incontinence care to prevent skin breakdown, hydration, and infection control. This requirement was not met as evidenced by. Licensee did not ensure staff was trained on turning R1, which poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 4, 2024

Plan of correction: Plan of Correction POC Licensee agrees to complete staff training for all residents on Hospice by the Hospice agency by POC due date 4/25/24

Allegation investigated: Facility is not maintained in a clean and sanitary condition.

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA identified herself and explained the purpose of the visit with Administrator Ramona Eleco. LPA toured the facility. LPA took photos of toilets and showers in residents rooms and mold in community shower. Based on observation, Facility is not maintained in a clean and sanitary condition. Based on observation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. Civil Penalty was issued for repeat violation. An exit interview was conducted with Administrator Ramona Eleco and a copy of this report along with appeal rights and plan of correction were provided. Substantiatedthe state’s words, verbatim · CDSS document, Mar 22, 2024 · control 24-AS-20240314094806

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 1, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Licensee did not keep common shower and toilets free from mold which poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 22, 2024

Plan of correction: Licensee agrees to clean the entire facility having it free from dust, mold, any stains of bodily fluids by POC due date 04/1/24. LPA will return to facility to clear POC by visit. Civil Penalty was issued for repeat violation.

Allegation investigated: Staff serve cold meals to residents.

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA identified herself and explained the purpose of the visit with Activities Director Candaleria Carrillo. Administrator Ramona Eleco responded to the faciltiy to assist with the visit. LPA conducted staff and resident interviews. Based on interviews, Staff are serving cold meals to residents that have meal tray service to their rooms. Based on interviews, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. An exit interview was conducted with Administrator Ramona Eleco and a copy of this report along with appeal rights and plan of correction were provided. Substantiatedthe state’s words, verbatim · CDSS document, Jan 18, 2024 · control 24-AS-20231109083251

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9) · Plan of correction due date: Jan 19, 2024

87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by: Licensee did not provide warm meals to residents recieving food tray service to their rooms which poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 18, 2024

Plan of correction: Plan of Correction: Licensee agrees to write a written statement on how this regulation will be met and will submit by POC due date of 1/19/24.

Allegation investigated: Staff is not maintaining residents hygiene. Staff does not provide residents with water. Staff allowing resident(s) to smoke in non-designated smoking area(s) of facility.

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to conduct a complaint investigation. LPA met with Administrator Ramona Eleco. LPA's disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. LPA interviewed Staff and Residents. LPA toured the facility. LPA took photo of water jug and designated smoking area. Based on observation and interviews, a water jug was observed in the dining area accessible for residents. Based on records review and interviews, facility has a shower schedule for residents. Facility logs when showers are given to residents. Based on observation and interviews, facility has a designated smoking are for residents in care. Unsubstantiated The Department has investigated the above allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 3, 2024 · control 24-AS-20230929142858

Allegation investigated: Staff do not ensure that resident needs are met

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to conduct a complaint investigation. LPA met with Administrator Ramona Eleco. LPA's disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. LPA obtained copies of R1's file. LPA requested copies of facility's incontinence log for R2 and R3 and reviewed the records. LPA interviewed Staff. Based on records review and interviews, it is undetermined whether or not the allegations occurred. 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. A copy of this report was provided to Administrator. Unsubstantiated Based on records review, R1 is paying less than the amount listed in the admissions agreement and did not pay for the month of December 2023. This agency has investigated the complaint alleging, Staff do not safeguard resident's funds, Staff did not keep the facility free of insects, and Staff are billing residents receiving SSI beyond the basic rate. Based on interviews records review, observation and photos, We have found that the complaint was UNFOUNDED, which means the the allegation could not have happened, and/or is without reasonable basis, therefore we have dismissed the complaint. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 3, 2024 · control 24-AS-20231228125044

Allegation investigated: Resident sustained unexplained bruising while in care.

