Nazareth House

Allegation investigated: Staff mismanaged resident’s medication.

On 07/28/2026 Licensing Program Analyst (LPA) M. Garza arrived at the facility for an unannounced complaint vsiit. LPA met with Assistant Director, Sara Guidry, explained reason for visit and was permitted entry into the facility. LPA completed a tour of the facility and Health and Safety check on residents in care. During visit LPA completed interviews, gathered and reviewed documentation. Based on records reviewed and intervies conducted the preponderance of evidence standard has been met per California Code of Regulations, Title 22. The allegation listed above is SUBSTANTIATED. Deficiency cited on attached 9099D. If not corrected the deficiency will have a direct impact to residents in care. Exit interview completed with Assistant Director, Sara. A plan of correction was developed by Assistant Director and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Jul 28, 2026 · control 24-AS-20260722115844

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 29, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by records reviewed and interviews conducted. The licensee did not comply with the section cited above in that medication was provided to R1 prior to the prescribed start date from the physician. This poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: Assistant Director stated they are going to complete medication training for both nurses involved. They have also has a training with both nurses about making sure that all medication orders go into the electronic records program. Training certificates/transcripts will be provided along with documentation on the electroic records program as proof of correction by POC date.

Type of visit: Required - 1 Year

On 06/27/26 Licensing Program Analyst arrived at the facility to complete an unannounced annual visit. LPA met with Licensed Vocational Nurse, Magadalena Garcia. LPA explained reason for visit and was permitted entry into the facility. Administrator, Rosemary O'neil was contacted and stated they were unavailable to come to the facility. Administrative Coordinator, Renee Martinez arrived a short time later to complete visit with LPA. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. Currently there are 7 resident receiving hospice services at this time. Pathways and doors were clear and free from obstruction. Facility was without odor. Common areas were adequately furnished, and adequately lit. Smoke detectors function on a system and were last serviced on 01/23/2026. Carbon monoxide detectors were present and operational at time of visit. Resident rooms observed to have the required furnishings and with adequate lighting. Sharps, chemicals and medications were located in locked cabinets/closets and cupboards. LPA observed sufficient seating under covered patio areas. The following issues were observed during today’s visit: Food in refrigerator/freezers in kitchen were not properly covered/dated. 2 of 2 medical personnel files reviewed did not have first aid certificates. Deficiencies cited per California Code of Regulations, Title 22, deficiencies are being cited on the attached 809D. If not corrected, the violation with have a direct and potential risk to the health, safety and/or personal rights of residents in care. LPA requested the following documents to be submitted to CCL by 07/03/26: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) and a current copy of liability insurance in order to update the facility file. Exit interview was conducted with Administrative Coordinator, Renee. A plan of correction was developed by Renee and reviewed by LPA. A copy of this report, deficiencies, and appeal rights were discussed and provided.the state’s words, verbatim · CDSS document, Jun 27, 2026

Type of visit: Required - 1 Year

On 5/1/2025, Licensing Program Analyst (LPA) J. Leffall arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry and was greeted by Staff (S1) Renee Martinez. LPA met with Administrator (A1) Rosemary Oneill and conducted facility tour with LPA. LPA reviewed resident and staff files. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report and ID Documentation. Staff files were reviewed for good health. Staff files had health screenings/ TB Clearance. It was verified that medical staff on duty are First Aide certified. Facility entry leads into two hallways that house resident rooms. Facility chapel toured. LPA toured dinning room at the end of the hallway and toured the facility kitchen. LPA observed a 7-day supply of non-perishable foods and 2-day supply of perishable foods. Two courtyards toured in between the hallways. LPA observed sufficient seating and space for activities in auditorium. Backyard courtyard toured. Resident rooms toured in separate building in the backyard courtyard. Laundry building toured. Fire extinguisher observed with a service date of 4/27/25. Resident’s rooms were toured with bed, dresser, and nightstand. Resident’s bathrooms were observed with shower chairs and non-skid mats. 5 resident’s bathrooms observed and water temperature ranged from 110.8 to 115.3 degrees F. Smoke detectors and carbon monoxide were observed to be operational. First Aide kit observed to have all of the required items. No deficiencies issued during this inspection. LPA is requesting the following documents be submitted to the Fresno CCL office by 5/15/2025: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted. A copy of this report and 9102 was provided to A1, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, May 1, 2025

