La Casita Residential Care

Allegation investigated: Staff are not addressing resident fall risk. Staff are not administering medication as prescribed.

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA Gonzalez was greeted by staff, and the purpose of the visit was explained. Administrator Humberto Santamaria arrived shortly after. The investigation consisted of the following: On 06/12/26, LPA Gonzalez interviewed staff 1- 2 (S1-S2) and interviewed resident #2 (R2). LPA obtained staff and resident rosters. LPA reviewed files for R1-R3 and obtained copies of Admission Agreement, medical assessment, pre-appraisal, functional capabilities assessment/needs and service plan, and staff notes for resident #1 (R1). During today’s visit, LPA delivered findings. continued on LIC9099C Unsubstantiated The investigation revealed the following: Regarding the allegation “Staff are not addressing resident fall risk,” it was reported that R1 has a history of multiple nighttime falls. Three (3) out of three (3) staff interviewed denied the allegation. S1 stated R1 had not sustained any falls while at the facility. S1 stated R1 would tell S1 about their night and would have mentioned if they had fallen. S1 stated caregivers report to each other what happened during the previous shifts so that the incoming staff were aware if anything had happened. LPA reviewed staff notes dated 05/28/26-06/30/26, staff did not mention any falls for R1. S2 stated no falls had been reported by caregivers. S3 stated they were nighttime staff. S3 stated R1 had been there for about one (1) month and had not sustained any falls. S3 stated R1 used a wheelchair and would ask for assistance when needed. S3 stated R1 would talk about their day and did not mention any falls. LPA interviewed R2. R2 stated they were not aware of any falls and staff always help. Regarding the allegation “Staff are not administering medication as prescribed,” it was reported that R1 intermittently takes their medications only when they feel they need them. Three (3) out of three (3) staff interviewed denied the allegation. S1 stated R1 never refused medication. S1 stated there were medications that were not given due to reading of R1’s vitals and medication not being necessary (per doctor’s prescription) but R1 always cooperated when assisted with medication administration. S2 stated R1 always took their medications. S3 stated they did not assist R1 with medication administration, but caregiver notes did not mention R1 refusing medication. Based on interviews and record review, although the allegation may have happened or is valid, there is no 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 to Administrator Humberto Santamaria.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 28-AS-20260623105515

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced Case Management visit regarding deficiencies noted during a complaint investigation visit conducted on 07/02/26 (Complaint # 28-AS-20260623105515). LPA met with Administrator Humberto Santamaria and the purpose of the visit was explained. On 07/02/26 during review of Medication Administration Record (MAR) log for the facility residents, LPA observed there was not a record of dosages of medications which were centrally stored for R1 maintained by the facility. LPA interview with S2 confirmed the facility did not have a record of dosages of medications for R1 and staff administered prescribed medications provided by R1’s family. During interviews with S1 and S2, staff revealed that on 06/21/26 R1 was ill and R1's family took R1 to the doctor. Administrator did not submit an incident report within seven days of the occurrence to Licensing.the state’s words, verbatim · CDSS document, Jul 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Jul 9, 2026

87465 Incidental Medical and Dental Care(a)A plan for incidental medical ...shall be developed by each facility... and provide for assistance in obtaining such care, by compliance with the following:(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interview and record review there was not a record of dosages of medications which were centrally stored for R1 maintained by the facility, which poses a potential health and safety risk for residents.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Licensee agree to review the regulation and submit to LPA statement of understanding. Licensee also will submit a Centrally Stored medication list for R1.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Jul 9, 2026

