Rachelle's Home I

Allegation investigated: Resident sustained a fracture due to staff neglect. Staff did not seek medical attention to resident in a timely manner.

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Assistant Administrator Tyrone Vega. On 04/15/2026, the department received a complaint with the above allegations. On 04/16/2026, the department conducted an initial complaint investigation. On 05/21/2026, LPA Marrufo conducted an additional complaint investigation visit. Allegation: Resident sustained a fracture due to staff neglect. When the department received the complaint, it was alleged that resident R1 sustained numerous falls at the facility, resulting in a femur fracture. On 04/21/2026, the department received a copy of R1’s hospital records. R1’s hospital records indicate R1 was admitted to the hospital on 04/08/2026 via ambulance for a chief complaint of vomiting, diarrhea, and acute respiratory failure with hypoxia. At the hospital, R1 was diagnosed with rhino virus and pneumonia. On 04/14/2026, R1 was discharged home to the facility with a final diagnosis of viral disease and pneumonia. R1’s hospital records contained no indication that R1 sustained a fracture. See LIC9099-C page for more information. Page 1 of 3. Unfounded Allegation: Staff did not seek medical attention to resident in a timely manner When the department received the complaint, it was alleged that staff observed R1’s health decline for several days without requesting care for R1. On 04/08/2026, the facility submitted an Unusual Incident/Injury Report (IR) to the department. The IR stated that on 04/08/2026, R1 displayed unusual lethargy and physical distress, leading to a coordinated medical intervention between facility staff, hospice nursing, and emergency services. The IR states that at 7:10 AM, staff were assisting R1 with his/her morning routine and observed that R1 seemed “off” and was not acting like his/her usual self. Staff proceeded to transition R1 to the dinning area for his/her meal. At 7:48 AM, R1’s condition declined. R1 refused the remainder of his/her meal, complained of abdominal pain, and began vomiting. At 8:00 AM, facility staff contacted R1’s hospice agency to report the change in R1’s condition. The attending nurse advised staff to administer anti-vomit medication and confirmed that he/she was enroute to the facility. At 8:27 AM, the hospice nurse arrived and performed a clinical assessment. R1’s oxygen saturation levels were noted to be below 90%. The nurse contacted R1’s family member/Power of Attorney (POA) to discuss the clinical findings. R1’s POA requested that R1 be transported to the hospital for further evaluation. At 8:40 AM, ambulance arrived at the facility. At 9:05 AM, the ambulance transported R1 from the facility to the hospital. On 05/07/2026, the department received copies of R1’s hospice agency records. R1’s hospice agency records indicate that on 04/03/2026 and 04/06/2026, R1 showed no signs or symptoms of infection during routine Skilled Nursing visits. On 04/08/2026, R1 required a Skilled Nursing visit due to vomiting and diarrhea. R1 denied pain but noted he/she was uncomfortable with shallow breathing. R1’s oxygen saturation was 90 and had a heart rate of 108. A staff noted R1 was more pale than usual. R1 was sent to the hospital for further evaluation. Page 2 of 3. During visit on 05/21/2026, LPA Marrufo interviewed staff S1-S3. S1 and S2 stated that they did not observe R1 experiencing any change in health condition prior to his/her hospitalization on 04/08/2026. S3 stated that he/she observed R1 having a cough two days before R1 was admitted into the hospital. S3 stated many of the residents and staff had also been coughing during that time. On 05/22/2026, LPA Marrufo conducted a telephone interview with staff S4. During interview, S4 stated he/she did not observe any change in R1’s health condition during the two days before R1 was hospitalized other than observing that R1 had a cough. This agency has investigated the complaint allegations listed. Based on interviews and review of records, the department has found that the complaint allegations are unfounded, meaning that the allegations were false, could not have happened, and/or are without a reasonable