Meison La Paz Elderly Care Home

Allegation investigated: Staff did not provide medical staff with resident’s DNR

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, the department toured the facility and interviewed staff and witness. Regarding the allegation that Staff did not provide medical staff with resident’s DNR, the investigation revealed the following: R1 had a “Do Not Resuscitate (DNR)” order effective April 28, 2024. On April 21, 2025, R1 started to choke on chopped pineapple at approximately 4:50 PM. Staff immediately started the Heimlich maneuver which was unsuccessful due to pieces of the pineapple being stuck in R1’s throat. 911 was called at 4:59 PM with paramedics responding at 5:04 PM. When the paramedics arrived, R1 was initially pulseless, apneic, asystole with pale skin. R1’s pupils were fixed and dilated, the primary impression of which was cardiac arrest per Orange County Fire Authority Incident Report. Paramedics were able to get a pulse, and resident was transferred to Saddleback Memorial Hospital where resident subsequently passed on April 24, 2025, with a cause of death listed as acute respiratory failure with Hypoxia and pneumonia due to CONTINUED ON LIC 9099C DATED 10/15/2025 Substantiated inhalation of secretions. Staff 1 reported they provided the DNR to the paramedics when they responded. Administrator stated the paramedics stated that R1 had to be transported to the hospital and R1’s family was upset that 911 had been called. Per Orange County Fire Authority Incident Report, there is no mention of DNR paperwork being provided and/or knowledge of R1’s DNR status. Records obtained from Saddleback Hospital, do not show that documentation of DNR was received by the paramedics. Hospital records document that the hospital became aware of DNR status from R1’s spouse who verbally advised them of R1’s DNR upon arriving at the hospital. Based on record review and interviews conducted, 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) are being cited on the attached LIC 9099D. Exit interview conducted and a copy of the report provided as well as appeal rights. Paramedics were able to get a pulse, and R1 was transferred to Saddleback Memorial Hospital where they subsequently passed on April 24, 2025. The cause of death was listed as Acute Respiratory Failure with Hypoxia and Pneumonia due to inhalation of secretions. Per Interview with Administrator, R1 would self-feed but due to their difficulty swallowing, R1’s food was always cut up in about .5 inches increments and was monitored by staff while eating. R1 could eat on their own but was very slow in the process. R1 did not want to be fed by staff and preferred to self-feed. Home Health notes showed R1 did not have food restrictions. Administrator as well as staff stated R1 always had thick-it mixed in with fluids due to the risk of choking. Three out of three staff state R1’s food was always cut up and resident was monitored while eating. Although R1 did choke on food prepared, it remains unclear if choking was caused due to the food not being prepared properly. Regarding the allegation that staff force fed resident, the investigation revealed the following: Per pre-appraisal dated December 24, 2024, and physician report dated January 06, 2025, R1 was able to self-feed with staff cutting up the food. R1 was on soft food diet as well. Nursing notes indicated resident had no food restrictions. Three out of three staff deny force feeding R1 and state they were able to self-feed. Staff reported R1 would take a long time to eat and sometimes would fall asleep while eating but the staff stated allowing R1 the time to feed themself. R1’s family member would provide specific food for R1 and staff would allow the resident time to finish. R1’s family member indicated observing facility staff force the resident to eat. Regarding the allegation that Resident sustained skin tear while in care due to neglect, the investigation revealed the following: Per physician report dated January 06, 2025, R1 is diagnosed with Parkinson’s Disease and Dementia. Physician report shows R1 was admitted with a foot heel ulcer. Prior to R1 moving into the facility, R1 was seen on December 30, 2024, for a non-healing left heel ulcer initiated by a pressure injury and complicated by Dementia. R1 was seen at Saddleback Memorial Center for the condition. While admitted, R1 received wound care, in which the diagnosis was a Stage III. After selective debridement, the ulcer was then diagnosed as a Stage II at the time R1 was admitted to the facility. Resident was receiving wound care from Accent Care Home Health as well as Providence Palliative Care from December of 2024 through April of 2025. Nursing notes from Accent Home Health show that R1 was being seen for wound care to left and right heel ulcers approximately every seven days. Accent Home Health Notes showed instructions for elevating R1’s heels and that staff reported following instructions. The Administrator stated R1 had received a skin tear after R1 put their arm out as they were passing through a doorway. Home Health nursing notes show R1 was being treated for the skin tear as well. Although R1 did sustain a skin tear, it remains unclear if the skin tear was caused due to neglect. Regarding the allegation that staff unable to communicate with resident due to language barrier, the investigation revealed the following: Two out of two staff and two out of two residents deny any issues with communication. Two out of two residents state having no issues communicating with the staff even though English is a second language. Both residents state staff are attentive and communicative to their needs. Staff state being able to communicate with the residents without challenge. LPA interviewed both staff without any translation services. Staff 1 demonstrated knowledge of calling for emergency services and what information to provide. Regarding the allegation that staff not administering resident's medication as prescribed, the investigation revealed the following: S1 is primarily responsible for medication administration. S1 states providing R1's medication four times a day before meals as instructed in the physician order. LPA reviewed the medication order for Carbidopa and Levodopa for Parkinson's Disease four times a day at breakfast, lunch, dinner, and nighttime. Facility does not use a medication administration record for routine medications. Two out of two residents state knowing what their medications are and they are being administered per physician order. Based on records reviewed and interviews conducted, the department is unable to corroborate the above allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted and copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 15, 2025 · control 22-AS-20250428152534

