Las Villas Del Norte

Allegation investigated: Staff are not meeting resident's dietary needs

On 07/14/2026, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to deliver findings for the allegation listed above. LPA met with Administrator Jolene Farish and Assistant Executive Director (AED) Reu Baggao who were informed of the purpose of the visit. It was alleged that facility staff are not meeting the dietary needs of Resident 1 (R1). A review of a resident roster dated 08/21/2025 and residency agreement documented that R1 resides in the independent living unit located on the facility premises. LPA toured the independent living unit to conduct an interview with R1. During the interview, R1 reported that they are independent and have never resided in the facility’s assisted living or memory care unit. The independent living unit located on the facility property is not licensed with Community Care Licensing. Therefore, it is not within this department’s jurisdiction. As result, this complaint is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Administrator Farish reported having to step away from the facility and directed LPA to conduct the exit interview with AED Baggao. An exit interview was conducted with AED Baggao and a copy of this report and Confidential Names list (LIC 811) were reviewed and provided to her. Unfoundedthe state’s words, verbatim · CDSS document, Jul 14, 2026 · control 18-AS-20250812142134

Type of visit: Required - 1 Year

On 05/29/2026, Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived at the facility to conduct an annual required inspection. Upon arrival, LPA met with Administrator Jolene Farish and the purpose of the visit was explained. LPA toured the interior and exterior of the facility with the Administrator. During the inspection, LPA observed that the facility consists of three separate buildings designated for independent living, assisted living, and memory care services. The facility is licensed to serve 198 non-ambulatory residents, of whom 86 may be bedridden. The facility maintains an approved hospice waiver for 28 residents, at the time of the visit, 27 residents were receiving hospice services. LPA observed an in-ground swimming pool located on the premises that was properly gated and secured with a master lock. Outdoor shaded seating areas were available for resident use. Interior and exterior walkways were observed to be free of obstructions. Fire alarm systems, carbon monoxide detectors, and fire extinguishers were observed and verified as maintained, with fire extinguishers last serviced on 04/27/2026. The last fire drill was conducted on 05/06/2026. LPA inspected the kitchen, walk-in refrigerator, walk-in freeze, and dry food storage area, and observed food supplies to be stored in a safe and sanitary manner. The facility maintains the required two-day supply of perishable foods and seven-day supply of non-perishable foods. Resident interviews indicated that dietary needs are accommodated and that a variety of activities and outings are available to residents. LPA observed that medications and resident medical records were maintained in the wellness rooms. Medications were secured in locked medication carts and accessible only to authorized personnel, including nurses and medication technicians. Cleaning supplies and disinfectants were stored in a locked storage area inaccessible to residents. Kitchen knives and other sharp instruments were secured and inaccessible to residents. Continue on LIC 809-C... LPA toured a sample of resident rooms and rooms were observed to be clean, organized, and free of odors. LPA also reviewed a sample of resident and staff records. Records reviewed were complete, current, and contained all required documentation. During today's inspection, LPA observed no health or safety concerns therefore no deficiencies were cited. An exit interview was conducted, and a copy of this report was reviewed with and provided to Jolene Farish, Administrator.the state’s words, verbatim · CDSS document, May 29, 2026

Type of visit: Required - 1 Year

On 5/30/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Administrative Executive Director, Reu Baggao who was informed of the purpose of the visit. The facility has a fire clearance for 198 non-ambulatory elderly residents, of which 86 may be bedridden. LPA toured the facility’s interior and exterior with Baggao. During the tour, LPA observed the facility is made up of three (3) buildings, which are designated for independent living, assisted living, and memory care. Indoor and outdoor passageways are free of obstruction. Outdoor shaded seating is available and there are several activities available for resident leisure. The facility has an in-ground pool that is gated and secured with a master lock. During tour of the kitchen, LPA observed the facility met Departmental requirements for a two-day supply of perishable foods and seven-day non-perishable food items, and sharps are secured and inaccessible to residents in care. Medications are secured in medication carts, only accessible to authorized personnel such as medication technicians. Cleaning solutions and disinfectants are secured in storage closets, inaccessible to the residents. LPA toured a sample of the resident bedrooms and private restrooms in the memory care unit, which appeared to be clean and sanitary with no foul odors. LPA also observed the facility installed protective covers to all of the memory care unit fire alarm pull stations. Baggao lifted one of the covers and showed LPA the warning horn that was placed as a preventative measure to help staff detect and possibly prevent false fire alarms. Baggao also showed LPA the new siren alarm installed on the courtyard gate to alert staff when the gate has been unexpectedly opened. LPA observed several fire extinguishers mounted throughout the facility that were last serviced on 4/21/2025 along with fire alarm systems and carbon monoxide detectors. During today's visit, no deficiencies were cited and LPA did not observe any health or safety concerns identified on 10/20/2023's non-compliance conference. An exit interview was conducted and a copy of this report was reviewed and provided to AED Baggao.the state’s words, verbatim · CDSS document, May 30, 2025

