La Jolla Casa Pacifica

Allegation investigated: Staff sexually abused resident Staff physically abused resident resulting in injuries Facility did not provide hygiene supplies Facility did not ensure face masks were available to visitors. Licensee did not comply with reporting requirements

*** This is an Amended Report *** On 9/30/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Administrator Jennifer Fernandez and explained the purpose of the call. Regarding the allegation of staff sexually abused resident and physically abused resident resulting in injuries, Reporting party (RP) stated that on 3/3/22 early in the morning, resident (R1) had been molested by a night time staff member (S1). During the course of the investigation, staff members were interviewed, and records were reviewed. On S1s interview, S1 shared that R1 will be combative and difficult when being changed. Sometimes R1 will be fine, but typically R1 is difficult and will resist. During R1s change, R1 was “screaming and yelling.” S1 denied grabbing or striking R1s legs. page 1 of 2 Unsubstantiated R1s primary physician (DR) was interviewed, as well as R1s hospice provider registered nurse (W1). The hospice medical records for R1 were obtained. Both the DR and W1 affirmed R1s mental state may be a factor in the allegation disclosures by R1. Facility staff were interviewed, as well as S1, who denied the allegations. There were no other staff present in the home when the alleged abuse occurred. The investigation for the allegations of physical and sexual abuse will be closed as unsubstantiated at this time. For the allegation of facility did not provide hygiene supplies, RP states that they have visited R1 in the past, and noticed there were no paper towels in R1s bathroom and asked staff for paper towels but was told 'there are none'. The Department conducted a visit last 3/10/2022. LPA observed 3 bathrooms. Bathroom #1 is used for visitors and staff, LPA observed paper towels and hand soap. Bathroom #2 is not used. The bathroom was empty. Bathroom #3 is used only by R3, LPA observed paper towels and hand soap there. LPA requested to see the stock of supplies. LPA also observed 2 medium sized bottles of hand soap and ¼ hand soap left in a large container. LPA also observed two small rolls of paper towels. LPA was taken to the garage and a nearby office where LPA observed approximately 8 boxes of gloves, approximately 7 small bottles of hand sanitizer, 2 small bottles of hand soap, various packages of diapers and some wipes. LPA asked staff member, S3, what the facility policy is when staff run out of hygiene items- S3 stated that there is another facility ten minutes away where they can obtain items from and they can also call the Administrators who can bring some. S3 indicated that they all have been informed to request more items when needed. Regarding the allegation of facility did not ensure face masks were available to visitors, RP stated that when they visited they asked for a mask, but RP was told 'there are none'. LPA requested to see the stock of masks, S3 could not find any. S3 stated that due to a COVID outbreak at another facility, the Administrators took PPE to that facility. S3 also stated that staff bring their own masks. LPA asked what staff do if a visitor does not have a mask, S3 indicated that they can provide one for the visitors, but there were no extra masks to provide. LPA asked what the facility policy was if a visitor arrives without a mask. S3 stated that this has not occurred yet, but that the facility would provide a mask for them. Regarding the allegation of Licensee did not comply with reporting requirements, RP stated that S1 did not notify Licensing or Law Enforcement of this incident. LPA asked S3 about S3s knowledge of CCLD reporting requirements if S3 knew what a mandated reporter was, S3 demonstrated understanding. S3 stated that most paperwork is handled by the facility Administrators. Based on interviews, observations and records review, the department has determined that 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. Report is reviewed and copy is provided. page 2 of 2the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 08-AS-20220308132302

Type of visit: POC

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Plan of Correction (POC) visit regarding two deficiencies that were cited on 8/29/25. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregiver Shahla Mirzaee. Staff Vinod Karpal arrived later in the visit on behalf of Administrator Sonya Karpal. On 8/29/25 LPA cited two (2) deficiencies for unsecured laundry chemicals left out and for lack of an annually updated resident appraisal. The POC due date for both deficiencies was set for 9/12/25. LPA did not receive Plan of Correction items and Licensee did not communicate to LPA prior to the POC due date for additional time. As the Licensee failed to correct the deficiencies and notify LPA by the due date, LPA conducted a POC visit to verify correction and to assess a Civil Penalty Violations for Failure to Correct. Two Civil Penalties (CPs) of $100.00 a day has been assessed from 9/13/25 to today's date (9/22/25) for a total of $2,000.00. The Civil Penalties will continue to be assessed at a daily rate until the deficiencies are cleared. An exit interview was conducted with Staff Vinod Karpal to whom a copy of this report, the two (2) LIC 421FC forms, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 22, 2025

