Lily of the Valley II

Allegation investigated: Staff over medicated a resident in care Facility did not seek medical attention in a timely manner

Licensing Program Analyst (LPA), Natasha Persaud conducted a telephone visit to conclude the complaint investigation regarding the above mentioned allegation. LPA contacted Licensee, Christine Matthews to discuss the finding. During the investigation, records were reviewed, and interviews were conducted with staff and outside sources. It was alleged that staff over medicated a resident in care and the facility did not seek medical attention in a timely manner. Both allegations were regarding Resident #1 (R1). On 05/04/24, an outside source visited R1 and R1 was very sleepy and could barely keep their eyes open. On 05/06/24 an outside source called the facility and spoke with staff who stated R1 was asleep. The outside source called back an hour later and staff stated R1 was asleep but fine. The third time the outside source called they were told the same thing, and requested staff wake R1 up because it was unusual for R1 to sleep all day and so late in the day. Continued on an LIC 9099C. Unsubstantiated Staff continued to state R1 was fine. On 05/05/24, the administrator asked R1 if they wanted to go to the hospital but R1 refused. R1 confirmed they refused medical treatment. On 05/07/24, the administrator sent R1 out for evaluation and R1 agreed. The outside source reported that once R1 was transported to the hospital they were told R1 had kidney failure and might need dialysis. Then the hospital reported that R1’s kidneys were fine and R1 was in the hospital so they could treat a different medical condition. The outside source reported the hospital wasn’t aware of what they were doing. The outside source also reported that R1 was anxious and didn’t want to leave the facility. R1 was prescribed a new medication for their anxiety. It was unknown if the new medication caused the drowsiness. The outside source added that R1 was their own responsible party. The facility does not document medications dispensed on a Medication Administration Record. The administrator and staff explained that they read the bottle and followed the directions, there were no medication errors. A review of R1’s hospital records dated 05/07/24, indicated R1 had multiple medical conditions. One of the medical conditions was where the body, or part of it, does not receive enough oxygen to function properly. There was no evidence to corroborate R1 was over medicated, as their medical condition resulted in their symptoms. Resident interviews confirmed they are receiving medications as prescribed. The facility staff did not observe any concerns and asked R1 if they wanted to go to the hospital, which was initially declined. The facility sent R1 out for medical care when it was necessary, there was no delay in treatment. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations were deemed unsubstantiated. An exit interview was conducted and athe state’s words, verbatim · CDSS document, Jun 4, 2026 · control 08-AS-20240520145352

Allegation investigated: Licensee neglected resident

Licensing Program Analyst (LPA), Natasha Persaud conducted a telephone visit to conclude the complaint investigation regarding the above mentioned allegation. LPA contacted Licensee, Christine Matthews to discuss the finding. During the investigation, records were reviewed, and interviews were conducted with staff and outside sources. It was alleged that the licensee neglected a resident. The administrator’s interview confirmed that individual was identified by the facility as a renter. The renter resided on the second floor of the facility, where there were no resident rooms. The renter has resided at the facility since 2006. A review of the Facility Personnel Report Summary indicated that the individual reported as a resident was fingerprint cleared and associated to the facility. Facilities are not required to fingerprint and/or associate residents. Title 22 Regulations outlines that any adults other than a resident, residing in the facility, shall have a criminal record clearance. Therefore, the tenant obtained one to remain in the facility as a renter. Continued on LIC 9099C. Unfounded Based on interviews and record review, this agency has investigated the complaint alleging Licensee neglected resident. 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 along with Licensee Rights (LIC 9058 03/22) were emailed to Licensee, Christine Matthews as the facility is closed.the state’s words, verbatim · CDSS document, May 15, 2026 · control 08-AS-20211027084921

Allegation investigated: Neglect of resident resulting in pressure injuries Staff did not seek medical attention for resident Staff restricted resident from calling 911 to seek medical attention Staff handled resident in a rough manner Staff did not meet incontinence needs of resident Resident was not accorded dignity in relationships with staff