Type of visit: Case Management - Incident

On 4/16/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced case management visit regarding an Unusual Incident/Injury Report (LIC 624) submitted by the facility reporting Resident 1 (R1) eloped from the facility on 4/4/2025. LPA was informed Administrator, Jolene Farish was not present in the facility and unavailable to meet with LPA. As a result, LPA met with Administrative Executive Director (AED), Reu Baggao and Resident Services Director (RSD), Ana Ramirez who were informed of the purpose of the visit. LPA conducted an interview with AED and RSD who reported on 4/4/2025 at approximately 11:00 a.m., the fire alarm near room 502 (memory care unit) was pulled, which caused all exit doors to be automatically disarmed. Facility staff conducted a resident head count and discovered R1 missing. Staff reported R1 was last seen 10 minutes prior to the fire alarm being pulled. The facility contacted law enforcement who located R1 a mile away from the facility. R1 was returned to the facility by Administrator Farish and RSD. R1 was assessed by paramedics and no apparent injuries were noted. LPA reviewed R1's Physician's Report (LIC 602A) dated 1/13/2025 noting R1 is unable to leave the facility unassisted. LPA also reviewed R1's appraisal dated 1/19/2025 noting concerns due to R1 having a history of eloping. LPA toured the facility with RSD and observed six (6) fire alarm pull stations with lid covers available for emergencies. LPA reviewed the facility's staff schedule for the week of 3/30/2025 noting four (4) caregivers were present on 4/4/2025 when the incident occurred. On 3/30/2025, Resident 2 also eloped from the facility/memory care unit after one of the fire alarms was pulled. As a result, civil penalties will be assessed during today's visit. No additional health or safety concerns were observed during today's visit. An exit interview was conducted and a copy of this report, LIC 809-D, Confidential Names list (LIC 811), LIC421FC, and Appeal Rights were reviewed and provided to AED.the state’s words, verbatim · CDSS document, Apr 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(e)(5) · Plan of correction due date: May 16, 2025

(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility without violating Sections 87468.1, Personal Rights of Residents in All Facilities and Section 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, the fire alarm was pulled which disarmed all exit doors resulting in R1 eloping from the facility with no staff supervision. R1 was located by law enforcement a mile away from the facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: AED reported the facility's goal is to have five (5) caregivers present in the memory care unit during the morning and evening shift. AED reported the facility will receive a staff training provided by an outside vendor regarding preventative measures for elopement and Title 22, Division 6, Chapter 8, regulation 87705 titled "Care of Persons with Dementia". AED added the facility will consult with the fire department to ask if they can install tamperproof shields and frames that sound a warning horn when lifted to help prevent false fire alarms without restriciting legitimate alarms. Proof of correction to be submitted to LPA by cob on 5/16/2025.