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...within seven days of the occurrence of any of the events specified in (A) through (D) below.... This requirement is not met as evidenced by: Based on interviews and record review, it was noted that on 06/21/26 R1 was ill and R1's family took R1 to the doctor. Administrator did not submit an incident to licensing which poses a potential health and safety risk for residents.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Licensee agreed to submit to LPA an incident report for R1's illness and subsequent doctor visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection. LPA was greeted by staff and explain the purpose for the visit. Administrator Humberto Santamaria arrived shortly after to assist with tour. The facility is a single story home located in Glendora. The home consists of dining area, kitchen, living room, six (6) resident bedrooms, two (2) bathrooms, garage with laundry, outdoor covered patio, front and back yards. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. Carbon monoxide detectors and smoke detectors are located in the hallways, were tested and are operable. LPA inspected six (6) resident rooms. All residents’ bedrooms contained required furniture, linens and lighting, all in good repair. Water temperatures in all grooming and bathing areas were measured to be 112.6 °F, which is within the 105 – 120 degrees F requirement. LPA observed grab bars near toilets and inside showers. Facility has video surveillance inside common areas and outside perimeter of the facility. Food Service: LPA observed sufficient supply of nonperishable for one week and perishable foods for a minimum of two days in the kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. All kitchen areas are be kept clean and free of litter, rodents, vermin and insects. continued on LIC 809C Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drill was conducted on January 2, 2026. Residents with Special Needs: No pools or large bodies of water were observed. LPA observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in a locked hall closet. The facility uses the Medication Administration Record (MAR) log to document medications given. Staffing: Administrator Certificate for Humberto Santamaria expires on 12/21/2027. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA reviewed three (3) staff files and all were observed to contain required annual training, valid CPR and First Aid, TB testing results, Health screening, fingerprint clearance and job. Operational Requirements: The fire clearance is approved for six (6) non-ambulatory. Hospice waiver for six (6) in place. Resident Records/Incident Reports: LPA reviewed Resident files for six (6) residents in care. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. Per California Code of Regulations, Title 22, and California Health and Safety Code, there are no deficiencies observed during today’s visit. Exit interview held, and a copy of this report was provided to Administrator Humberto Santamaria.the state’s words, verbatim · CDSS document, Apr 10, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit on 06/24/2025 and was greeted by Caregiver Margarita Betancourt. Administrator Humberto Santamaria arrived shortly after to assist with tour. LPA Ramirez explained the purpose of the visit. The facility is located on a main street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms. All resident bedrooms contained required furniture, linens and lighting. LPA Ramirez observed a manual Hoyer lift in bedroom#3. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed a commode shower wheelchair in bathroom#1. Showers were observed to be wheelchair accessible. Facility has video surveillance inside common areas and outside perimeter of the facility. Food Service: LPA Ramirez observed sufficient supply of nonperishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. See 809-C Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 04/05/2025 & 01/05/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in kitchen pantry. Residents with Special Needs: No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Staffing: Administrator Certificate for Humberto Santamaria expires on 12/21/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for three (3) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for two (2) out of the three (3) personnel records reviewed. S3 did not have Health screening in personnel record. LPA Ramirez will issue Type B deficiency based on this record review. LPA Ramirez did not observe staff training on use of Hoyer lift. LPA Ramirez will issue Technical Violation for lack of documentation of staff training on Hoyer lift. Staff on duty were able to demonstrate use of Hoyer lift when asked by LPA Ramirez. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for six (6) non-ambulatory. This facility may retain no more than six (6) hospice residents. There were five (5) residents under hospice care during inspection. Resident Records/Incident Reports: LPA reviewed Resident files for six (6) residents in care. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. One (1) violation was observed during visit. Exit interview conducted. A copy of this report, 809-D, LIC 9102 and appeals rights was provided via email.the state’s words, verbatim · CDSS document, Jun 24, 2025

Allegation investigated: Questionable Death. Staff abandon resident. Staff are unable to communicate with resident due to language barrier.

