Sage Villa

Allegation investigated: Staff not meeting the needs of residents with pressure injuries Staff are scratching residents Staff do not treat residents with dignity Residents are left in soiled diaper

Licensing Program Analyst (LPA) Nacole Patterson conducted a virtual visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Licensee Rina Chang. On 12/10/2021 it was alleged that staff did not meet the needs of residents with pressure injuries, staff scratched residents, staff did not treat residents with dignity, and residents were left in soiled diapers. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff interviews revealed that that no staff had observed a pressure injury on a resident outside of pre-existing conditions or hospice residents where minor pressure-related skin conditions were common and monitored by the hospice agency. Interviews revealed that the only resident observed to have scratches was known to scratch themselves and displayed combative behaviors resulting in minor injuries. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) Interviews further revealed that one resident was typically soiled in the mornings due to frequent urination, but was changed by staff at regular intervals. No staff observed another staff yelling at residents or treating them without dignity. Outside source interviews corroborated staff statements regarding residents on hospice care at the facility. Outside source interviews did not corroborate the allegations, as outside sources had not observed staff treating residents without dignity or neglecting their care. Outside sources stated that staff communicated resident needs and provided great care. Residents were not able to be verified as accurate historians for interview due to cognitive impairments. Review of relevant records revealed that certain residents had diagnosed behavioral disturbances, skin discoloration, diagnosed skin issues and/or rashes, edema, unsteadiness, and pre-existing skin tears and bruises. Resident care plans showed consistent expectations of staff to assist residents with incontinence, activities of daily living, and transfers. Body check logs showed that staff documented skin issues, rashes, redness, and skin conditions. No record evidence was found to corroborate the allegations. The evidence found does not support the allegations and shows that resident co-morbidities, behavioral and medical conditions contributed to the observed pressure injuries, bruises, and scratches. Evidence showed that some injuries/bruises existed prior to the resident moving into the facility. Due to lack of specifics regarding which allegations pertained to specific residents, correlation of abuse was not able to determined, if any. Resident records were consistent with staff statements regarding resident care. No evidence was found to show that staff did not provide the care required for each resident in their care plans, including incontinence care. Records also showed that five of six residents were being followed by either Hospice or Home Health. Evidence was not found to show that staff did not communicate care needs for any resident. Staff and outside source interviews did not corroborate the claim that staff yelled at residents. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Licensee Rina Chang, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 14, 2026 · control 08-AS-20211210155900

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to House Manager Beth Aquino. The facility's license shows a maximum capacity of six (6) residents ages 60 and over, three (3) of whom may be non-ambulatory. During today’s inspection there were six (6) residents in care. LPA, House Manager Beth Aquino, and Administrator Maria Rina Chang toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, 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 client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per House Manager Beth Aquino, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Maria Rina Chang, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 2, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to House Manager Beth Aquino. The facility's license shows a maximum capacity of six (6) residents. Three (3) non-ambulatory, of which three (3) may be bedridden. During today’s inspection there were 6 residents in care. LPA and House Manager Beth Aquino toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, 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 client activities. Facility contained 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. No toxic chemicals/poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed staff and client records/files. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Mary Jane Estiller to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 23, 2024