Type of visit: Case Management - Incident

On 4/3/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced case management visit regarding an Unusual Incident/Injury Report (LIC 624) submitted by the facility reporting Resident 1 (R1) eloped from the facility on 3/30/2025. LPA met with Administrator, Jolene Farish and Memory Care Director (MCD), Lorena Vivar who were informed of the purpose of the visit. LPA conducted an interview with Administrator Farish and MCD Vivar and both reported the following information. On 3/30/2025 at approximately 6:00 a.m., Resident 2 pulled the fire alarm disarming all exit doors, which were secured with electric magnetic lock systems. At the time, all residents were accounted for and caregivers assessed and secured all exit doors except the courtyard gate. The doors leading to the courtyard gate were not disarmed as they require a keyed entry and were locked when the fire alarm was pulled. As a result, caregivers reportedly overlooked/failed to ensure the courtyard gate was secured. At approximately 5:30 p.m., Staff 1 went to R1's room to check on them but was unable to locate them. Staff conducted a thorough search of the facility but were unable to locate R1. Staff found the courtyard gate closed but unsecured. The facility notified local law enforcement and R1's responsible person. Caregivers reported last seeing R1 at approximately 5:00 p.m. At approximately 8:00 p.m., R1 was returned to the facility by law enforcement. Upon arrival, R1 was assessed and no visible injuries were noted. LPA reviewed R1's Physician's Report (LIC 602A) dated 7/25/2024 noting R1 is unable to leave the facility unassisted. The facility has since conducted an in-service staff training regarding fire alarm and elopement procedures and purchased a new siren alarm for the courtyard gate. On 3/31/2025, LPA received a voicemail from Administrator Farish reporting the incident. LPA reviewed the facility's training and Elopement Drill Records dated 9/24/2024, 12/19/2024 and 2/26/2025 noting the facility conducted routine elopement drills. Although the facility met the reporting requirements timely, trained their staff, and took appropriate action upon learning of the incident, the facility will be cited pursuant to California Code of Regulations (Title 22, Division 6, Chapter 8) regulation 87705(e)(5). During today's visit, LPA did not observe any health or safety concerns. An exit interview was conducted and a copy of this report and Appeal Rights were reviewed and provided to Administrator Farish and MCD Vivar along with Confidential Names list (LIC 811), LIC 809-D.the state’s words, verbatim · CDSS document, Apr 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(e)(5) · Plan of correction due date: Apr 11, 2025

(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility without violating Sections 87468.1, Personal Rights of Residents in All Facilities and Section 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, facility staff failed to ensure the courtyard gate was secured after knowing all doors had been disarmed. Furthermore, R1 eloped from the facility with no staff supervision and was returned by law enforcement. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: LPA was informed the facility has since conducted an in-service staff training regarding fire alarm and elopement procedures and purchased a new siren alarm for the courtyard gate. The facility was advised to update their Missing Person Elopement policy dated 7/5/2024 to include all exit doors are secured including courtyard gate to prevent another similar incident.

Allegation investigated: Staff are not practicing proper food safety practices.

On 2/25/2025, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to deliver amended findings for the allegation listed above. LPA met with Administrator, Jolene Farish who was informed of the purpose of the visit. It was alleged the facility may have unsanitary food practices and servers did not wash their hands on 1/2/2025, due to a resident’s visitor falling ill after having a meal provided by the facility. LPA toured the facility, conducted interviews, and reviewed records. During tour of the kitchen, LPA observed the freezer was maintained at a temperature of 0 degrees Fahrenheit (F) and refrigerator at 31 degrees F. LPA also observed kitchen staff wearing gloves while preparing food. LPA observed perishable and non-perishable food stored in a safe manner. LPA toured the memory care bistro and did not observe any issues or concerns regarding food safety requirements. *This is an amended version of the original report. Unsubstantiated Administrator Farish was interviewed and reported several residents and staff experienced symptoms of Norovirus beginning 12/30/2024, and all residents and their responsible persons were notified of the outbreak at the facility. Administrator reported the written notification requested visitors wash their hands before and after leaving the facility as a safety precaution for residents and staff. Administrator added they also placed copies of the written notification in common areas including near the main entrance where visitors sign in. Administrator explained upon discovery of the outbreak, facility staff received additional training regarding proper hand washing techniques and cleaning protocols. Administrator reported facility staff consistently disinfected high-touch surfaces in common areas throughout the facility. LPA reviewed a copy of the written notification which noted the request for visitors to wash their hands before and after leaving the facility. LPA interviewed three (3) staff who were present during the alleged incident date, and all reported on 1/2/2025, they regularly washed their hands and wore gloves when serving residents and their visitors food. LPA reviewed the facility’s Inservice Record Sheet dated 12/30/2024 signed by staff along with the training material which noted staff were trained on safe practices to prevent and address Norovirus and other gastrointestinal illness outbreaks. LPA also reviewed the facility’s Course Completion History dated 1/10/2025 noting staff completed training regarding food safety. LPA conducted an interview with the alleged victim who reported the meal provided by the facility tasted fine and they observed facility servers wear gloves and face masks when serving meals. The alleged victim added the facility did not appear unsanitary. 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 reviewed and provided to Administrator Farish. *This is an amended version of the original report.the state’s words, verbatim · CDSS document, Jan 10, 2025 · control 18-AS-20250108152134