Licensing Program Analyst (LPA) Alberto Lopez made subsequent visit to investigate the above allegations. LPA met with Humberto Santamaria, Administrator and discussed the purpose of the visit. 04/03/24 Investigation consisted of the following: LPA Lopez requested a copy of the Staff and Resident roster, and conducted a tour of facility bedrooms, bathrooms, and common areas. LPA also reviewed and obtained files for Resident (R#1). LPA observed the residents in the facility to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did observe several Health and/or Safety concerns. LPA addressed those concerns on a Case Management report. It has been determined that the above-mentioned allegations will require further investigation. (continued on 9099C) Unsubstantiated The investigation consisted of LPA taking tour of facility, interviews with two (2) facility residents, Five (5) staff of the facility, two witnesses (W#1 W#2) and the department interviewed home health nurses. The investigation revealed: Allegation: Questionable Death. It is alleged that facility neglected and did not provide care to resident resulting in resident being admitted to hospital and passing at the hospital. No neglect was reported by the persons interviewed. Five (5) of five (5) staff interviewed denied the allegations and reported sending the victim to the hospital for medical assessment due to nausea/vomiting on 01/06/2024. R1 passed away on 01/23/2024 at the hospital due to complications. Two (2) of two (2) residents interviewed could not corroborate the allegation. Review of R1 Home Health records did not uncover any neglect concerns. No abuse or neglect concerns noted in resident's hospital records. The information and evidence obtained did not sufficiently support the allegation. Allegation: Staff abandon resident. It is alleged that staff took resident to hospital on 01/06/2024 and left resident there, abandoning resident. Five (5) of (5) staff denied the allegation. Two (2) of two (2) residents could not corroborate the allegation. S1 stated that S1 took resident to hospital on the request of daughter after staff discussed change of condition with daughter. S1 stated that daughter stated she would meet S1 at hospital with resident. S1 stated daughter called S1 to informed S1 that daughter was at emergency door and S1 stated that he gave resident to daughter and left the hospital. S2, who is spouse of S1 stated that the facility called daughter about taking resident to hospital and that daughter told facility staff that she was tending to her cat and that was more important to her. S2 stated S1 left resident with nurse at the hospital entrance and stated that daughter had not yet arrived. There are inconsistencies in the statements of S1 and S2, however, no report of abandonment was sent by hospital and there is not enough information or evidence that staff abandoned resident at hospital. (continued) . Allegation: Staff are unable to communicate with resident due to language barrier. It is alleged that facility staff do not speak or understand English and that makes it difficult to communicate. Five (5) of five (5) staff denied the allegation. Two (2) of two (2) residents could not corroborate the allegation. S1 stated that staff understand simple commands. S2 stated that the allegation is not true. S2 stated they live close and that the caregivers meet all the needs of the residents. S3 who was working at facility previously stated she understands English but prefers Spanish. S3 stated S3 met all the needs of residents when S3 was working at facility. S4 stated S4 really does not understand English too well but enough to be able to meet the resident’s needs. S5 stated S5 is new to facility and is able to meet the needs of the residents. LPA interviewed five (5) staff in English and four (4) of five (5) staff were able to answer questions. LPA was present during meal time and 3 residents were served different food, when asked S4 why, S4 explained that one resident is vegetarian and the prefer different meals. The residents appeared clean and well taken care off. The staff present is competent to meet the needs of all the residents currently. There is not enough information or evidence to proof this allegation. Based on statements and interviews conducted, review of residents files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Sep 24, 2024 · control 28-AS-20240402153426

Allegation investigated: Resident sustained pressure injury while in care. Resident choked while in care. Staff did not seek medical assistance for resident in a timely manner. Staff mismanaged resident's medication. Staff administered unprescribed medication. Illegal eviction. Staff restrained resident. Staff handled resident in a rough manner. Staff did not safely use resident's wheelchair.

