Pruneridge Residential Care Home, Facility #2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with caregiver, Concordia Casabar and stated the purpose of today's visit. LPA Rai observed 3 staff and 4 residents at the facility. LPA Rai spoke with Licensee/Administrator, Leilani Cortes and stated the purpose of today's visit. Facility has an approved waiver for 4 Hospice residents and currently there are 3 residents receiving Hospice services. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the facility to include 5 resident rooms, 1 staff room, living room, dining room, kitchen and laundry room. 5 Out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom and kitchen sink ranged from 113.0 - 113.9 degrees F. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. LPA Rai observed 1 fire extinguisher was observed and inspected last on 12/27/2024. Caregiver, Concordia stated there is only 1 fire extinguisher at the facility and the last time it was inspected was on 12/27/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drills were conducted on 04/23/2026 and 04/24/2026. LPA Rai observed a complete first aid kit at the facility. LPA Rai reviewed facility records for 3 staff. LPA Rai reviewed facility records for 3 residents. LPA Rai reviewed resident medications and central stored medication records. Resident R1 did not have 1 centrally stored medication (MED1)'s start date recorded on the Centrally Stored Medication Record. Resident R2 did not have 1 centrally stored medication (MED2)'s start date recorded on the Centrally Stored Medication Record. Resident R3 did not have 1 centrally stored medication (MED3) recorded on the Centrally Stored Medication Record. Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. Technical Violation was provided. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Caregiver, Concordia Casabar and LPA Rai reviewed the LIC 809D with Licensee/Administrator Lelani Cortes over the phone. A copy of the report was provided. LIC 858 and LIC 859 were provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, May 19, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: May 26, 2026

87465(h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement is not met as evidenced by: Based on record review, Licensee did not ensure 3 medications which were centrally stored had start dates or recorded on the Centrally Stored Medication Record which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure resident's centrally stored prescription medication are recorded on the Centrally Stored Medication log by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87203 · Plan of correction due date: May 26, 2026