Allegation investigated: Licensee did not provide healthful accomodations for resident.

Licensing Program Analyst (LPA), Amy Rodgers conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegations. LPA was greeted at the front lobby by Executive Director, Jolene Farish and was granted entry after identifying herself and disclosing the purpose of the visit, which was to further invistagate a complaint. During the invistagation the facility was toured, records reviewed, and interviews conducted with staff and outside sources. (continued on 9099-C) Substantiated (continued form 9099) In July of 2021, it was reported to Community Care Licensing Division (CCLD) that the Licensee representative spoke improperly about death to the reporting party, not to R1. Interviews with staff and outside sources were not able to provide any information to support or deny the complaint allegation. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Executive Director XXXX, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22). (continued from 9099) According to regulation CCR 87468 (titled "Personal Rights"), Licensee was required to provide “safe and healthful living accommodations.” In July of 2021, it was reported to Community Care Licensing Division (CCLD) Resident #1(R1)(See LIC 811 for confidential name) had ants crawling on their person and their bedding while residing in the memory care unit (Generations) of the facility. The Department was able to locate individuals who had been present at the facility during the time period identified in the complaint allegation. Interviews with outside sources and staff revealed ants were present inside the memory care unit of the facility during the time identified in the complaint allegations. Interviews with staff and an outside source revealed they observed R1 to have ants crawling on their person and in their bedding. The Department has investigated the allegation that Licensee did not provide healthful accommodations for resident and has found that, based upon evidence found during interviews and record review, the preponderance of the evidence standard has been met. Therefore, this allegation is deemed substantiated. This deficiency is noted on the attached 9099-D and is cited in accordance with the California Code of Regulations, Title 22. A copy of this report, along with Licensee/Appeal Rights, An exit interview was conducted with Executive Director XXXX, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 08-AS-20210628125732

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 10, 2025

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is met as in evidence in: Based on records and interviews the licensee did not provide healfull and comfortable accomodations in 1 of 51 persons in the memory care unit which posed a potential Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: Licensee agrees to provide all staff with resident personal rights training by plan of correction date. Training and documents will be due to CCL by POC date.

Allegation investigated: Staff did not ensure a resident was properly fed Staff are mistreating a resident while in care

On 10/21/2024, Licensing Program Analyst (LPA), Janette Romero made an unannounced visit to the facility to investigate the allegations listed above. LPA met with Administrator, Jolene Farish who was informed of the purpose of the visit. It was alleged a resident arrives to the dining room at 11:30 a.m. and their food is not served until 1:00 p.m. It was also alleged the resident walked away from the dining room with no food due to the long wait time(s). It was further alleged Staff 1 (S1) and Staff 2 (S2) yell at the resident and are rude to them. The alleged victim's name was not disclosed; therefore, LPA interviewed a sample of five (5) residents. Culinary Service Director (CSD), George "Lynn" Sharp was also interviewed and reported the facility offers a daily menu where breakfast is scheduled to be served at 8:00 a.m., lunch at 12:00 p.m and dinner at 5:00 p.m. CSD also reported the facility offers an alternative menu with options available from 8:00 a.m. to 6:30 p.m. Unsubstantiated CSD explained some residents arrive to the dining room approximately one (1) hour before daily menu options are scheduled to be served and consider it waiting time, however meals from the daily menu are not ready until the scheduled serving times. CSD also explained if many residents request a custom meal or options from the alternative menu, this may delay food orders for a few minutes but not an hour and half. Three (3) of five (5) residents interviewed reported waiting over an hour to receive their meals on a daily basis, but were unable to report whether they arrive to the dining room an hour before meals are scheduled to be served or if they request a custom meal. Two (2) of five (5) residents interviewed refuted the allegation and reported they only wait a few minutes for their meals to be served. All five (5) residents interviewed reported they have never walked away from the dining room without a meal due to extensive wait times. Five (5) residents interviewed reported facility staff do not yell at them and are not rude, including S1 and S2. Only one (1) of five (5) staff interviewed reported having knowledge of S1 yelling at a resident but they were unable to identify the resident or provide a description of the resident. During today's visit, LPA sat in the dining room during lunch time and did not observe any residents waiting for meals to be served for an extended period of time. LPA shared a dining room table with Resident 1 and observed their lunch was served six (6) minutes after they placed their order with the server. Based on the aforementioned, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations 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 Farish.the state’s words, verbatim · CDSS document, Oct 21, 2024 · control 18-AS-20241015095756