Licensing Program Analyst (LPA), Natasha Persaud conducted a telephone visit to conclude the complaint investigation on this closed facility. LPA spoke with Licensee, Christine Matthews and emailed reports. During the investigation, the facility was toured, records reviewed and interviews conducted with staff, residents, and outside sources. It was alleged neglect of Resident #1 (R1) resulting in pressure injuries. R1 sustained bilateral Stage 3 and Stage 4 pressure injuries on their coccyx. On 08/25/22, the pressure injuries were observed and documented by a medical professional. R1 was receiving Home Health (HH) services with a certification period of care from 02/2022 through 08/19/22. R1 was provided weekly visits from nurses. On 08/19/22, the HH agency discharged R1 and documented R1’s centered goals per plan of care were met. R1’s vital signs were stable, skin remains intact. There was no documentation of a Stage 3 or Stage 4 pressure injury reflected in the HH discharge notes. R1 was discharged from HH on 08/19/22 and admitted to the hospital on 08/25/22. However, it cannot be determined that the facility contributed to the pressure injuries before R1’s admission to the hospital. Continued on LIC 9099C. Unsubstantiated R1’s physician indicated due to R1 not being seen in one (1) month could have resulted in pressure injuries. It was also reported by staff that R1 was not compliant with medications and/or care. R1’s physician was unaware of any current pressure injuries and indicated R1 had a severe medical condition, which can cause the skin to become irritated and breakdown. R1’s physician also stated R1 preferred sitting in their wheelchair and did not get up enough to avoid their buttocks becoming red and irritated. R1’s physician confirmed they did not witness any negligence by facility staff. It was also alleged that staff did not seek medical attention for R1. A review of Facility Progress Notes indicated any change of condition and requests made by R1 to be sent out to the hospital. There was no record to indicate that R1 was denied timely medical care. R1’s physician conducted facility visits and the home health staff visited R1 regularly. R1 received extended amount of medical care and support through their medical provider. It was also alleged that staff restricted R1 from calling 911 to seek medical attention. On 08/25/22, R1 had a bowel movement on themselves due to a chronic medical condition. R1 requested to go to the hospital. Staff interviews revealed they told R1 they will call 911. However, they needed to clean R1 up prior to going to the hospital, as R1 had feces all over themselves, their wheelchair, and the floor. R1 did not present any medical condition requiring immediate medical attention. Staff stated R1 requested to use staff cell phone to call 911. Staff went to retrieve their cell phone from the counter top in the kitchen and R1 accused them of denying access to call 911 themselves. Staff reported they handed R1 their cell phone and R1 became upset and threw the phone across the room. R1 was not restricted from calling 911. Lastly, the following allegations were alleged that staff handled R1 in a rough manner, staff did not meet incontinent needs of R1, and that R1 was not accorded dignity in relationships with staff. A review of R1’s medical records dated from 07/11/22-08/10/22 reflected R1 was observed as “dry” when assessed by Home Health. Incontinent residents were interviewed and confirmed staff were meeting their incontinent needs. Staff were interviewed and denied handling R1 or any residents in a rough manner. Residents were interviewed and said they were treated well by staff. Outside sources reported no mistreatment by facility staff. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations were deemed unsubstantiated. A copy of this report along with Licensee Rights (LIC 9058 03/22) were emailed to Licensee, Christine Matthews.the state’s words, verbatim · CDSS document, May 1, 2026 · control 08-AS-20220825132357

Type of visit: Case Management - Other

Licensing Program Analyst (LPA, Natasha Persaud conducted a Case Management - Other. LPA was greeted and allowed entry into the facility by Administrator, Rodelio Aquino. On 05/01/25, the licensee submitted a letter for closure due to ongoing financial challenges. The administrator provided relocation addresses for the remaining residents. The new locations have been have verified. Today, LPA toured the facility, there are no residents in care. The facility is ready for closure. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Rodelio Aquino whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jul 7, 2025

