Las Estancias Assisted Care

Type of visit: Required - 1 Year

LIcensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 (S1) at 1:15pm. LPA met with Administrator Celia Rodriguez and explained the purpose of the visit. The facility is a five bedroom, three bathroom single-story residence with an approved fire clearance for five non-ambulatory and one bedridden. The facility is approved for a hospice waiver for three. Currently no residents are on hospice at this time. During the visit LPA toured the kitchen and observed the refrigerator had two days of perishable items and seven days of non-perishables. All appliances were operational. Sharps and knives are secured and cleaning supplies are locked underneath the sink. The washer and dryer room are adjacent to the kitchen and are in working order. The fire extinguisher was charged and serviced and the facility conducted a fire drill on April 14, 2026. Smoke and carbon monoxide detectors were inspected and were operational. LPA toured resident rooms and all bedrooms had linens, and required furnishings. The facility was clean and there were no odors detected. LPA tested hot water temperature in two of two resident bathrooms. The hot water temperature ranged between 108.5 to 113.5 degrees Fahrenheit. Bathroom showers had grab bars and non-skid flooring. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. A First Aid Kit had the required elements and a First Aid Book was obtained. (Continued on LIC 809-C) .(Continued from LIC 809) Upon walking the exterior, LPA observed all walkways were clear and unobstructed. There is ample space for walking and outdoor activities and shaded seating areas are available. Emergency supplies and water were stored in the garage and the facility has two generators. LPA reviewed two of two staff training and fingerprint records and conducted a complete review of resident records. Bedrail orders for half and full side rails were observed. Files were maintained and it was discussed that paperwork is required to be retained for three years. LPA discussed updating Appraisal Needs and Services Plans and Medical Assessments if any changes of condition occur. Staff training documentation was electronic and was recommended to print in each employee file. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on July 19, 2026. Administrator (AD) will be paying fees by due date and a fact sheet for Legionnaire's Disease was given to the AD for review. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Administrator (AD) Celia Rodriguez and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Apr 15, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Celia Rodriguez, Administrator, at 12:30pm, and explained the purpose of the visit. The facility is a five bedroom, two client bathroom, single- story residence with an approved fire clearance of five non-ambulatory residents of which one may be bedridden. The facility currently has a census of three residents in care. At time of entry residents were enjoying lunch and one had a visiting family member. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 112.6 and 117.8 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and the facility’s last fire drill was conducted on January 25, 2025. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. Sharps and disinfectants were secured and appliances were in working order. LPA observed additional Personal Protective Equipment and emergency supplies in the garage. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. The First Aid kit had all the required elements. LPA toured the facility exterior and observed a shaded seating area, a small birdbath and ample outdoor space for walks and activities. The facility has a self-latching, unlocked exterior gate and the outside perimeter has video surveillance. (Continued on LIC 809-C) (Continued from LIC 809) LPA reviewed two of two staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on July 19, 2026. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Celia Rodriguez, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Mar 27, 2025

Allegation investigated: -Patient's rights violaton. -Resident is being evicted illegally from the facility.

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrived at facility and was greeted at the door by staff and granted entry. LPA spoke with Celia Rodriguez, Administrator and explained the purpose of the visit. Findings are based upon this investigation which included records review, interviews with the following: 3 out of 3 staff interviewed, a witness and 3 of 3 residents. It is alleged that patient’s rights violation. Record review from Providence St. Jude Medical Center on May 5, 2024, indicated that resident (R1) was discharge as follows patient other criteria for discharge: will go with infinite hospice to board and care. Records for Newport Hospice indicate that R1 was admitted on hospice care on May 6, 2024, singed by R1’s responsible party. Interview with 3 of 3 staff indicated that R1 was in the hospital and when discharged they were placed on hospice care. When R1 returned to the Continued LIC9099-C Unfounded facility they were already on hospice care. R1 was discharged on Infinite Hospice, but R1’s responsible party decided to go with Newport Hospice the day R1 was released, and it was changed. Interview with 3 of 3 residents indicated that they had never witnessed staff yelling at another resident or to them. It is alleged that resident is being evicted illegally from the facility. Interview with witness (W1) revealed that the Administrator told them, “They would be happier if they moved somewhere else". The Administrator denied this report. The Administrator reported that an eviction notice was never sent to R1 or their responsible party. This information was verified by W1. R1 was moved out on May 29, 2024, by choice of responsible party. R1's belongings were moved out of the facility by June 8, 2024. W1 verified that they decided to move R1 out of the facility and they were not forced to move. None of the evidence gathered supports the allegation. We have found the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Administrator and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Nov 4, 2024 · control 22-AS-20240521101351