Type of visit: Case Management - Health Checks

On 9/20/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced case management visit at the facility to follow up on concerns identified in the Non-Compliance Conference (NCC) held on 10/20/2023. LPA met with Administrator, Jolene Farish and Resident Care Director, Ana Ramirez who were informed of the purpose of the visit. LPA conducted a walk-through of the facility with Administrator Farish for any health or safety concerns. During the tour, LPA observed residents relaxing in their rooms and in common areas. The facility was working utilities, required food supply, and adequate staffing. During today's visit, LPA did not observe any health or safety concerns as identified on 10/20/2023's NCC. An exit interview was conducted and a copy this report was reviewed and provided to Administrator Farish.the state’s words, verbatim · CDSS document, Sep 20, 2024

Allegation investigated: Staff do not ensure facility is clean

On 8/20/2024, Licensing Program Analysts (LPAs) Janette Romero and Debbie Palacios arrived unannounced to deliver findings regarding the above complaint. LPAs met with Administrator, Jolene Farish and Resident Care Director (RCD), Ana Ramirez who were informed of the purpose of the visit. On 7/23/2024, it was alleged there is no housekeeping staff to clean the Memory Care Unit (MCU). On 7/31/2024, LPA Romero toured the facility, conducted interviews, and obtained copies of pertinent documentation. LPA Romero toured nine (9) resident bedrooms and bathrooms with Regional Director (RD), Nathan Condie and RCD Ramirez and observed six (6) of nine (9) resident bathrooms appeared to have feces stuck inside the toilet bowls, on the toilet seats, on the bathroom floor, and/or on the outside bedroom door handles. Three (3) of nine (9) resident bedrooms and bathrooms toured appeared to be in sanitary condition. LPA also observed feces on the floor in the shower near room 311. Substantiated Eight (8) of nine (9) interviews conducted reported not having knowledge of residents getting sick after eating food that is left out. 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 Farish. Administrator, Jolene Farish was interviewed and reported the facility had five (5) housekeepers and recently faced a housekeeping shortage due to one (1) housekeeper retiring, one (1) going on leave unexpectedly, and one (1) going on vacation for two (2) weeks. LPA reviewed the July 2024 staff schedule for the housekeepers, which indicates two (2) housekeepers were assigned to MCU on 7/31/2024. On 7/31/2024, RCD Ramirez reported Staff 1 (S1) was assigned as the housekeeper for MCU that day. On 7/31/2024, LPA Romero was in the MCU from approximately 10:00 a.m. to 12:15 p.m and did not observe S1 or any other housekeeping staff cleaning the MCU. During LPA’s visit on 7/31/2024, RD Condie had S1 go to the MCU to begin cleaning the six (6) resident bedrooms/bathrooms toured identified to require cleaning. RD Condie reported the MCU would be thoroughly cleaned. Administrator Farish reported the facility has hired a new housekeeper and is in the process of filling the remaining vacancies. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided to Administrator Farish.the state’s words, verbatim · CDSS document, Aug 20, 2024 · control 18-AS-20240723150513

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(a)(2)(A) · Plan of correction due date: Aug 30, 2024

(a) (2) (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary... This requirement was not met as evidenced by: LPA observed 6 of 9 resident bedrooms/bathrooms toured appeared to have feces stuck inside the toilet bowls, on the toilet seats, on the bathroom floor, and/or on the outside bedroom door handles. This poses a potential health/safety/personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2024

Plan of correction: Administrator Farish reported the facility has since hired two (2) new housekeepers and now has a total of 6 housekeeping staff to ensure the facility is maintained in sanitary condition. POC met.

