La Salle Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin arrived at 8:53 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator, Merla Ventura and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The fire extinguisher was last charged and inspected on 5/27/25. The facility has 4 resident bedrooms but is now utilizing only 2 rooms for residents and 2 bathrooms. The facility has a smoke and carbon monoxide detector that was tested and was working properly during visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort and safety. Toilet, hand washing and bathing facilities are operational and secure grab bars are present. The facility has sufficient space inside and outside for activities and visiting. The facility has a secure backyard and front patio for client use with plenty of shade. The facility has telephone and internet service for residents’ use. Operational Requirements: The facility has a current plan of operation on file with the department. The facility is operating in compliance with the granted fire clearance. Liability insurance is current and expires on 6/23/26. The facility is approved for a capacity of 6. The fire clearance is granted for 2 ambulatory, and 4 non-ambulatory. Hospice is approved for 1. Staffing: The facility currently employes 2 full-time staff. Staff records are being updated and will be provided to LPA. Administrator has a current certificate that expires 3/17/27. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. LPA reviewed 2 resident files for signed Admission Agreements, LIC 602A Physicians report, Appraisals Needs and Services Plan, Emergency and ID forms. Food Service: The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirements. Fresh fruits, proteins, and snacks are available. Incidental Medical Services: The facility uses Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed resident medications and found all medications were recorded and regulations are followed. LPA observed that medications were not expired and were kept in their original containers. Residents with Special Health Needs: The facility does accept dementia residents in care. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Oct 14, 2025

The state marks this report as 23 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Due to Lack of Supervision resulted in resident eloping several times Facility not providing medication per physician order Facility failed to report elopement appropriately

Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced visit on a complaint investigation regarding the above-mentioned allegations. LPA identified themselves and met with Administrator Merla Ventura, to discuss the purpose of the visit and elements of the complaint. LPA was accompanied by Long Term Care Ombudsman (LTCO) Viviana Padova. During the visit LPA reviewed/collected facility records, conducted a tour of the front of the facility, specifically door alarms, and interviewed staff. Prior to the visit, on 06/13/2025 LPA interviewed Witness 1 (W1) and Resident 1 (R1) and collected relevant documents from W1. Documentation stated R1 was admitted to the facility on 05/01/2025. Interviews confirm that R1 moved out same day following the last elopement on 05/10/2025. On the allegation – Due to Lack of Supervision resulted in resident eloping several times. It was alleged on 05/05/2025, 05/07/2025, and 05/10/2025, R1 eloped from the facility. On 05/05/2025 at approximately 5:48 p.m. Administrator contacted W1 stating that R1 had left the facility. Substantiated Administrator stated to LPA during visit that they were unable to follow due to other residents at the facility and believed that family lived a couple blocks away per discussion with family, so R1 would be safe. R1 was found by W1 and was taken to the Emergency Room (ER). Documentation of ER visit on 05/05/2025 was provided to LPA. On 05/07/2025 administrator contact W1 that R1 had left the facility at approximately 10:55 a.m. and administrator confirmed they were unable to follow due to residents remaining at the facility. R1 was found by W1 at a bus stop located between W1’s residence and the facility. Following elopement R1 was taken to the Primary Care Physician (PCP), medication to assist with agitation was prescribed, documentation of new pharmacy order was provided via screen shot image of order to LPA, and confirmed by administrator during complaint interview. On 05/10/2025 R1 was found by W1 at their residence locked in their personal vehicle. R1 attempted to contact W1 via phone call, call log noting a missed call at 3:54 a.m. and 4:28 a.m. for the date of 05/10/25 provided to LPA. W1 stated they heard a car honk around 4:00 a.m., 6:00 a.m., and the last car honk at approximately 7:00 a.m. W1 went outside and found R1 in back-seat of vehicle. W1 stated after waiting a few hours, they went to the facility at approximately 10:30 a.m. to move out R1’s personal belongings. When W1 arrived, W1 stated that staff told them R1 was still sleeping. Administrator believe that R1 was in the restroom. After stating R1 was at their home, staff allowed W1 to gather residents’ items. Interview with Administrator and staff on 06/17/2025 confirmed that elopements occurred. On the allegation - Facility not providing medication per physician order It was alleged that following elopement on 05/07/2025, R1 was seen by PCP who prescribed Seroquel. Image of prescription order was provided to LPA via W1. W1 stated when medication was given to facility, they stated they cannot accept residents on this medication. W1 stated that they then took the medication back and did not leave the medication with the facility so that R1 could remain. Interview conducted on 06/17/2025 with administrator confirmed that this occurred. Administrator was concerned that medication would cause R1 to be violent and unmanageable due to prior experience, Administrator was to attend next PCP appointment to discuss concerns, but discharge occurred prior to this happening. Administrator was informed by LPA that doctor’s orders must be followed. Continued on 9099-C On the allegation - Facility failed to report elopement appropriately Due to substation that R1 did elope from the facility on 05/05/2025, 05/07/2025, and 05/10/2025, Community Care Licensing reviewed records and noted that facility did not provide required reporting of the incidents. LPA asked facility why no report was made, administrator stated that due to the short time R1 was at their facility, they did not believe that a report was needed. Based on LPAs observations, interviews conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Jun 17, 2025 · control 29-AS-20250613100655

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 20, 2025

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following personal rights ...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. This requirement was not met as evidenced by: Based on investigation interviews with Witness 1 and administrator, the licensee did not comply with the section cited above, as resident was not properly supervised which led to three elopements, which posed an immediate safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Administrator will review facilities Plan of Operation that discusses elopement and dementia processes. Licensee will provide a written statement to CCL by 6/20/25 stating how they will prevent future incidents from reoccurring.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 30, 2025