basis. This report was reviewed with Assistant Administrator Tyrone Vega and a copy of this report was provided. On 04/16/2026, the department obtained a copy of R1’s Appraisal/Needs and Services (ANS) Plan. The Needs subsection of the Physical/Health section of R1’s ANS states, “[R1] requires support with mobility, strength, and overall physical health, including assistance with daily activities due to his decreased strength and diabetes.” The Objective/Plan subsection of the Physical/Health section of R1’s ANS states, “Provide regular assistance, mobility support, and health monitoring to maintain [R1’s] strength, safety, and overall physical well-being.” The Person(s) Responsible for Implementation subsection of the Physical/Health section of R1’s ANS states, “Staff, Management.” During visit on 04/16/2026, LPA Marrufo obtained a copy of R1s Training Plan, dated 10/25/2023. The document states, “…the staff will be trained to identify symptoms of low and high blood sugar levels, actions to take should [he/she] experience hypoglycemia or hyperglycemia, and emergent conditions that warrant immediate Emergency Medical Assistance (911).” The document states, “Staff will also be able to: …Demonstrate through return demonstration the proper use of [R1’s] blood sugar monitor.” On 05/21/2026, LPA Marrufo interviewed staff S1-S3. During interview, S1 stated the staff are supposed to monitor R1’s glucose levels in the morning, but the pharmacy has not delivered R1’s test strips to check his/her glucose levels. S1 stated the staff have been calling the pharmacy for more test strips. During interview, S2 stated the staff used to measure R1’s glucose levels, but after R1’s updated Care Plan from September 2025, R1’s glucose levels no longer need to be measured. S2 stated R1’s Hospice Agency no longer provides the facility with test strips. During visit, LPA Marrufo obtained a copy of R1’s Blood Sugar Log Sheets from January, February, and April 2026. LPA Marrufo observed that some entry rows on the log stated, “No Strips” and some entry rows were blank. S2 stated he/she did not know why some entry rows were blank. S2 stated that although the staff no longer need to measure R1’s glucose and R1’s hospice agency no longer provides test strips, staff still write “No Strips” on the Blood Sugar Log Sheet to provide a record to Quality Assurance inspectors from San Andreas Regional Center (SARC). S2 stated that S4 has called R1’s Hospice Agency requesting more test strips, but R1’s Hospice Agency nurse stated R1 does not need test strips and is no longer eligible for test strips. Page 2 of 3. LPA Marrufo requested that S2 provide documentation from R1’s Hospice Agency indicating that the Hospice Agency had discontinued R1’s test strips. On 05/22/2026, LPA Marrufo received an email from S2 that included a Medication Order/Prescription Authorization Form for R1 from R1s Hospice Agency as an attachment. The Medication Order/Prescription Authorization Form stated, “Discontinue routine blood glucose checks and discontinue glucose test strips.” The Medication Order/Prescription Authorization Form is dated 05/21/2026. S3 stated during interview that he/she has been working at the facility for three months. S2 stated R1 does not have any test strips and no staff monitor R1’s glucose levels. On 05/22/2026, LPA Marrufo conducted a telephone interview with S4. S4 stated that he/she called R1’s Hospice Nurse last month to ask for test strips and R1’s Hospice Nurse told S4 that R1’s test strips were discontinued. S4 stated he/she remembers that R1’s test strips were discontinued since January 2026. LPA Marrufo made attempted telephone call interviews with R1’s Hospice Nurse on 05/22/2026 and 06/24/2026 and left a voicemail requesting a return phone call. LPA Marrufo was not able to reach R1’s Hospice Nurse for an interview. Based on information from interviews conducted with staff and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. No deficiencies were cited under California Code of Regulations Title 22 This report was reviewed with Assistant Administrator Tyrone Vega and a copy of this report was provided. Page 3 of 3. END REPORTthe state’s words, verbatim · CDSS document, Jun 24, 2026 · control 26-AS-20260415123051