Allegation investigated: Licensee does not ensure that resident(s) are provided with hot water while in care. Licensee does not ensure that the facility is clean or santized.

Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Executive Director, Jolene M. Farish, where LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observation, interviews with staff members and residents, and records review. On 06/19/2024, Community Care Licensing received a complaint alleging facility does not ensure that the residents are provided with hot water while in care and the facility does not ensure that the facility is clean or sanitized. It was reported that the facility did not have hot water and shower the residents with cold water. LPA sampled 5 random resident’s rooms’ water temperature and all areas met regulation’s standards. Information obtained from an interview with Executive Director stated the facility has hot and cold water and there were no maintenance issues that would give the resident’s only cold water. Unfounded LPA interviewed staff members and residents and no issues were advised with being able to use the hot water. LPA interviewed Facility Maintenance Manager, Michael Vitalli and advised that there was a maintenance issue regarding the hot water heater, but that the maintenance issue did not affect the resident’s ability to use hot or cold water. LPA was unable to interview additional witnesses. LPA reviewed records of the hot water heater repair made on 06/13/2024. The repair was done in a reasonable amount of time. In regards to the allegations that the facility did not ensure that the facility was clean or sanitized, LPA interviewed Building Services Director, Christian Herbert. Herbert stated there are 2 housekeepers that complete cleaning tasks at the facility every day from 7:30 to 4:00. LPA reviewed house keeper’s logs at random date during June and all the assigned cleanings appeared to be completed. LPA also interviewed housekeepers who indicated there are no issues with cleaning or sanitizing the facility. LPA also toured the facility and did not observe any safety concerns, regarding cleaning or sanitizing violations. Information obtained from interviews with residents indicated there were no issues or concerns with the facility being clean or sanitized. Based on the LPA’s observation, interviews conducted, and record review regarding the allegations that Licensee does not ensure that residents are provided with hot water while in care and does not ensure that the facility is clean or sanitized, these allegations are unfounded. This agency has investigated the complaint allegations and we have found that the complaint was 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 of this report, was discussed with and provided to the Executive Director, Jolene M. Farish,the state’s words, verbatim · CDSS document, Jul 15, 2024 · control 18-AS-20240619164822

Type of visit: Case Management - Health Checks

On 6/14/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced case management visit at the facility to follow up on concerns identified in the Non-Compliance Conference (NCC) held on 10/20/2023. LPA met with Administrative Executive Director (AED), Reu Baggao who was informed of the purpose of the visit. LPA conducted a walk-through of the facility with Administrative AED Baggao for any health or safety concerns. During the tour, LPA observed residents relaxing in their rooms and in common areas. The facility was working utilities, required food supply, and adequate staffing. During today's visit, LPA did not observe any health or safety concerns as identified on the NCC held on 10/20/2023. An exit interview was conducted and a copy this report was reviewed and provided to AED Baggao.the state’s words, verbatim · CDSS document, Jun 14, 2024

Type of visit: Case Management - Deficiencies

On 4/22/24 Licensing Program Analyst (LPA) Javina George made a unannounced case management deficiencies visit. LPA met with Executive Director Jolene Farish and explained the purpose of the visit. LPA conducted a review of three (3) Generations (Memory Care) staff files and training transcripts which revealed three (3) out of three (3) staff to not have receive twelve (12) hours of dementia care training, six (6) of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. Based on records review a citation will be issued on the attached 809 D, in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted where a copy of this report, 809 D, appeal rights and LIC9098 were reviewed and provided to Jolene Farish, Executive Director.the state’s words, verbatim · CDSS document, Apr 22, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.626(a)(1) · Plan of correction due date: Apr 23, 2024