87211 Reporting Requirements (a)(1)A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events specified…(D) Any incident which threatens the welfare, safety or health of any resident, such as… unexplained absence of any resident. This requirement is not met as evidenced by:Based on interview and record review, facility failed to provide report of elopement incidents to Licensing as required which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Licensee will review 87211 reporting requirements and provide CCL with a written statement of understanding. Licensee agrees to complete a Unusual Incident Report for each elopement and submit them to licensing by 06/30/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 30, 2025

87465 Incidental Medical and Dental Care (a)A plan for incidental medical…care shall be developed…plan shall encourage routine medical…care and provide for assistance in obtaining such care...(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview and record review, Resident 1(R1) did not received medication ordered by physician which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Administrator agrees to submit a written statement of understanding of CCR 87465 in its entirety. As well as review Medication guidance from the Technical Support Program.

Allegation investigated: Illegal Eviction

Licensing Program Analyst (LPA) Erika Miller conducted an unannounced initial complaint visit to the facility above on September 13, 2024. LPA met with Administrator, Merla Ventura (Ventura), and explained the purpose of the visit. LPA interviewed staff and residents and obtained relevant documentation. It was alleged that Resident 1 (R1) received an eviction notice from La Salle Care Home administrator, Merla Ventura. Reporting party (RP) alleges that the eviction notice is deficient and thus invalid. RP reports it does not list any specific violation of one of the five rules that are acceptable for eviction. RP alleges that the eviction notice does not state what rules have been broken, and it does not document “dates, places, circumstances surrounding the event(s) and identification and statements of witnesses” as per regulations (CCR 87224(d)). (Continued on 9099-C) Substantiated On September 4, 2024, LPA Miller communicated with Ventura via telephone and sent an email communication to summarize the requirements of the eviction notice dated August 31, 2024. LPA Miller advised Ventura that the eviction notice was not valid. As such, Ventura was required to revise and reissue the eviction notice with a new effective date. Merla was advised that pursuant to Title 22 Section 87224(d) Eviction procedures, states in part that “the licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.” Ventura was further advised that, pursuant to Title 22 Section 87224(d)(1)(D) Eviction procedures, you must include the following exact statement in the eviction notice, as specified in Health and Safety Code Section 1569.683(a)(4): "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." On September 9, 2024, administrator submitted a revised eviction notice for review by CCLD. Administrator was advised that the notice remained non-complaint and that R1 is under no obligation to vacate the premises. Administrator was advised that she may rescind the eviction notice in writing, previously issued, or reissue a revised eviction notice that met all requirements. During the complaint visit, Administrator advised LPA that a new eviction notice dated September 10, 2024, was provided to R1. Administrator only provided copy of notice at the time of complaint visit. R1 stated that she did not receive the eviction notice dated September 10, 2024. R1 provided a copy of eviction notices dated August 1, 2024 and August 31, 2024. LPA noted that Administrator did not provide CCL a copy of the eviction notice dated August 1, 2024. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations are being cited on the attached LIC 9099-D. An Exit interview conducted and a copy of this report issued.the state’s words, verbatim · CDSS document, Sep 13, 2024 · control 29-AS-20240909105000

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Sep 20, 2024

87224(d) Eviction Procedures. The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidenced by: Based on observations, interview and record review, the licensee did not comply with the section cited above when they issued an invalid eviction notice to R1, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 13, 2024

Plan of correction: In LPA’s presence, Administrator informed R1 the eviction notice was invalid and was rescinded. Administrator agreed to submit a signed statement of understanding of regulation 87224 Eviction Procedures.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Miller arrived at 8:45 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator, Merla Ventura and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan, The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectant spray and cleaners. The facility has a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environment Safety: The fire extinguisher was last charged and inspected on 4/18/24. The facility has 3 resident bedrooms and 2 bathrooms. LPA was authorized to enter and inspect facility. The facility has a smoke and carbon monoxide detector that was tested and was working properly during visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. LPA observed a bottle of Clorox bleach was left near toilet and accessible to residents in care. Administrator immediately removed bleach. The facility has sufficient space inside and outside for activities and visiting. The facility has a secured backyard and front patio for client use with plenty of shade. The facility has telephone and internet service for resident use. Continued 809-C Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 6/23/25. The facility is approved for a capacity of 6. The fire clearance is granted for 2 ambulatory, and 4 non-ambulatory. Hospice is approved for 1. Staffing: The facility currently employes 2 full time staff. Staff records were not available at the time of inspection. LPA observed a female cleaning kitchen, bathroom and preparing food for resident. Administrator identified worker as a family member helping for the day. It was determined that family member did not have a background clearance completed and was required to leave the premises. Administrator Certificate is expired. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. LPA reviewed 4 resident files for signed Admission Agreements, Safeguard for property and valuables, LIC 602A Physicians report, Appraisals Needs and Services Plan, Emergency and ID forms. Food Service: The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirement. LPA observed that freezer stored in garage is defrosting, as there were signs of melted ice in frame of door. Administrator will have repairman look at freezer as soon as possible. Incidental Medical Services: The facility uses Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed resident medications and observed that Administrator made notations on pharmacy label. Administrator was advised not to alter labels. LPA observed that medications were not expired and were kept in their original containers. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility currently has residents receiving home health services. Pursuant to Title 22 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D) and a civil penalty was assessed. An exit interview was conducted, a copy of the report, Civil Penalty, and appeal rights were issued. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Sep 13, 2024

The state marks this report as 17 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.