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Oct 16, 2025

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services. This requirement is not met as evidenced by: Based on interviews conducted, Licensee failed to ensure resident was able to reject medical care. R1 had a "DNR" on file which was not provided to first responders. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: Licensee to conduct an in-service on the process of DNR and first responders and forward proof to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced required visit to the facility for the purpose of conducting the required annual inspection. LPA Rodriguez explained reason for visit and was greeted and granted entry by staff on duty. During the visit, staff on duty contacted facility administrator (AD) Hermelinda Perez about visit. For this visit, there are 2 staff members on duty, of which are background cleared and associated on Guardian. The PUB475 "See Something, Say Something" poster was observed to be located at the entrance of the facility. LPA observed the Administrator's Certificate for Hermelinda Perez which expires on 10/30/2026. LPA toured the interior and exterior portions of the facility with AD Perez. The facility is a two level structure and is licensed for 6 non-ambulatory residents, of which 0 may be bedridden and 4 may be on hospice. For this visit, there are a total of 6 residents in care, of which 2 are on hospice and 0 are bedridden. On the first level, there are a total of 3 resident bedrooms, of which all 3 rooms are shared resident rooms and 2 bathrooms. LPA 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. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. On the second level, there are a total of 2 bedrooms and 1 bathroom of which is only designated for staff use. LPA observed that there are no residents or resident belongings residing on the second floor. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. Water temperature was measured to be at 112.9 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 at the entrance of the facility. Fire extinguishers were dated and tagged for the date of January 2025. LPA 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 garage. LPA observed that First Aid Kit had all the required components. Medications and toxins were also observed to be locked and inaccessible to residents in care. For the exterior portion, LPA observed patio furniture under shading, and the grounds were free of any hazards. There is 1 gate in the backyard, which is 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 Perez. A copy of this report was explained and provided.the state’s words, verbatim · CDSS document, Sep 23, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Hermelinda Perez and explained the reason for the visit. LPA observed the See Something Say Something Poster (PUB 475) posted in the entry way of the facility. The Administrator, Hermelinda Perez's Administrator's certificate expires on October 30, 2024. LPA and Administrator toured the facility. The facility is a 2 story house with 5 bedrooms, living room, kitchen, dining room, 3 bathrooms and a 2 car garage. The facility is licensed for 6 non-ambulatory residents, hospice waiver for 2, no bedridden allowed. LPA observed both bathrooms are clean and operational. The hot water measured 109.4 degrees Fahrenheit. LPA observed all resident rooms had the required furnishings and bed linens. The smoke detectors/carbon monoxide detectors tested operational. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The 4 burner gas stove lights unassisted. LPA observed the knives and sharp objects are kept locked in a kitchen drawer. LPA observed the garage is kept locked and used for storage of supplies, extra food and emergency food and water. LPA observed the medication is kept locked in a cabinet in the garage. LPA toured the backyard. LPA observed there is a plastic shed in the backyard. The shed is used for storing extra furniture and kept locked. The exit gates leads to the front courtyard. No bodies of water observed. There is shaded seating in the backyard. No obstacles or hazards observed in the backyard. LPA toured the second floor of the facility. No residents live upstairs. There are 2 bedrooms upstairs and 1 bathroom. LPA reviewed 2 staff files, no discrepancies observed. LPA reviewed 6 resident files and medications, no discrepancies observed. There is no facility record of an emergency disaster drill taking place in the last 3 months. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Oct 14, 2024