Training requirements for direct care staff:(1) 12hrs of dementia care training, 6 shall be completed before a staff member begins working independently with residents, & the 6 hrs shall be completed within the first 4 weeks of employment. All 12 hrs shall be to the care of persons with dementia. This requirement is not met as evidenced by: Based on record review the Licensee did not comply with section cited above S1, S2 and S3 work at the facility without the required initial training posing an immediate health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Apr 22, 2024

Plan of correction: Licensee agreed to submit an audit of Proof of Required Trainings needed for the (12-15) memory staff to the department by 5pm on the POC due date.

Type of visit: Required - 1 Year

On 4/12/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Administrator, Jolene Farish who was informed of the purpose of the visit. LPA toured the facility’s interior and exterior with Administrator Farish. During the tour, LPA observed the facility is made up of three (3) buildings, which are designated for independent living, assisted living, and memory care. The facility is licensed for 198 non-ambulatory residents of which 86 may be bedridden. The facility has an approved hospice waiver for 28 residents and LPA was informed the facility currently has 10 residents receiving hospice services. The facility has an in-ground pool on the premises that is properly gated and secured with a master lock. Outside shaded seating is also available for resident use. Indoor and outdoor passageways are free of obstruction. LPA observed fire alarm systems, carbon monoxide detectors, and charged fire extinguishers serviced on 3/13/2024. LPA toured the kitchen, walk-in refrigerator and dry food storage room and observed food was stored in a safe and healthful manner. The facility met Departmental requirements for a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Resident interviews revealed kitchen staff accommodate residents’ dietary needs and there are several activities and outings available for resident leisure. Medications and residents’ medical files are stored in wellness rooms. Medications are secured in medication carts, only accessible to authorized personnel such as facility nurses and medication technicians. Cleaning solutions and disinfectants are secured in a storage closet. Knives and sharp instruments are stored in the kitchen, inaccessible to the residents. The facility is in the process of removing hallway carpets and adding new flooring. During today’s visit, LPA did not issue any deficiencies. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Farish. There are no health and safety concerns observed as identified on the non-compliance conference held on 10/20/2023the state’s words, verbatim · CDSS document, Apr 12, 2024

Allegation investigated: Staff overcharged resident for care

On 1/4/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced complaint visit to deliver amended findings regarding the allegation listed above. LPA met with Administrator Jolene Farish. Regarding the allegation of “Staff overcharged resident for care” it was alleged that Resident 1 (R1) was over charged for monthly care fees after the resident was absent from the facility for over fourteen days due to hospitalization. LPA reviewed R1’s Admission Agreement and found that on page 13, subsection 6, titled, “Absences” stated, “If you are absent from LAS VILLAS DEL NORTE for more than fourteen (14) consecutive days, you will receive a pro-rated credit toward your Monthly Care Fee starting on day fifteen (15).” *This is an amended version of the original report. Substantiated This confirms the facility is to issue a pro-rated credit towards R1’s monthly care fees if the resident was absent from the facility for more than fourteen consecutive days. R1 was absent from the facility on April 17, 2023 – July 7, 2023. Per the admission agreement, R1 was to receive a pro-rated credit for monthly care fees. LPA found that due to a clerical error, R1 was overcharged $3,400.00 in monthly care fees during R1's absence from the facility. Although LPA determined that the overcharge did not occur due to the facility operating in bad faith, the allegation of "Staff overcharged resident for care" is valid. Based on interviews conducted and record review, the preponderance of evidence standard has been met; therefore, the allegation was found to be SUBSTANTIATED. The facility will be cited per California Code of Regulations, Title 22, regulation 87507(f). An exit interview was conducted, and a copy of this report was discussed and provided to Administrator Farish along with a Confidential Names List (LIC 811) and LIC9099-D. *This is an amended version of the original report.the state’s words, verbatim · CDSS document, Jan 4, 2024 · control 18-AS-20230728094657

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jan 5, 2024

(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not complye with the requirement noted above by overcharging Resident 1 for care. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 4, 2024

Plan of correction: Licensee stated that the facility will implement a policy to ensure that the facility's new Business Office Director will receive additional training regarding the admission agreement and refund policies. Licensee stated that POC to be submitted to CCLD by close of business on 1/5/2024.