87203 All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation, there is 1 fire extinguisher at the facility which was last inspected on 12/27/2024, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure fire extinguisher is inspected or purchased new and placed at the facility by POC due date. Administrator agreed and understood.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Santino Fortes conducted an unannounced annual inspection, and met with Caregiver (CG) Concordia Casabar. CG stated facility has 2 staff and 6 clients. LPA toured the facility inside and out. There were (1shared/4single) resident rooms, 1 staff rooms, 1 living room, and Kitchen. LPA observed resident rooms each with a chair, night stand, sufficient lighting and chest of drawers. Room temperature was 71.9* F. Hot water temperature was Bathroom, 112*F, Bathroom 111.9* F and kitchen 113* F. LPA observed the first aid kit to be complete. Smoke and carbon monoxide detectors functioned properly when tested. Fire extinguishers were serviced on 12/27/24. Staff conducted a fire drill on 4/30/25. Restrooms observed to have non skid flooring. LPA observed 2 days perishable food supply and 7 days non-perishable food supply. Refrigerator temperature observed at 32* F and Freezer temperature -2* F. LPA observed medication storage, knives storage, and cleaning product storage locked and inaccessible to clients in care. The front and back yards of the facility were inspected. Exits and walkways were unobstructed. Facility has 2 storage sheds, used to store unused mattresses, care supplies, and furniture. LPA observed Facility License and Resident Personal rights were posted. LPA reviewed facility records for 3 staff, 5 clients and observed to be complete. LPA reviewed 5 client’s medications, centrally stored medication records and observed to be complete. No deficiencies were cited during today's visit as per California Code of Regulations Title 22. Exit interview was conducted with CG. This report was reviewed and a copy was provided to CG for signature.the state’s words, verbatim · CDSS document, May 27, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to continue the annual inspection from 5/2/2024. LPA Rai met with Lead Staff (LS) Mary Ann Villanueva. LPA Rai observed 2 staff and 6 residents at the facility. At this time, the facility has 2 hospice residents. During today's visit, LPA Rai followed up with 2 staff files. On 5/2/2024, LPA Rai reviewed 1 staff file for S1 where first aid training was expired. During today's visit, LPA Rai observed S1's first aid training was completed on 5/3/2024. On 5/2/2024, LPA Rai reviewed staff file for S2 where S2's Tuberculosis (TB) test was not included in the health screening and a separate TB test results were not found in the file. During today's visit, LPA Rai observed S2's TB test result in the file with a note stating the new records were from another facility the Licensee currently manages along with this current facility. During today's visit, LPA Rai reviewed 2 resident files who are not on hospice services. LPA Rai observed R1-R2''s file did not contain the Appraisal/Needs and Services Plan. R2's file did not contain a signed order for half-side rails attached to R2's bed and LS clarified R2 is not on hospice services. R2's file did contain an Admission Agreement but it's not for this current facility. LPA Rai observed the water temperature in the bathroom sinks ranged from 118.4 degrees Fahrenheit - 119.3 degrees Fahrenheit. The water temperature in the kitchen sink was 118.9 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 4/5/2024. LPA Rai observe the thermometer in the freezer was measured at 0 degrees Fahrenheit and the thermometer in the fridge was measured at 40 degrees Fahrenheit. Continuation on LIC 809-C, Page 1 of 3. Page 2 of 3. During today's visit, LPA Rai reviewed 2 resident medications and central stored medication records for resident R1 and R2. For R1, 1 out of 3 medications were not given as prescribed to the resident. Medication #3 was prescribed as 1 tablet 3 times a day as well as PRN as needed. The medication bottle was started on 4/29/2024 and the medication in the bottle when opened were 60 tablets. LPA Rai and LS counted the tablets in medication #3's bottle and observed 27 tablets. LPA Rai observed PRN sheet noted PRN medication was administered on 3/22/2024, prior to this current medication bottle was started. LPA Rai observed there were 3 tablets were missing from bottle. LS stated resident does ask for PRN in the evenings for pain, however, LS stated she did not write the information in the PRN log. For R2, resident's file does not contain a document where R2's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication. In addition, 4 out of 4 medications were not given as prescribed to the resident. Medication #4 was prescribed as 1 tablet a day and the medication bottle was started on 4/21/2024. It was logged on the Centrally Stored Medication Record (CSMR) as 94 tablets in the bottle when started. LS stated R2's medications came from another facility so LS counted all the medications when R2 was admitted and recorded in on R2' Centrally Stored Medication log. LPA Rai and LS counted the tablets in Medication #4 bottle and observed 71 tablets. LPA Rai observed there were 5 tablets tablets missing from the bottle. LS looked at medication cabinet and discovered R2's medication bottles that LS stores medication when R2 refused medication. LS provided LPA Rai a medication bottle which was not the original container for medication #4 and contained two different medications. LPA Rai observed 5 tablets matched the color and size of medication #4 and two tablets that were a different size and color. LPA Rai advised LS to keep medications in the prescribed bottles and not to mix medications into a different medication bottle. LS agreed and understood. Medication #5 was prescribed as 1 tablet given on Monday, Wednesday and Friday and the medication bottle was started on 4/10/2024. It was logged on the CSMR as 100 tablets in the bottle when started. LPA Rai and LS counted the tablets in Medication #5 bottle and observed 89 tablets and there should be 61 tablets in the bottle, LPA Rai observed there were 28 extra tablets in the bottle. LS stated R2 will refused the medication. LS provided the Medication Administration Record, and LPA Rai observed the medication was initialed by LS stating the medication was given to resident as prescribed but there were still 28 tablets extra in the bottle. Page 3 of 3. Medication #6 was prescribed as 1.5 tablets at bedtime. It was logged on the CSMR as 87 tablets in the bottle when started on 4/9/2024. LPA Rai and LS counted the tablets in Medication #6 bottle and observed 44.5 tablet and there should be 43.5 tablets, LPA Rai observed there was 1 extra tablet in the bottle. LS stated R2 will refused the medication. LS provided the Medication Administration Record, and LPA Rai observed the medication was initialed by LS stating the medication was given to resident as prescribed. LS stated R2 will drop the medication on the floor when the room is dark and LS has had to replace the medication and throw the dropped tablet in the trash. LS stated she did not log on the destruction log. LS stated she might have started the medication on 4/10/2024 not as logged on CSMR as 4/9/2024. LPA Rai advised LS to correctly document the CSMR log as accurately as possible. Medication #7 was prescribed as 1 tablets daily and the medication bottle was started on 4/9/2024. It was logged on the CSMR as 24 tablets in the bottle when started. LPA Rai and LS counted the tablets in Medication #7 bottle and observed 24 tablets and there should be 26 tablets, LPA Rai observed there were 2 missing tablets in the bottle. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. 87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs. Lead Staff attempted to reach Licensee Leilani Cortes over the phone and Licensee was not available and was not present at the other two facilities managed by Licensee. Exit interview was conducted with Lead Staff, Mary Ann Villanueva. A copy of this report was provided to Lead Caregiver, Mary Ann Villanueva. Appeal Rights were provided. .the state’s words, verbatim · CDSS document, May 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: May 15, 2024