Type of visit: POC

Licensing Program Analyst (LPA), Natasha Persaud conducted a Plan of Correction visit. LPA was greeted and allowed entry by Administrator, Rodelio Aquino. On 12/23/24 a Required 1 Year visit was conducted. During that visit, deficiencies were issued along with civil penalties for repeat violations. The administrator submitted documentation for the corrections. Today, LPA assessed additional civil penalties for the repeat violations. The repeat violations have now been corrected and cleared. No deficiencies were issued today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Rodelio Aquino whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Dec 31, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility and conducted the visit with Administrator, Rodelio Aquino. LPA, accompanied by administrator, toured the interior and exterior of the facility, and inspected each room. The facility was not clean and sanitary, as there were rat droppings on a mattress and on the carpet located upstairs. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. 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 resident activities. Hot water temperature at taps accessible to residents measured at 113 F.. 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 sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, but not stored in locked areas. There was a centrally stored location for medications. However, the administrator allowed Resident #1 (R1) to store their own medications but did not provide a lock box for R1's medications. R1's Physician Report dated 12/19/24 indicated R1 requires assistance with administering medications but is able to store their own medications. Therefore, R1 was storing medications in their drawer, which were accessible. There was another resident that resides in the room across from R1 but unable to transfer independently out of their bed to their wheelchair. Medications were also located in a open plastic container upstairs, along with a hammer, all made accessible. The facility has a large quantity of medications for previous residents that require destruction. Continued on an LIC 809C. No pools or bodies of water were observed on the premises. Per the administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within 12 month period. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files did not contain required documents. R1's file was incomplete and missing multiple required documents. Resident # (R2) did not have a current physician's report on file to reflect hospice status. Also, R2 does not have current hospice records on file or any hospice documentation regarding hospice staff visits to the facility. Confidential records were stored in locked areas. Disaster drills are not being conducted or documented. Deficiencies were observed or cited during today's annual inspection. Civil penalties were assessed for repeat violations within 12 month period. The civil penalties will be ongoing until corrected. An exit interview was conducted with Administrator, Rodelio Aquino to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Dec 23, 2024

Allegation investigated: Staff sexually assaulted a resident in care

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Vanessa Cruz. Administrator Rodelio Aquino arrived during the visit. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that staff sexually assaulted a resident in care, specifically that staff 1 (S1) sexually assaulted Resident 1 (R1) during an incontinence brief change. Review of R1’s most recent medical assessments dated May 2023 revealed that R1 had a diagnosis of mild cognitive impairment, was not confused or disoriented, and was able to follow directions and communicate needs. Continued to LIC9099-C page... Unsubstantiated Interviews and records review revealed that in August 2023, R1 alleged that S1 sexually assaulted R1 during an incontinence brief change. The day following the alleged assault, R1 notified the Administrator regarding S1’s actions and the sexual assault. Interviews revealed that R1 was not sent to the hospital to be evaluated and R1 did not sustain any injuries or receive medical attention for the alleged incident. R1 remained consistent regarding their statement and description of the alleged incident with S1 across multiple interviews. However, interviews with staff and residents could not corroborate R1’s allegation against S1. Interviews revealed that the Administrator questioned S1 regarding R1’s allegation and S1 denied engaging in any inappropriate actions. Interviews revealed that the Administrator fired S1 after being informed of the sexual assault allegation and speaking with S1. Interviews revealed that S1 worked in the facility for only one day during which S1 provided personal care to residents in care, including R1. Interviews with S1 revealed that S1 was consistent with their description of their actions during personal care of R1 in August 2023 and denied any inappropriate or sexual actions while providing incontinence care to R1. S1 stated that they are very thorough when cleaning and caring for residents during incontinence care. Interviews with staff revealed that S1’s description of personal care and brief changes procedures were consistent with the procedures followed by other staff. Interviews with staff regarding the incontinence care policy revealed that it was a common procedure for staff to apply rash cream onto residents during incontinence brief changes. Interviews with residents did not reveal any concerns about the care provided by the other staff working at the facility. 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 Administrator Rodelio Aquino, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).the state’s words, verbatim · CDSS document, Oct 14, 2024 · control 08-AS-20230828094536