Allegation investigated: Facility currently has only one operational toilet available for an approved 14 capacity due to overflowing septic. Facility did not report physical plant or maintenance issue at the facility to licensing which threatens resident's welfare, safety or health.

On 10/22/2025, the Department received a complaint with the above allegations. On 10/29/2025, LPA Marrufo conducted an initial complaint investigation visit. On 02/12/2026, LPA Marrufo conducted an additional complaint investigation visit. Allegation: Facility currently has only one operational toilet available for an approved 14 capacity due to overflowing septic. When the department received the complaint, it was alleged that the facility had a damaged septic system. See LIC9099-C pages for more information. Page 1 of 3. Substantiated Allegation: Facility did not report physical plant or maintenance issue at the facility to licensing which threatens resident's welfare, safety or health. When the department received the complaint, it was alleged that the facility had not reported that the facility had a damaged septic system for two months. On 10/28/2025, the department received an Unusual Incident/Injury Report (IR) from the facility. The IR was dated 10/28/2025 and stated that date of occurrence of the incident was 10/28/2025. The IR states, “On October 28, 2025, at approximately 9:00 AM, plumbing inspection and repair work began in the main bathroom of Rachelle’s Home I. The inspection was scheduled and confirmed by the facility’s maintenance. Due to the scope of the bathroom repair, residents were temporarily relocated to the other areas of the home to ensure safety and privacy during the work.” Based on records review, interviews, and observations there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegations are substantiated. See LIC9099-D for deficiencies cited as per the California Code of Regulations, Title 22. This report was reviewed with Assistant Administrator Tyrone Vega and a copy of this report and appeal rights were provided. Page 3 of 3. END REPORT During visit on 10/29/2025, LPA Marrufo toured the facility and observed two out of two resident bathrooms. One bathroom, on the left side of the facility, had a handwritten sign posted on the door that said, “Out of Order.” LPA toured the inside of the bathroom. During visit on 10/29/2025, LPA Marrufo interviewed staff S1-S3 and Licensee Rachelle Recinto. S1 stated that the left-side bathroom had been intermittently out of order for about a month. S2 stated that the left-side bathroom had become clogged shortly after he/she began working at the facility, but S2 did not specify a time. S3 stated the left-side bathroom had become clogged about a month prior and would go back and forth between being operable and inoperable. Licensee Rachelle Recinto stated the left-side bathroom had become clogged on 10/20/2025. Licensee stated the a repair appointment had been attempted but there was no availability. Licensee stated a facility maintenance staff had rented a “snake” and fixed the plumbing, but there was still a plumbing appointment that was scheduled. On 02/17/2026, LPA Marrufo obtained a copy of an invoice from a plumbing contractor. The invoice is dated 10/15/2025. The invoice identifies the address of the job as identical to the address of the facility. The invoice project description states, “Upon video inspection from 2-way cleanout [redacted] found old cast iron main sewer line towards building compromised by severe rust scale build up along interior walls of sewer pipe. [Redacted] will restore main sewer line by descaling, sanding and flushing all heavy rust scale out of sewer line. This will also include pulling toilet in 1 of 2 back to back bathrooms to descale sewer branch line to lateral sewer.” The invoice states Witness W1 was a technician on the project. On 04/09/2026, LPA Marrufo conducted a telephone interview with W1. During interview, W1 stated that he/she had been at the facility doing maintenance work and the facility staff told him/her that the bathroom on the left side of the facility had not been working for months. W1 stated he/she found that the left-side bathroom was not working. W1 stated he/she pulled out five gallon-sized buckets worth of wipes, which he/she stated should not be flushed down the toilet. W1 stated that the sewage line from the left bathroom probably had a blockage that had not been removed for multiple months. W1 stated that although rust build ups occur with aging cast iron pipes, blockages make the rust build ups worse. W1 stated the blockage could have been avoided by having the sewage pipes services when they became blocked. Page 2 of 3.the state’s words, verbatim · CDSS document, Apr 16, 2026 · control 26-AS-20251022113846

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(6) · Plan of correction due date: Apr 17, 2026

87303(e)(6) Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement was not met as evidenced by: Licensee did not ensure that 1 out of 2 facility toilets had a sewage line that was maintained in operating condition, which posed an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Apr 16, 2026

Plan of correction: Licensee shall submit a Plan of Correction by POC date of 04/17/2026 stating how the Licensee shall ensure that toilets, handwashing, and bathing facilities will be maintained in operating condition, including contracting a professional plumbing service when needed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 23, 2026

87211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: Licensee did not ensure that a report was furnished to the licensing agency regarding inoperability of one out of two facility toilets and its attached sewage line, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 16, 2026

Plan of correction: Licensee agrees to conduct in-service training with staff on ensuring that reports are made to the licensing agency for any incident which threatens the welfare, safety, or health of any resident, including reporting when a toilet or sewage line is no longer in operating condition. Once training is complete, the Licensee shall submit copies of training records, including names of staff trained, training dates, training topics, and names and qualifications of trainers by Plan of Correction due date of 04/23/2026.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Mylen Sumalde. During visit, LPA Marrufo obtained copies resident records. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Mylen Sumalde and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 12, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Tyrone Vega. During visit, LPA toured the facility inside and out. LPA toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the first aid kit and found it to be complete. LPA toured 9 out of 9 resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA tested the smoke and carbon monoxide detectors in the resident bedrooms, hallways, and dinning area and found them to function properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels. The water temperatures in the bathrooms measured from 108 F to 114 F. LPA toured the outside area of the facility and found the outdoor exit to be clear of obstructions. LPA reviewed five out of five resident records and found them to be complete. LPA reviewed 5 staff records and found them to be complete. See LIC809-C page for more information. Page 1 of 2. LPA Marrufo requests the following documents be updated and copies sent to the department by 12/23/2025: LIC500 Personnel Report LIC308 Designation of Administrative Responsibility Liability Insurance LIC610 Emergency Disaster Plan No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Tyrone Vega and a copy of this report was provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Dec 16, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management - Annual Continuation Visit and met with Office Manager, Yuly Romero. This annual inspection is a continuation of the annual visit that was conducted on 12/27/2024. LPA reviewed 9 client records. 9 out 9 client records contained emergency contact information, physician's reports and needs/service plans. LPA reviewed 5 staff records. 5 out of 5 staff records included background fingerprint clearance, health screenings with TB results, and staff training. S3, S4 and S5 did not include first aid certification. S5 record was unavailable for review. Staff stated S3, S4 and S5 obtained first aid certification and will submit copies to the department. Staff stated S5 record was not at the facility. LPA advised staff to ensure all staff files were available for inspection by the Department. During tour LPA measured water temperature at 116.3 degrees F for the facility. LPA observed damaged flooring in the hallway outside bedroom #1, and damaged blinds in bedroom #5, and dark spots on the ceiling of bathroom #1, and water damaged areas on the ceiling outside bedroom #1. Facility states maintenance was notified of the damaged areas on 12/30/2024 and is scheduled to repair on 1/7/2025. LPA advised staff that the facility should be in good repair at all times for the health and safety of clients in care. See LIC809-C LPA reviewed 9 out 9 Centrally Stored Medication and Destruction Records (CSMDRs). 9 out of 9 CSMDRs were observed to be complete with all medication documented. Deficiencies were cited during today's visit per California Code of Regulations Title 22. See LIC809-D for more information. An exit interview was conducted with Office Manager Yuly Romero and a signed copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 31, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80087(a) · Plan of correction due date: Jan 1, 2025