Allegation investigated: Resident was unlawfully evicted from facility

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Administrator Celia Rodriguez and explained the reason for the visit. The investigation revealed the following. LPA interviewed the Administrator and staff. It was alleged that Resident 1 (R1) was unlawfully evicted from the facility. Witness 1 (W1) reported that the Administrator told them, "they would be happier if they moved somewhere else". The Administrator denied this report. The Administrator reported that an eviction notice was never sent to R1 or their responsible party. This information was verified by W1. R1 moved out on May 29, 2024. All witnesses interviewed verified this report. R1's belongings were moved out of the facility by June 8, 2024. W1 verified that they decided to move R1 out of the facility and they were not forced to move. None of the evidence gathered supports the allegation. Based on the evidence gathered through interviews the allegation is deemed UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy the report provided. Unfoundedthe state’s words, verbatim · CDSS document, Jun 13, 2024 · control 22-AS-20240605160556

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Celine De Perio and Faith La conducted an unannounced required annual inspection. LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) Celia Rodriguez. The PUB475 "See Something, Say Something" poster was observed to be posted in the kitchen. LPAs observed the Administrator's Certificate for Cecila Rodriguez, which expires on 7/19/24. LPAs toured the interior and exterior portions of the facility with AD Rodriguez. The facility is a single level structure and is licensed for 6 non-ambulatory, 1 bedridden and 3 hospice. For this visit, there are 0 residents on hospice and 0 bedridden. There are a total of 5 bedrooms, of which 4 are private resident rooms and 1 shared resident room. LPAs toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 3 restrooms of which were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 110.4 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen. LPAs observed the emergency disaster and evacuation plan, which is posted in the kitchen. Facility had back-up emergency food and water supply, located in the kitchen and in the garage. LPAs observed that First Aid Kit had all the required components. Medications and toxins were also observed to be locked and inaccessible to residents. For the exterior portion, LPAs observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which were self-closing and self-latching. No bodies of water were observed. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued. An exit interview was conducted with AD Rodriguez. A copy of this report was explained, and provided.the state’s words, verbatim · CDSS document, Apr 11, 2024

Allegation investigated: Licensee did not report abuse as mandated.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver findings for the complaint received on June 7, 2023. LPA arrived at the facility and explained the purpose of today’s visit, was greeted, and granted entry by facility administrator (AD) Celia Rodriguez. The complaint was investigated by the Department which involved interviews and record review. It was alleged that licensee did not report abuse as mandated. On August 31, 2023, interviews were conducted with staff and residents at the facility. An interview conducted with AD stated that upon learning about the allegation, AD informed Licensing via phone call, contacted Adult Protective Services (APS), the police, and that the facility conducted their own internal investigation. Per AD, “since I called about it, there was no reason for me to write a report”. Due to APS also being informed about the incident, APS initiated their own investigation. 5 interviews conducted with residents were unable to provide further information regarding this allegation. Substantiated 4 interviews conducted with staff stated that if there was abuse occurring, the facility would have reported it immediately. LPA De Perio conducted reviews of incident reports from the facility, and it was observed that the facility did not submit a written incident report. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, the preponderance of evidence standard has been met, therefore the allegation is SUBSTANTIATED. An exit interview was conducted with AD Rodriguez. A copy of this report and appeal rights were provided and explained. Following that statement, R1 became visibly and verbally agitated and stated, “let me go, let me go”. R1 then refused to answer any more questions, and upon the conclusion of the interview, R1’s demeanor had changed, and was smiling. Per R1’s physician report dated for March 8, 2023, R1 has mild cognitive impairment, is non-ambulatory, is unable to transfer self independently, on and off the bed, and was on hospice. The investigation revealed that R1 never provided any disclosure regarding sexual assault or being hurt by any staff. LPA De Perio interviewed 5 out of 5 residents who confirmed not being hurt or witnessing anyone being hurt. 4 interviews conducted with staff, denied observing any resident being hurt or abused in the facility. It was alleged that staff did not contact the police/doctor upon resident request. On August 31, 2023, interviews were conducted with staff and residents at the facility. The 5 interviews conducted with residents stated that if needed or requested, the facility contacts 911 upon resident’s request. Resident 1 (R1), resident 2 (R2), resident 3 (R3) and resident 4 (R4) specified that the facility does a “good job” at communicating with each resident’s medical team. 4 interviews conducted with staff stated that the facility contacts the appropriate responders such as police, and 911 regardless if the resident requests it or not and depending on the incident. Staff 1 (S1) specified “we would rather be safe than sorry”. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with AD Rodriguez. A copy of this report was provided an explained.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 22-AS-20230607152424

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 2, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency... This requirement is not met as evidence by: Based on record reviews, and interviews, facility administrator informed licensing agency regarding the allegation via phone call, however, did not complete and submit a written report. This poses a potential threat on the health and safety to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: Licensee will provide a training to all staff regarding the regulation cited, obtain signatures of staff present, and submit proof of understanding to assigned LPA on or by 11/02/2023.