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to cite deficiencies observed during a complaint visit that are unrelated to the complaint allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Administrator Rodelio Aquino. During the unrelated complaint visit, it was determined that Staff 1 (S1) was not associated to the facility during the one day that S1 worked at the facility in August 2023. Interviews conducted during the complaint investigation confirmed that S1 was present and working at the facility for at least one day in August 2023. Review of the S1’s Guardian profile revealed that S1 had not been associated to the facility during the day S1 worked at the facility in August 2023. Therefore, a deficiency regarding staff not being associated to the facility is being cited per California Code of Regulations Title 22 and noted on the attached LIC809-D page. Additionally, a civil penalty in the amount of $100 is being issued on an LIC421BC. An exit interview was conducted with Administrator Rodelio Aquino, whose signature below confirms receipt of a copy of this report, LIC421BG, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Oct 14, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Oct 14, 2024

87355(e) All individuals subject to a criminal record review… shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance… This requirement has not been met as evidenced by: Based on interviews and record review, the licensee did not ensure that S1 was associated prior to working in the facility. This posed an immediate safety risk to 3 of 3 residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2024

Plan of correction: Administrator fired S1 in August 2023 and S1 is not employed by the facility and has not worked at the facility since.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA was greeted and met with Administrator, Rodelio Aquino. On 06/23/24, the facility self reported an incident involving Resident #1 (R1). The incident occurred on 06/08/24, indicating R1 had a pressure injury and the administrator cleaned the area and applied barrier cream. The administrator was not aware of the stage of the pressure injury but stated it was reddened but not open. The report also stated the administrator prepared R1's belongings and R1 was transported back to their private home on 06/08/24 by the resident's choice. R1 was receiving hospice services. Title 22 Regulations require incidents to be reported within seven days of occurrence. However, the incident was reported wihin fifteen days. A review of records indicated, the facility did not have required hospice documentation for R1. In addition, the facility did not have hospice documentation for Resident #2 (R2). The administrator explained R1 no longer resides at the facility and the responsible party took the records and he did not retain copies. The administrator was advised records shall be maintained for three years. The administrator stated he will obtain hospice records for R2 and place them in the resident's file. Deficiencies were issued and listed on the attached LIC 809D. A civil penalty was assessed for a repeat violation within a 12 month period. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Rodelio Aquino whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Aug 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 3, 2024

Reporting Requirements. A written report shall be submitted...within seven days of the occurrence...(A) through (D) below. This report shall include... date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not ensure an incident report was completed for 1 out of 4 residents [R1], which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2024

Plan of correction: Administrator stated it was an oversight. Administrator agreed to attend training on reporting requirements and submit proof by POC due date. A civil penalty was assessed for a repeat violation wthin a 12 month period.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(d) · Plan of correction due date: Sep 3, 2024

Resident Records. All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not ensure an incident report was completed for 2 out of 4 residents [R1-R2], which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2024