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to conduct a complaint investigation. LPA met with Administrator Ramona Eleco. LPA's disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. The Department has investigated the above allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 18, 2023 · control 24-AS-20230928111604

Allegation investigated: Staff did not ensure that a resident's incontinence needs were met Licensee does not provide residents with activities

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to conduct a complaint investigation. LPA met with Administrator Ramona Eleco. LPA's disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. LPA interviewed Staff and Administrator. LPA obtained copies of staff schedule, records and R1's file. R1 has an incontinence schedule showing when checked/changed. Records show R1 is being checked/changed every 2 hours. LPA reviewed activties schedule and obtained a copy of the schedule. Last week the facility had a Christmas party, music, movies, and religious services ect. Based on record review and interviews, it is undetermined whether or not the allegations occurred. 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 was conducted with the Administrator and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 18, 2023 · control 24-AS-20231213120605

Allegation investigated: Staff make inappropriate comments towards residents Staff do not treat residents with dignity Staff are not able to effectively communicate with resident Staff are mismanaging resident's medication

Licensing Program Analyst (LPA) Shawna Doucette arrived unannounced to conduct a complaint investigation. LPA identified herself and discussed the purpose of the visit and delivered findings. LPA met with Activities Director Candaleria Carrillo who contacted Administrator Ramona Eleco who gave permission to sign for this report. LPA obtained R1's file and interviewed staff and residents. Based on interviews with staff and residents, Staff did not treat residents with dignity, do not communicate effectively with residents and make inappropriate comments towards residents. Based on record review and interviews, staff are mismanaging residents medications. According to records R2, R3 and R4 missed medications on 07/31/23. Substantiated Based on interviews, it is unknown whether or not staff are refusing to provide residents with food. Per interviews facility provides a serving of the original meal to residents, however for a second serving if facility runs out of the original meal residents are provided a peanut butter and jelly sandwich. Based on interviews and shower schedule, it is unknown whether or not staff are meeting residents shower needs. Based on interviews and record review although the AC needed to be repaired facility contacted AC repair company, offered to move residents to a unit with AC or offered residents a fan until the AC unit was fixed. Based on record review and interviews, it is undetermined whether or not the allegations occurred. 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 was conducted and a copy of this report was provided. Based on record review and interviews, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. An exit interview was conducted with Activities Director Candaleria Carillo and a copy of this report along with appeal rights and plan of correction were provided.the state’s words, verbatim · CDSS document, Nov 15, 2023 · control 24-AS-20230731144332

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Dec 1, 2023

87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Licensee did not ensure S1 treated R2 and R6 with dignity and respect, which poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2023

Plan of correction: Plan of Correction Licensee agrees to conduct a staff training on personal rights and will submit an agenda with sign in sheet by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 1, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by: Licensee did not administer medications on 7/31/23 for R2, R3 and R4, which poses an immediate health safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2023

Plan of correction: Plan of Correction Licensee agrees to conduct a medication training and submit agenda and sign in sheet by POC due date 12/1/23.

Allegation investigated: Staff do not keep the facility free of insects/spiders

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to conduct a complaint investigation. LPA met with Administrator Ramona Eleco. LPA's disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. LPA reviewed records and interviewed Administrator. LPA interviewed the pest control technician. LPA obtained copies of faclities pest control records. Based on interviews and records review, facility has a pest control service that is servicing monthly. This agency has investigated the complaint alleging, Facility staff abandoned resident at the hospital. Based on interviews and records review, We have found that the complaint was UNFOUNDED, which means the the allegation could not have happened, and/or is without reasonable basis, therefore we have dismissed the complaint. A copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Oct 30, 2023 · control 24-AS-20231024154146

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Darius Williams conducted a visit to return Resident 1's file. LPA Williams met with Administrator and provided R1's file. An exit interview was conducted and a copy of this report will be provided via e-mail.the state’s words, verbatim · CDSS document, Oct 4, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Darius Williams conducted a visit to the facility. LPA Williams met with Administrator Mona and discussed the purpose of the visit. LPA Williams toured the facility and noticed Resident 1 lying in their bed with full bed rails (bed rails the entire length of the bed). LPA Williams reviewed their Hospice Care Plan, dated 8/29/2023, and only located mention of half bed rails. Administrator did not locate any mention of full bed rails in the Hospice Care Plan. Administrator reported she will contact R1's hospice agency and either change to half bed rails, as stated in the care plan, or specify the need for full bed rails. Plan of correction was reviewed and discussed with the Administrator. An exit interview was conducted and a copy of this report will be provided via e-mail.the state’s words, verbatim · CDSS document, Sep 29, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Sep 30, 2023

..(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who... have a hospice care plan that specifies the need for full bed rails. This requirement was not met evident by: Based on observation and record review, the Licensee did not ensure the use of full bed rails was specified in R1's hospice care plan, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Administrator agreed to contact R1's Hospice Agency and request the bed be changed to half rails or specify the reason for ful bed rails by POC due date of 9/30/2023.