87411 Personnel Requirements - General (c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by: Based on record review and interview, S1's file did not contain first aid training on 5/2/2024 and S1 provides direct care to residents which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure staff who provide care to residents receive first aid training before certification expires. The written plan is due by POC due date. Licensee/Administrator agreed and understood. During today's visit, LPA Rai observed S1's file contained first aid training which was conducted on 5/3/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: May 15, 2024

87412 Personnel Records (a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement was not met as evidenced by: Based on record review and interview, S2's file did not contain TB test results with the health screening and on 5/2/2024 staff file was incomplete at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure staff files are maintained at the facility by POC due date. Licensee/Administrator agreed and understood. During today's visit, LPA Rai observed S2's file contained the TB test result.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: May 15, 2024

87463 Reappraisals (a) The pre-admission appraisal shall be updated...The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidenced by: Based on record review, 2 out of 2 resident files (R1-R2) did not contain Appraisal/Needs and Services Plan which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure R1 and R2 have completed Appraisal/Needs and Services Plan in resident's file by POC due date. Licensee/Administrator agreed and understood.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(5)(A) · Plan of correction due date: May 15, 2024

87608 Postural Supports (a)(5)(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Based on record review, 1 ouf of 2 resident files (R2) did not contain a physician's order to use half-bed rail for mobility and R2 is not receiving hospice services which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure physician's order for half-bed rail is in R2's resident file by POC due date. Licensee/Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: May 9, 2024

87465 Incidental Medical and Dental Care (h) (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by: Based on recored review, observation and interview,LPA Rai osberved a medication bottle containing two different types of medication different than the one on the bottle label which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure medications are stored in its original container by POC due date. Licensee/Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: May 9, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on record review, interview and observation R1's 1 out of 3 meds not administered to R1 as prescribed by the MD and R2's 4 out of 4 meds were not administered to R2 as prescribed by the MD which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure staff receive medication training by POC due date. Licensee/Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: May 9, 2024

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on record review, interview and observation, R1-R2 e MARs noted medications administered but LS stated R1 requested for PRN medication and R2 refused medication, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure staff are trained in accurate record keeping which reflects the medication administed to the residents in care by POC due date. Licensee/Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d) · Plan of correction due date: May 9, 2024

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met ad evidenced by: Based on interview, record review and observation, ADM did not adequate provide attention to the management & administration of the facility by conforming to the applicable laws, rules and regulations which poses/posed an immediate Health, Safety, or Personal Rightsthe state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation by POC due date. Licensee/Administrator agreed and understood. (con't) risk to persons in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: May 15, 2024

87465 Incidental Medical and Dental Care (h)(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes. This requirement is not met as evidenced by: Based on interview and record review, R2's Centrally Stored Medication Record is not accurate as stated by Lead Staff (LS). LS stated R2's medication was started on 4/10/2024, when the log states 4/9/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure Centrally Stored Medication Record is accurate and maintained for R2 by POC due date. Licensee/Administrator agreed and understood.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87565(b) · Plan of correction due date: May 15, 2024

87465 Incidental Medical and Dental Care (b)If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication... This requirement is not met as evidenced by: Based on record review, R2's physician has not stated in writing that the resident is able to determine and communicate his/her need for PRN medication which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure resident file is complete with necessary documents from physician to administer PRN medication by POC due date. Licensee/Administrator agreed and understood.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(a) · Plan of correction due date: May 15, 2024

87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidenced by: Based on interview and record review, R2's file did contain an Admission Agreement but it was not for the current facility where R2 resides which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure resident's Admission Agreement is accurate to where the resident is currently residing by POC due date. Licensee/Administrator agreed and understood.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Lead Staff (LS) Mary Ann Villanueva. LPA Rai spoke with Licensee/Administrator over the phone and obtained verbal authorization for LS to review and sign the report. LPA Rai observed 2 staff and 6 residents at the facility. At this time, the facility has 2 hospice residents. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 2 sheds which are not used as habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the resident bedrooms. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. Fire extinguisher was observed and inspected on 01/05/2024. LPA will return another day to complete annual inspection. This report was reviewed with Lead Staff (LS) Mary Ann Villanueva and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 2, 2024