Plan of correction: Administrator stated he will attend training on resident records and provide proof of training by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Deficiencies visit. LPA was greeted and met with House Manager, Rodelio Aquino. LPA was at the facility conducting a complaint investigation, when deficiencies were observed. LPA observed ten (10) medications, including Narcan in Resident #1's (R1) room, unattended. The house manger explained the staff forgot to retrieve the medications once R1 self dispensed. There is no documentation on file that R1 was able to administer their own medications, as the facility did not obtain a physician's report upon admission. R1 was admitted to the facility on 04/26/24, and there is still no physician's report or other required documentation on file. Resident #2 (R2) had three (3) prescriptions in their room. R2 has a Major Neurocognitive Disorder and their Physician's Report was dated 04/04/23. The house manager stated he's working on obtaining a current physician's report and was aware the report is due annually. Resident # 3 (R3) was recently admitted to the facility and there are no records on file. A review of resident records indicated the house manager is admitting residents prior to obtaining signed lawful Admission Agreements, Pre-placement Appraisals, Negative Tuberculosis results, and Physician Reports, along with other required documentation. Staff #1 (S1) started employment at the facility today and has not been associated. The house manger stated it was due to timing and will work on it. The house manager is running the facility and is aware of the admission process but has been too busy to get around to following the process. The house manager also stated residents are needed to bring income into the facility, as it's a business. Therefore, the residents were admitted and he's working on obtaining all required documentation. Resident #4 (R4) went to the hospital on 05/07/24 and the incident was not reported to Community Care Licensing. Per the house manager it was due to timing. Deficiencies were observed and cited on the attached LIC 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to House Manager whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, May 28, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 29, 2024

Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observations, the licensee did not ensure medications were centrally stored for 2 out 6 [R1-R2] residents in care which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2024

Plan of correction: House Manager stated he's told staff to lock the medications. He agreed to have staff attend vendor training but use a different vendor from last time, since the same issue is occurring. House Manager will schedule the training by POC due date and provide scheduled training information. In addition, the training will be submitted within 2 weeks.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: May 29, 2024

Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by: Based on interviews the licensee did not ensure 1 out 6 staff [S1] received a criminal record clearance transfer, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 28, 2024

Plan of correction: House Manager stated S1 began employment today but due to timing he was not able to get her fingerprints transferred. House Manager agreed to submit required documentation for S1 by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jun 7, 2024

Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: Based on record review, the licensee did not ensure 1 out of 5 [R2] residents had an annual assessment on file, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 28, 2024

Plan of correction: House Manager stated he was aware and working on it. House Manager will submit a current physician's report for R2 by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Jun 7, 2024

Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not ensure 2 out of 5 residents [R1, R3] have complete current records on file, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 28, 2024

Plan of correction: House Manager stated he's working with the residents' responsible party's to obtain the required documentation and will submit them by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 7, 2024

Reporting Requirements. A written report shall be submitted...within seven days of the occurrence...(A) through (D) below. This report shall include... date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not ensure an incident report was completed for 1 out of 5 residents [R4], which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 28, 2024

Plan of correction: The House Manager stated it was an oversight and will submit the incident report for R4 by POC due date.

Allegation investigated: Staff did not meet resident's needs Staff did not provide food of good quality Staff did not provide basic laundry services

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Staff, Editha Daep. During today's visit, LPA briefly toured the facility, requested records, interviewed staff and residents. It was alleged staff did not meet Resident #1's (R1) needs concerning showering, dressing, and transferring. R1 was admitted to the facility on 02/14/24. The Admission Agreement was signed and outlined R1 required assistance with dressing, toileting, bathing, grooming, mobility task, laundering of personal clothing, and clean bed linens weekly or as often as needed. R1 had an injury and required assistance from staff. Staff interviews revealed R1 refused assistance and R1 stated they could handle it themselves. Therefore, staff only assisted when R1 requested assistance. Resident interviews confirmed staff are assisting them with their activities of daily living. Some resident interviews revealed they don't always want assistance even if it's provided. Further resident interviews revealed R1 complained about everything and R1 was refusing care. Continued on an LIC 9099C. Unsubstantiated It was also alleged, staff did not provide food of good quality. It was reported the facility served ham, which was possibly spoiled, as it didn't look or smell right. Also, tuna sandwiches were served and the tuna appeared bad due to the smell and dark color. LPA did not observe any ham or tuna in the fridge. Staff stated they do not serve spoiled food or of poor quality. Resident interviews revealed the food was not of poor quality and they enjoy the ham. Lastly, it was alleged staff did not provide basic laundry services. R1's signed Admission Agreement outlined laundering of personal clothing, and clean bed linens weekly or as often as needed. It was reported R1's clothing was not being washed and they had to wear items for three (3) days in a row. According to staff, R1 did not have much clothing but it was washed. Resident interviews revealed their clothing is being washed. LPA observed a sufficient supply of laundry detergent. It was also reported the bed linens were not being changed. Staff stated the R1 was provided with clean sheets upon arrival. Resident interviews confirmed their linens are being changed. Interviews also revealed resident's will refuse the weekly change of linens. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report, along with Licensee Rights (LIC 9058 03/22), were left at the facility. Staff, Editha Daep refused to sign.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 08-AS-20240311115112