LPA Nune Margaryan amended the original report and redelivered complaint report on 05/16/24. Upon arrival LPA met with Humberto Santamaria and explained the purpose of the visit. The amendments to the report do not affect or change the findings on this complaint. Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent complaint visit to deliver findings to the above mentioned allegations. LPA meet with Alisia Gomez. Shortly after Administrator Humberto Santamaria arrived. Reason for the visit was explained. The investigation consisted of the following: On 1/11/22 and 04/12/24 facility tour was conducted including residents rooms and common areas, interviews were conducted with the Staff #1 and Staff # 2, obtained copies of staff and residents roster. LPA also requested and obtained the copies of file (including Hospice documents) for Resident #1(R#1) and Resident #2 (R#2) for review. Continue 9099C Unsubstantiated The investigation revealed the following: Regarding the allegations that Resident sustained pressure injury while in care and Staff did not seek medical assistance for resident in a timely manner. It was alleged that before R1 death R1 had “gurgling noises”, had a vaginal bleeding and was in severe pain many times and facility staff never called a doctor for pain,bleeding or for aspiration. Also, it was indicated that R1 developed a sore on her foot. R2 had a low blood pressure and staff said that they not going to call 911 and were not going to give blood pressure medication. Interviewed Administrator and Assistant administrator denied the allegation. They stated that both residents were under the same hospice care: “Comfort Hospice Care”, and they were instructed to call hospice 24/7 for any reports/significant changes, which they did. Hospice nurse visited residents twice a week and staff always contact / report to the hospice when they noticed any significant changes on R1 and R2. LPA obtained and reviewed Hospice notes for R1 and R2. For R2 it said that at the time of nurse visits on 2/1/2019 ”vital signs are low but are still within normal parameters including blood pressure”. R2’s daughter requested doctor’s visit and the visit scheduled at the next day. Hospice MD was notified and obtained new order for R2. Administrator stated that R1 was incontinent and when staff changed the resident, they never noticed that R1 was bleeding. Review of hospice agency documentation shows that R1 never had vaginal bleeding. Hospice documents showed that R1 started continuous care (round a clock nursing supervision) from 5/28/2019 – 5/30/2019 because of R1’s last stage of their life. Patients/residents declining and last stage of their life they always have moaning and gurgling noises. The gurgling noise is due to patient unable to swallow their saliva. R1 admitted under Comfort Hospice Care as of 04/08/2019. Per Register Nurse's Initial evaluation and head to toe assessment patient did not have any wounds but had very sensitive skin and on high risk for open wounds. R1 transferred to facility with DTI (Deep Tissue Injury) which is very common for patients with CVA (cerebral vascular accident) diagnosis. Patient never had a pressure ulcer not in the hospital (from R1 was transfered to the facility), not at the facility. On 05/24/2019 report from visiting nurse said that R1’s Left Foot Deep tissue injury has opened and is now a Stage II Left foot pressure ulcer, which is very common with bed bound patients /residents. Wound has been treated appropriately and reported to doctor. For the pain R1 was prescribed Tylenol, Tramadol and at the letter time Morphine for lot of pain by the Hospice Doctor. Continue 9099C Regarding the allegations that Resident choked while in care and Staff handled resident in a rough manner. It was alleged that staff very rough with R1 specifically S3 and staff would aggressively feed R1 which caused resident to choke. During interviews, Administrator and Assistant Administrator stated that staff have never handled residents in a rough manner. They have never witnessed that staff handle residents in a rough manner. They stated that staff treat residents with dignity and respect. Administrator has never received any complaints from residents and staff that S3 has handled R1 in a rough manner or aggressively feed R1 which caused resident to choke. Interviewed Administrator and Assistant Administrator indicated if residents could feed themselves, staff would let residents eat at their regular time and will never force them. Staff will help / assist residents if it’s necessary. LPA observed on the hospice notes says that assistance needed for R1 with feeding. At the lunch time, during the visit