Type of visit: Case Management - Deficiencies

On 9/22/25 Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to the facility. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregiver Shahla Mirzaee. Staff Vinod Karpal arrived later in the visit on behalf of Administrator Sonya Karpal. During the visit, LPA noted that no staff members were associated to the facility. Further review of system actions revealed that the Licensee had personally removed five (5) staff members from the staff association list on 6/16/25 -- including themselves, and three (3) others were not previously associated to the facility. LPA verified that all staff members on the facility roster, including those present during LPA's visit, had eligible background clearances. One type A Deficiency was cited during the visit per California Code of Regulations, Title 22, Division 6 on the attached LIC 809-D. In addition, a Civil Penalty is being assessed for Zero Tolerance Violations regarding Criminal Record Clearances and are noted on the attached LIC 421BG form in the combined amount of $4,000.00. An exit interview was conducted with Staff Vinod Karpal to whom a copy of this report, the LIC 421BG, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Sep 29, 2025

87355(e)(2) "All individuals subject to a criminal record review [...] shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)" This requirment is not met as evidenced by: Based on LPA file review and interview, the licensee did not comply with the section cited above in ensuring that eight (8) staff did not have their clearances transfered, which poses an immediate health, safety, and personal rights risk to 3 out of 3 persons in care.the state’s words, verbatim · CDSS document, Sep 22, 2025

Plan of correction: Licensee will submit proof of staff members having been associated to the facility to LPA by POC due date.

Allegation investigated: Licensee did not follow reporting requirements regarding pending facility sale.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to deliver findings regarding the above mentioned allegation. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit to Caregiver Shahla Mirzaee. LPA spoke with Administrator Sonya Karpal over the phone as well to inform them of the reason for the visit and findings. On 04/16/2025, the Department received a complaint where it was alleged that the facility owners did not follow reporting requirements in informing the Department and residents/their responsible parties of the home being sold. Per Title 22 Regulation 87109(b), the Department, residents and/or resident responsible parties must be informed a minimum of 30-days prior to the transfer of property or at the time a bona-fide offer is made, whichever is longer. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff, residents, and outside sources. [Continued on LIC 9099-C] Unsubstantiated [Continued from LIC 9099] The facility's Licensee did report to the Department on 4/15/25 that there was a pending sale of the property and provided an estimated date of escrow completion for 4/18/25. Outside sources interviewed all corroborated that the facility Administrator and/or Licensee communicated to them of intentions to sell the home and business through a change in ownership. One (1) outside source interviewed revealed that a written notification was provided on 4/15/25 and two (2) others revealed that they had been given verbal notice weeks earlier. File review of emailed communications confirmed that a notice was sent out to all resident responsible parties of the proposed change of ownership in both property and facility management on 4/15/25. Resident interviews revealed mixed information of if they were informed or not, but several communicated that their families would know for certain. Resident interviews did not reveal any concerns about their care or the transition to new owners. Staff interviews revealed that staff were not made aware of the impending change of ownership and learned through other means or after-the-fact. An outside source interview revealed that the official completion of sale occurred in June 2025, which was corroborated by a staff interview -- well past the required 30-days from 4/15/25. Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred – therefore the allegation has been determined to be UNSUBSTANTIATED. An exit interview was conducted with Caregiver Mirzaee to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 5, 2025 · control 08-AS-20250416111525

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregiver Shahla Mirzaee. LPA spoke with Administrator Sonya Karpal over the phone as well to inform them of the visit. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, one (1) of which may be bedridden. Bedridden resident may reside in bedroom #5 only. Additionally, the facility is approved for two (2) hospice waivers. During today’s inspection there were three (3) residents in care. LPA and Caregiver Mirzaee toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Common bathroom sink by laundry room was 108F and common bathroom sink by kitchen was measured at 110F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents in care. [Continued on LIC 809-C] [Continued from LIC 809] While touring the laundry room, LPA noted that a jug of laundry detergent was left out on the counter by the washer and dryer. Per interview with staff, they had just started a load of laundry as LPA arrived and the jug is normally stored in the locked cabinet beneath the counter. As LPA arrived to the home, they did observe staff present in the laundry room through the window starting laundry before coming to open the door for LPA. Staff immediately secured the detergent jug. A Type B citation was issued for the unsecured chemicals. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Caregiver Mirzaee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced July 2025. First aid kit was readily accessible, however a first aid manual was missing from the kit. A Technical Violation (TV) was issued and guidance given for maintenance of a complete kit. Required licensing postings were observed in visible areas of the facility. LPA interviewed one (1) staff and one (1) clients, and interviews did not reveal any licensing or regulatory concerns. LPA observed residents to be tended to quickly and treated with respect. LPA reviewed facility records. The files reviewed by LPA contained required documents, but LPA did note that one resident (identified as R1) had an outdated appraisal. A type B citation was issued due to lack of an annually updated appraisal as required. Confidential records were stored in locked areas. Two Deficiencies were cited during the inspection due to the accessible laundry chemicals and non-updated resident appraisal. An exit interview was conducted with Cargiver Mirzaee to whom a copy of this report, the LIC 9102 (TV form) and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 29, 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.