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management visit. LPA was greeted and allowed entry into the facility by Staff, Editha Daep. Today's visit was to ensure corrections have been madeOn 01/24/24, the facility was issued deficiencies. The deficiencies have been corrected and the ongoing civil penalties have ceased. Corrections were made. Today, LPA observed 56 eggs sitting out of the fridge. According to staff they were busy and needed time to put the eggs back in the fridge. The eggs stayed out for approximately 2 hours, until the LPA asked staff to please refrigerate the already refrigerated eggs. The previous unwanted items were removed from the backyard according to the photos taken back on 01/24/24. However, today there were new unwanted items including molded doors, old screens, rusted metal gating, and wood paneling obstructing the walkway and a hole under a kitchen drawer, possibly allowing rats to enter. The garage was unlocked, which stores cleaning supplies, making them accessible. There was also a malodorous smell in the garage that smelled like a dead animal or rat. Per staff, the exterminator is trying to locate the issue. The facility now has an Emergency and Disaster Plan but it's not in accordance of how the facility will operate in an emergency. An updated Emergency and Disaster Plan is needed along with a new proof of training of the plan. Staff, Rodelio Aquino submitted proof of 20 hours of training but not all required topics were met, as there was some confusion. The facility will have an opportunity to rectify the training. The medication closet was unlocked making medications accessible. The facility has a Hospice Waiver for one (1) resident. However, they currently have three (3) residents requiring hospice services. Staff, Rodelio Aquino stated he faxed a hospice exception but it was not received. A review of the hospice documents at the facility were insufficient. Staff will resubmit the hospice exception with all required documentation. A review of records indicated the facility had a new admission on 02/14/24 and they are using outdated Admission Agreements (02/05). Also, required licensing documentation was not completed for the new admission. Deficiencies were observed today and cited on the attached 809D, along with Technical Advisories, and civil penalties. An exit interview was conducted and a copy of this report, Licensee Rights (LIC 9058 03/22), and LIC 421's were left at the facility. Staff, Editha Daep refused to sign.the state’s words, verbatim · CDSS document, Mar 14, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Mar 15, 2024

Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observations, the licensee did not ensure medications were locked for 3 out of 3 residents [R1-R3], which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 14, 2024

Plan of correction: Staff locked the medication closet, removing the immediate threat. All staff will attend vendor training regarding medications being inaccessible to residents. Staff will schedule training by POC due date and provide proof of scheduling training. In addition, staff will submit training within 2 weeks.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Mar 15, 2024

Storage Space. Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observations, the licensee did not ensure cleaning solutions were inaccessible to 3 out of 3 residents [R1-R3] which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 14, 2024

Plan of correction: Staff locked the garage, removing the immediate threat. All staff will attend vendor training regarding items that could pose a danger be made inaccessible to residents. Staff will schedule training by POC due date and provide proof of scheduling training. In addition, staff will submit training within 2 weeks.