Type of visit: Case Management - Health Checks

On December 29, Licensing Program Analyst (LPA), Venus Mixson conducted an unannounced case management Health and Safety Check. LPA Mixson met with the Residential Care Coordinator, Normalin Paulo and introduced herself and stated the purpose of the visit. Today's visit is in response to previous information received by Community Care Licensing regarding the health and safety of the residents in care. LPA Mixson conducted a Health and Safety check at the facility. There were no health or safety issues identified. LPA Mixson requested and received pertinent documents. LPA Mixson observed a sample of the residents rooms and the rooms had the required furnishings per the regulations. There were sufficient staff to resident for supervision and the staff were engaging the residents in activities, the meal of the day, and medications were being distributed. LPA Mixson interviewed the facility nurse and the asked who is in charge of bathing the residents and the nurse stated there are four caregivers, one nurse, and two med techs on the assisted living side. They get assistance about twice a week but some residents only request for once a week. There are some residents who may be scheduled for three times a week but they have the right to refuse and if they do refuse it is logged. There were no deficiencies observed or cited during this visit. An exit interview was conducted and a copy of this report was provided to the RCC, Normalin Paulo.the state’s words, verbatim · CDSS document, Dec 29, 2023

Allegation investigated: Facility does not have adequate food supply.

Licensing Program Analyst (LPA), Jacqueline Shaw Ross made an unannounced visit to the facility to commence a complaint investigation regarding the allegation listed above. LPA met with Jolene Farish, Executive Director and explained the purpose of the visit and the elements of the allegation. During the investigation, LPA Shaw-Ross conducted interviews with five (5) residents, and five (5) staff members, that included the facility chef. The investigation also consisted of observation and record review. LPA was unable to interview additional witnesses due to not being able to obtain contact. On 9/28/2023, Community Care Licensing received a complaint alleging the facility does not have an adequate food supply. Of all five (5) residents interviewed, four (4) stated there was a supply of plenty of food and that food served was adequate. One (1) resident (R5), corroborated the allegation by stating they have a new chef and the food has not been so great. R5 further stated the kitchen staff ran out of food a couple of months ago and there was no juice and no milk. R5 further stated they believe the chef puts water on the cereal when there was no milk. This is an amended version of the original report crafted on 12/01/2023. Unfounded Cont'd from LIC9099.... R5 also stated they believe the lasagna served last week could have caused food poisoning among some of the residents, and that a number of residents have been sick with diarrhea since last week. Of the five (5) staff interviewed, all indicated there is a stomach virus that is going around, and some residents have been sick however, it is not related to food service. LPA conducted an interview with the facility chef who stated all meals are eaten by both staff and residents, and that none of the staff members have reported food poisoning. The facility chef also stated they have always maintained an ample supply of quality food and have never substituted water for milk in cereal. Facility chef further stated the only time they have had a milk shortage was approximately two months ago, there was a mix up with the delivery of milk. He further reported they immediately made a run to a local grocery store across the street to obtain milk, and it was replenished the same day. LPA toured the kitchen and observed an ample supply of both perishable and non-perishable food and drink. LPA also reviewed pertinent documents from the facility that included a four (4) month supply of grocery receipts from June 2023 through September 2023. Review of receipts show a consistent supply of food and drinks were purchased prior to the allegation. Based on observation, interviews, and records review, the allegation that the facility does not have adequate food supply, is UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. This is an amended version of the original report crafted on 12/01/2023.the state’s words, verbatim · CDSS document, Dec 1, 2023 · control 18-AS-20230928103442

Type of visit: Collateral

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Collateral Visit. LPA was greeted by, identified himself to, and discussed the purpose of the visit with Receptionist Cindy Villasenor. LPA then met and spoke with Executive Director Jolene Farish. During today’s visit, LPA conducted resident interviews to aid in an investigation occurring at another licensed care facility. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Farish, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 5, 2023