Allegation investigated: Staff did not provide DNR form to emengency personnel Staff did not destroy resident's medication

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced follow up complaint investigation visit and delivered findings. The LPA introduced himself and disclosed the purpose of the visit to Staff Linda Gonzalez. Licensee Gus Fernandez arrived during the visit and assisted the LPA. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources. It was alleged staff did not provide a Do-Not Resuscitate (DNR) form to emergency personnel. On December 19th, 2024, it was reported to the Department staff summoned emergency medical personnel for Resident # 1 (R1), but staff did not provide paramedics R1’s DNR form. Interviews with internal and external sources confirmed R1 was on hospice and had a DNR form on file. During the incident in question, staff handed paramedics R1’s facility profile but did not hand paramedics R1’s DNR form. One source reported R1’s file had two DNR forms. (See LIC 9099-C for continuation of report.) Substantiated One form was blank inside the binder and the completed DNR form was placed on the front sleeve of the binder. An interview with the licensee revealed that during the incident in question staff called the licensee and advised the fire chief wanted to speak with the licensee. The fire chief reported not being able to locate the DNR form. The licensee instructed the fire chief to look in the resident's file. It was alleged staff did not destroy resident's medication. It was reported to the Department facility staff did not destroy R1 medication, but instead handed R1’s medication to R1’s family, after R1 was deceased. Interviews with internal sources reported staff released R1’s medication to R1’s family after R1’s hospice agency approved for the medication to be released. Additional interviews with internal sources revealed it was not the facility’s protocol to release medication to families, nor the hospice agencies. The facility’s protocol called for two staff to destroy the medication and sign the required destruction form. An interview with R1’s hospice service provider confirmed there was no indication the agency had approved the release of R1’s medication, and it was not common for this agency to retrieve, or destroy medication. Based on evidence obtained, the allegations were substantiated and cited in an LIC 9099-D form. Plans of Corrections (POCs) were jointly formulated with Licensee Gus Fernandez. An exit interview was conducted with Gus Fernandez, to whom a copy of this report, LIC 9099-D, LIC 811, and Licensee/Appeals Rights (LIC 9058), were provided. The hospice agency reported having a notification on file that the facility reported the death at approximately 9:30 AM on the day of the incident, but no previous notes noting aspiration, nor R1’s impending death. Although hospice did not have any previous notes indicating staff had called the agency, it is unclear if the messages were not received, or if staff did not contact the agency. The LPA made several attempts to contact a pertinent sources to confirm if staff notified the agency, but these attempts were unsuccessful. It was alleged staff did not provide R1 incontinence supplies. It was reported to the Department R1 resided at the facility for two days and required incontinence pads. The facility allegedly did not have any supplies available. Interviews with internal sources revealed it was the resident’s, hospice providers, or resident’s responsible party to provide incontinence supplies. One interview revealed it had occurred staff had to barrow supplies from other resident to assist an other resident. Although one source reported the facility may run low on incontinence supplies, it was reported staff always provided incontinence supplies to residents. The LPA toured the facility on multiple occasions an observed extra incontinence supplies, including briefs, wipes and pads. Based on the evidence obtained, the allegations were unsubstantiated. An exit interview was conducted with Licensee Gus Fernandez, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Apr 29, 2025 · control 08-AS-20241219145135

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87469(c)(1) · Plan of correction due date: Apr 29, 2025

87469 Advanced Directives and Requests Regarding Resuscitative Measures (c) If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following:(1) Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel and identify the resident as the person to whom the order refers. This requirement was not met as evidenced by: Based on interviews and review of records, the Licensee did not ensure R1's DNR form was provided to emergency medical personnel, which posed a potential health, safety, and personal rights risk to R1.the state’s words, verbatim · CDSS document, Apr 29, 2025

Plan of correction: Administrator agreed to provide training to all staff reagarding DNR forms, and provide the LPA an attendance sheet by 5/29/25. Administrator nos keeps DNR forms above each residents bed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Apr 29, 2025

87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: This requirement was not met as evidenced by: Based on interviews, the Licensee did not ensure R1's medicaiton was destroyed, which posed a pontential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2025

Plan of correction: Administrator agreed to provide all staff training regarding medication destruction procedures and submit attendance sheet to LPA by 5/29/25.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Administrator Jennifer Fernandez. The facility was licensed for a capacity of six (6) non-ambulatory residents, of which one may be bedridden in room number 5. The facility was also approved a hospice waiver for two (2) residents. The LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon monoxide detectors, facility telephone, and Fire extinguisher(s) were present. A first aid kit(s) was readily accessible. Required licensing postings were observed in visible areas of the facility. The LPA interviewed staff and reviewed multiple staff and resident records/files. Several personnel records were not present at the time of the visit. Additionally, a fire clearance violation regarding a bedridden resident was observed. These deficiencies were cited in an LIC 809D. An immediate $500 civil penalty was assessed in an LIC 421IM form. A plan of correction was jointly formulated with Fernandez. An exit interview was conducted with Administrator Fernandez, to whom a copy of this report, LIC 811 Confidential names list, LIC 809D, and the Licensee/Appeal Rights (LIC9058), were provided.the state’s words, verbatim · CDSS document, Aug 29, 2024