LPA didn’t observe that staff force feeding residents. During the visit, LPA was informed that S3 is no longer employed at the facility. LPA was unable to contact S3 for an interview. Regarding the allegations that Staff mismanaged resident's medication and Staff administered unprescribed medication. It was alleged that facility staff overmedicating R2, and facility administrator and assistant administrator were adjusting the medications dosage without doctor’s order: giving Ativan without doctor’s order and increasing dosage of medication at night. R1 was always sleepy, and staff inform family member that R1 was really loud, so they give R1 something to make R1 sleep. Interviewed Administrator and Assistant Administrator denied the allegations. They stated that medications from hospice always coming in bubble pack and medication dispensed in the facility are under Dr. orders, they never dispense,they never hold or provide any extra medications without Dr. orders. R1 and R2 got their medications timely and as prescribed. LPA obtained and reviewed Hospice notes for R1 and R2. R1 was under hospice care since 04/08/2019. LPA noticed that for R1 there was a doctor’s order for the medications; Xanax 0.25mg/ daily, Xanax 0.25mg/daily at bedtime as needed for agitation/anxiety, Restoril 15mg/daily, Melatonin 10mg/ daily, Seroquel 25mg/twice daily for agitation/anxiety and insomnia. Hospice notes said under the influence of those medications’ patient/resident sleep during the day. R2 was under hospice care since 12/15/2018. For R2 was doctors order for Ativan/Lorazepam 2mg daily every 4 hours as needed for agitation/restlessness, Seroquel 100mg, Trazodone 100mg daily for Insomnia. On 02/08/2019 per R2 family member/ granddaughter those medications were discontinued by the Hospice doctor. There was new doctor’s order for R2, Start Ativan /Lorazepam 1mg/1 tab by mouth daily at bedtime as needed for agitation/insomnia. Facility staff and family were informed about changes. Continue 9099C Regarding the allegation: Illegal eviction. It was alleged that R2 will be evicted due to the R2’s granddaughter interference and administrator offered to transfer resident to another facility. Administrator and Assistant administrator denied the allegation. They stated that there was never any eviction notice issued to R2, even though R2 had several moments of aggression towards the caregivers and other residents. R2 would punch, scream, and would throw anything that she could grab on. That was family decision to move R2 from the facility. On 02/10/19 R2 relocated to R2’s daughter home, under the hospice care. Regarding the allegation: Staff restrained resident. It was alleged that R1 had a gait belt on her wheelchair and R1 was dressed over the gait belt which was against R1 skin. R2’s daughter came to visit and found armchair furniture all around R2’s bed. Administrator and Assistant Administrator denied the allegation. The use of restrain were never use with any of the residents. In or out of the bed. They never used armchairs around of resident’s bed to restrained them. Administrator stated that R1 had a gait belt on their wheelchair to prevent falls not for restraint resident. During the record review LPA observed the gait belt that R1 used was prescribed by the doctor for resident safety and fall prevention. On Hospice notes were nothing indicated about R1's skin damaged / injury /wounds because of gain belt against the skin. Administrator also indicated R1’s family members were acknowledged the gait belt.The gait belt used around the wheelchair for safety issues. Continue 9099C Regarding the allegation: Staff did not safely use resident's wheelchair. was alleged that facility would not always put foot pedals on the wheelchair and caregivers would “pop wheelies” in order to maneuver resident. Interviewed Administrator and Assistant Administrator denied the allegation. Wheelchair pedals are always attached to resident wheelchair, unless PT (Physical Therapist) moves and walk around and to prevent injury we removed, but we notified the doctor. Administrator and assistant administrator never witnessed that caregivers “pop wheelies” to maneuver resident. Facility staff very careful when they are assisting residents on the wheelchair. At the time of visit LPA observed residents on the wheelchair in the living room. All wheelchairs have a foot pedals and caregivers handled residents very carefully. Based on statements and interviews conducted, review of residents files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held with Administrator Humberto Santamaria and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 28-AS-20220110090635