80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by: LPA observed damaged flooring in the hallway outside bedroom #1, and damaged blinds in bedroom #5, and dark spots on the ceiling of bathroom #1, and water damaged areas on the ceiling outside bedroom #1 which poses a safety risk to clients in care.the state’s words, verbatim · CDSS document, Dec 31, 2024

Plan of correction: Licensee states maintenance will be at the facility on 1/7/2025 to address the damaged flooring, damaged ceiling and damaged blinds bedroom #5 and dark sports on ceiling in bathroom #1. Licensee states the facility will conduct an in-service staff training by 1/10/2025, and submit documentation to CCL.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Marcella Tarin and Kenneth Madrigal conducted an unannounced annual inspection and met with Staff Yuly Romero. LPAs toured the interior and exterior of the facility with ADM to include the kitchen, office, client rooms, dining room, bathrooms, back and front of the facility. Facility thermostat temperature display was observed at degrees F. All exit and passageways were free and clear of obstruction. LPAs toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. LPA toured 8 resident bedrooms. 8 out of 8 resident bedrooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPAs toured 2 resident bathrooms. 2 out of 2 bathrooms had hand soap, paper towel, functioning lights, and covered trash bins. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM. Fire extinguishers were last serviced on 6/25/2024. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was on 9/12/2024. Drills are being conducted quarterly LPA reviewed 9 client records. Due to time constraints this annual inspection will need to be continued at a later date. No deficiencies were issued at this time. An exit interview was conducted with Office Manager, Yuly Romero and a copy of this signed report was provided.the state’s words, verbatim · CDSS document, Dec 27, 2024

Allegation investigated: Facility not following COVID 19 screening protocols for visitors. Staff spoke to resident inappropriately

Allegation: Facility not following COVID 19 screening protocols for visitors. Based on interviews and observation during the tour of the facility, the department observed COVID 19 screening protocols for visitors and staff. At the time of the complaint the facility was alleged to have not checked temperatures of staff or residents the department was unable to confirm or deny this based on the available infromation today. Allegation: Staff spoke to resident inappropriately. All staff interviewed denied witnessing or speaking to any of the residents inappropriately. Staff interviewed stated that the residents are treated with respect and dignity. The above allegations are unsubstantiated Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 19, 2024 · control 26-AS-20210806153730

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 31, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors This requirement not met as evidenced by photos taken and observation. LPA and staff observed ceramic roof tiles stored on the ground by the back fence, frames for patio furniture, a space heater, other miscellaneous items.the state’s words, verbatim · CDSS document, Oct 19, 2024

Plan of correction: The facility will clean the area and submit photo evidence to the LPA to confirm that the area is clean and free of debris by POC date 10/31/2024.

Allegation investigated: Facility staff did not administer prescribed medications to resident resulting in resident suffering pain. Facility did not notify hospice agency of resident's change in condition

On 10/19/2024, LPA Johnson arrived unannounced to deliver findings for the above allegations. LPA met with Magali and later joined by Alquin Gamab. Based on records review and interviews with current staff the department was unable to determine if R1 suffered as a result of the facility neglecting to notify the hospice agency about a change in condition. The alleged lack of notification could have contributed to R1 having trouble with pain referred to in this complaint. If there was discomfort or pain it could have been addressed by the hospice agency. The department could not confirm that the hospice agency was notified of the R1's change in condition, nor could the department from the review of records identify that R1 had a change of condition that would have warrant a call to the hospice agency. R1's condition on discharge from the skilled nursing facility to this care home on hospice was unmanaged right hip pain. The above allegations are unsubstantiated Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 19, 2024 · control 26-AS-20220404103902