Type of visit: Case Management - Annual Continuation

On 6/12/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct a continuation Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff. LPA met with Assistant Director Sara Guidry. LPA observed Pull station fire alarm system installed. Sample of bedrooms were checked. Centrally stored medication observed in med carts in Nurse's station. A sample medication audit was conducted. LPA observed Paint cans in the courtyard backyard sitting next to the wall; accessible to residents in care. Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. An exit interview was conducted with staff. Report signed on-site; a copy of this report, 809D with appeal rights will be provided via email due to technical difficulties.the state’s words, verbatim · CDSS document, Jun 12, 2024

Type of visit: Required - 1 Year

On 5/15/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff. LPA met with Daisy Cervantes, Director of resident care. Assistant Director Sara Guidry arrived a short while later. LPA reviewed resident and staff files. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report and ID Documentation. Staff files were reviewed for good health. Staff files had health screenings/ TB Clearance. It was verified that current staff on duty are CPR certified. LPA conducted a tour of the facility with Assistant Director. Facility entry leads into two hallways that house resident rooms. Facility chapel toured. LPA toured dinning room at the end of the hallway and toured the facility kitchen. LPA observed a 7-day supply of non-perishable foods and 2-day supply of perishable foods. Two courtyards toured in between the hallways. LPA observed sufficient seating and space for activities in auditorium. Backyard courtyard toured. Resident rooms toured in separate building in the backyard courtyard. Laundry building toured. Due to time constraints, LPA will return at a later date for an annual continuation. LPA is requesting the following documents be submitted to the Fresno CCL office by 5/22/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted with Assistant Director. Report signed on-site; a copy of this report was provided via email due to technical difficulties.the state’s words, verbatim · CDSS document, May 15, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst LPA K.Kaur conducted a Case Management to follow up on two incidents that were reported to CCLD that occurred on 1/18/2024 and 3/13/2024. LPA was met with Assistant Director Sara Guidry and Administrator Rosemary O’Neill. LPA discussed the purpose of the visit. LPA interviewed staff regarding incidents. Regarding Incident dated 1/18/2024 for resident’s (R1) funds that went missing facility provided a short-term fix by reimbursing residents family the missing monies. For a long term fix the facility and family decided to not have such large amounts of cash kept with the resident. Facility notified Licensing, Ombudsman, and Police department. Facility followed proper procedures. No deficiencies cited. Regarding Incident dated 3/13/2024 Resident (R2) medication error. Per Administrator Resident medication was not discontinued on the MARs and resident received medication in error. Based on record review LPA observed MARs dated 3/1/2024 to 3/12/2024 with two entries for the same medication with the same dosage that was being given twice a day. Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. An exit interview was conducted with Administrator discussing the plan of corrections. Report signed on-site; a copy of the report with 809D page and appeal rights will be emailed due to technical difficulties.the state’s words, verbatim · CDSS document, Apr 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 24, 2024

87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above for Resident (R2) who was receiving the same medication/dose twice a day since two entries were made into the MARs one for bedtime and one entry for “daily” in error which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2024

Plan of correction: Plan of Correction Administrator agrees to submit medication training on administration and logging of all medication, which will include an agenda, qualified presenter and staff signatures.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kamaldeep Kaur arrived unannounced to conduct a case management visit regarding a Decision and Order notice from the Caregiver Background Check Bureau (CBCB) requiring removal of Staff #1. LPA met with Administrator Rosemary O’Neill and informed the reason for visit. LPA spoke with Administrator who confirmed S1 was not on premises. Administrator confirmed S1 was terminated on 10/19/2019 and disassociated on that date. The facility did not have a termination letter or any evidence in proof since records have been destroyed. Exit interview conducted. Report signed on site by Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 27, 2023

Type of visit: Case Management - Other

On 12/27/2023, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct a case management regarding a complaint the department received regarding multiple falls Resident (R1) had that were not reported to Licensing. LPA met with Administrator Rosemary O’Neill and informed the reason for visit. LPA completed facility file review and observed very few incident reports from October 2023 to December 2023. LPA reviewed incident report submitted to Licensing on 9/15/2023 for R1 regarding a fall and death report from 9/17/2023. No deficiencies observed. An exit interview was conducted with Administrator. Report signed on-site by Administrator and printed copy provided with appeal rights.the state’s words, verbatim · CDSS document, Dec 27, 2023