Type of visit: POC

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Plan of Correction visit. LPA was greeted and allowed entry into the facility by Staff, Khymberlie Talledo. On 12/20/23, the facility was issued deficiencies due on 01/16/24. Staff, Rodelio Aquino requested an extension through 01/30/24, which was approved for the following deficiencies: Proof of liability insurance and remove all the unwanted items in the backyard and repair or replace all the torn window screens. As of today, the following deficiencies have not been corrected: Hospice exception for Resident #1; and Incident Report for Resident #2. There were also repeat violations for deficiencies: Hot water temperature and medications not locked. Today, LPA observed the hot water temperature measured at 125 degrees F., Resident #3 had medications in their room on a tray table in front of them for easy access, and the refrigerated medications were not locked. Based on observations, repeat violations and failure to correct were issued along with civil penalties. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Staff, Khymberlie Talledo whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jan 24, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility by Staff, Khymberlie Talledo. Today's visit was to complete an annual continuation inspection. The inspection was conducted with staff. LPA observed medications requiring refrigeration was not locked, medications were in Resident #5's (R5) bedroom made accessible to all residents, and medications were being pre-poured 24 hours in advance. The hot water temperature measured at 125 degrees. There was not a 2 day supply of perishables, the facility had apples and molded cucumber. There was also a large amount of expired food with dates from 2017, 2020, 2022, and 2023. Some of the items were growing mites. Preserves/jellies were opened but not refrigerated, they were placed back in the cabinet. There was a 150 count box of eggs sitting on a cabinet that stated on the box refrigeration was required. Some food items such as bread and pasta were molded. Food was stored with medications and medication was in food box. Multiple rat traps were present in the facility. A rat was also observed running across the kitchen floor. Multiple roaches were observed with the food/medication cabinet and in drawers coming from a large hole under a drawer located in the kitchen next to the sink. The facility also had a large hole in R5's bedroom, bathroom cabinet doors were hanging and/or missing. Facility has a supply of cleaning supplies but they are using soap and water to clean to the facility. Resident #2's (R2) bedroom has a strong urine odor. Resident #1 (R1) and R2 has half bed rails at the top of the bed and at the waist of the bed but there are no orders on file for the bed rails. Also, Resident #5 has half bed rails and no orders on file. Confidential resident information was sitting on the dining room table accessible to all. Review of resident records indicated staff do not have required documentation or training on file. Residents are receiving hospice services and there were no hospice care plans or documentation from the hospice agencies of services rendered at the facility on a weekly basis. Some residents did not have a current physician's order on file for medications. The facility does not conduct disaster drills and does not have a disaster and emergency plan. The facility does not have a current administrator. The administrator appointed has expired as well as the designated staff, Rodelio Aquino, whose administrator certificate expired on 07/25/23. A review of staff records did not contain required documentation. Continued on an LIC 809C. Based on observations, interviews, and record review, deficiencies were observed and cited on an LIC 809D. Also, Technical Advisories were issued. LPA will return to complete the visit at a later date. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Staff, Khymberlie Talledo whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jan 24, 2024

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility by Staff, Editha Daep. The visit was conducted with Staff, Rodelio Aquino. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, However, there was not a sufficient supply of Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents measured at 129 F.. 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 sharp objects, and toxic chemicals/poisons accessible to residents. The cleaning supplies under the kitchen sink, had a broken lock on the cabinet. Knives were in an unlocked drawer in the kitchen, accessible to all residents. There were medications in the fridge, made accessible to all residents. Gardening tools to include shovels, rake, and sharp digging tools were accessible in the backyard, along with a cleaning supply and paint. A resident uses syringes and the facility does not have a sharps container to properly dispose of the syringes. The backyard had unwanted clutter piled up on the tables. Multiple window screens were torn and ripping. No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, and facility telephone were all working. The facility did not have sufficient emergency lighting. First aid kit was incomplete, there was no manual or tweezers. Required licensing postings were not all posted. The facility does not have an Emergency Disaster Plan. The facility did not report an incident involving a resident going to the hospital. Continued on an LIC 809C. There is a bedridden resident in a non-bedridden room. The facility has a hospice waiver for one (1) resident but currently has two (2) residents on hospice. Facility does not have written statement on file for a resident sharing a bedroom with a hospice resident. The inspection was not completed due to time constraints, an Annual Continuation visit will be conducted at a later date. Deficiencies were observed and cited during today's annual inspection. An exit interview was conducted with Staff, Rodelio Aquino to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Dec 19, 2023