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alberto Lopez conducted a Health and Safety check visit in response to complaint allegations. LPA was greeted by DSP Karla Enriquez who allowed entry. Administrator, Humberto Santamaria and Spouse Carmen Santamaria arrived a few minutes later and LPA explained the reason for the visit. During the health and safety check, LPA observed several deficiencies. Four residents were observed with gait belts wrapped around the wheelchair without a quick release. LPA observed client using oxygen without a sign on the entrance and no report to provided to Fire Department. Carmen Santamaria, Spouse of Licensee stated that they have 4 residents on hospice but never notified the department of the initiation of Hospice services. Facility also failed to submit incident report(s) when resident(s) were hospitalized and death report for resident that passed away in January 2024. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the 809D exit interview held, report, citations, and appeal rights provided,the state’s words, verbatim · CDSS document, Apr 3, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(2) · Plan of correction due date: Apr 4, 2024

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (2) Postural supports shall be fastened or tied in a manner that permits quick release by the resident. This requirement is not met as evidenced by: LPA observed 4 residents wearing gait belts without a quick release which poses/pose a health and safety hazard for residents in care.the state’s words, verbatim · CDSS document, Apr 3, 2024

Plan of correction: Administrator will obtain quick release belts that are used as postural supports and send proof to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87618(b)(3)(a) · Plan of correction due date: Apr 5, 2024

(a) Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who requires the use of oxygen gas administration under the following circumstances: (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility. This requirement is not met as evidenced by: LPA observed one resident using oxygen and no written report has been submitted to fire department.the state’s words, verbatim · CDSS document, Apr 3, 2024

Plan of correction: Administrator will send written report to fire department and send proof to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Apr 5, 2024

87211 Reporting Requirements; (a) Each licensee shall furnish...: (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence... (A) Death of any resident from any cause regardless of where the death occurred... This requirements is not met as evidence by: Based on documents reviewed, and facility failed to report death of R#1 within the seven days of occurrence which poses a potential Health, Safety, and Personal Risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2024

Plan of correction: Facility will submit death report for R#1. Licensee and administrator to review reporting requirements regulations section 87211 by POC due date 4/05/2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR87632(d)(2) · Plan of correction due date: Apr 10, 2024

Hospice Care Waiver The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. This requirement is not met as evidenced by: Facility has four residents currently on Hospice and failed to notify the department which poses a potential Health, Safety, and Personal Risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2024

Plan of correction: Administrator will send notifications of initiation of hospice for four residents currently on Hospice.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Licensee/Administrator, Humberto Santamaria, and explained the purpose for the visit. During today's visit, LPA Maldonado conducted a tour of the physical plant with Licensee, observed the facility food supplies, reviewed (6) resident medications, (6) resident files, (6) staff files, and conducted interviews with (2) staff, and attempted interviews with (6) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. The fire clearance is approved for (6) non-ambulatory residents and has an approved Dementia Care Plan. Facility has an approved Hospice Waiver for (6) residents. There are currently (4) residents receiving hospice care. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file, as required. LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are (2) full bathrooms in the home- both equipped with required grab bars and non-skid mats. The hot water was tested and measured at 114*F, which is in compliance. Food supplies was observed and was sufficient as required. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. Fire extinguishers were observed throughout, with current inspections and were fully charged. Smoke/Carbon Monoxide detectors were tested and observed operational, during the visit. The last fire drill was conducted on 01/14/2024. An auditory devices is installed and interconnected at the home. It was observed to operate for all entrances/exits of the home, as required. LPA observed several surveillance cameras in the front yard, back yard, and common areas inside the home. Per Licensee, the surveillance cameras have been installed and operational since they were first established in 2013, prior to the change in ownership and remained operation through the change in ownership. (Report Continued on LIC809-C...) LPA reviewed the Plan of Operation provided by Licensee for this facility and was unable to confirm the approval of use of surveillance cameras. Resident files were reviewed and observed to be complete with all the required documentation. Staff files were reviewed. (2) of (6) staff files were missing the required Health Screening. Resident medications were reviewed. Resident#5 (R5) had several stored medications that are being administered without written prescriptions on file, and one of the medication bottles was empty, requiring a refill. Per Licensee, R5's family is responsible for refilling and providing the documents to Licensee. However, after many attempts of speaking with the family to resolve the matter, Licensee has been unsuccessful with the medication requirements/needs from R5's family. Per California Code of Regulations, Title 22, Deficiencies were observed and will be cited on the LIC809-D. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 2, 2024