Santa Fe Home Care Homes

Type of visit: Required - 1 Year

On 09/05/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff Ma Nita Abuan. This facility is licensed to serve six adults ages 60 and above, of which four may be non-ambulatory residents. Rooms 1 & 4 are for ambulatory residents. Rooms 2 & 3 are for non-ambulatory residents. The facility is a one-story house located in a residential street. The home consists of 4 resident bedrooms, 1 staff bedroom, 2 ½ bathrooms, living room, kitchen/dining/tv room, attached garage, and front and backyard patio areas have shaded seating. Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Resident bedrooms had the required furniture and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Continue to LIC809-C. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew, a non-skid mat was in place, and hot water temperature properly measured at 112 degree F. Resident bath towels, toiletries, and personal hygiene supplies were adequately stocked. Common areas were clean, clear of hazards, and doorways were free of obstruction. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced September 16, 2024 was observed in the kitchen area. A Fire Prevention Inspection was conducted on 06/24/2025. Staff tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional. Five staff records were reviewed, five out of five staff records had required criminal record clearances or criminal record exemptions. Five resident records were reviewed, five out of five resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed. An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Staff Ma Nita Abuan.the state’s words, verbatim · CDSS document, Sep 5, 2025

Type of visit: Case Management - Other

On 07/30/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced case management – other visit and met with Staff and explained the purpose of this visit. The purpose of this visit is in association with the noncompliance conference (NCC) meeting on 11/24/2024 involving Community Care Licensing and the Licensee. The facility is licensed to serve four (4) non-ambulatory residents and two (2) ambulatory residents age 60 and over. Rooms #1 and #4 are for ambulatory residents and rooms #2 and #3 are for non-ambulatory residents. During today's visit, LPA reviewed three staff records. LPA spoke with Administrator Designee Charesa Reyes over the phone. No deficiencies observed. An exit interview was conducted and a copy of this report was provided to Caregiver Manita Abuan.the state’s words, verbatim · CDSS document, Jul 30, 2025

Type of visit: Case Management - Deficiencies

On 06/24/25, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced case management – deficiency and met with Staff and explained the purpose of this visit. The purpose of this visit is to issue a deficiency observed on 06/19/25 and during today’s visit. On 06/19/25, Licensing Program Analyst (LPA) Regina Cloyd conducted a Case Management - Other visit in association with the noncompliance conference (NCC) with the Licensee on 11/24/2024. The facility is licensed to serve four (4) non-ambulatory residents and two (2) ambulatory residents age 60 and over. Rooms #1 and #4 are for ambulatory residents and rooms #2 and #3 are for non-ambulatory residents. On 06/19/25, record review of medical assessments for R1 – R4, R6 revealed that the residents are non-ambulatory. R2 was the fifth non-ambulatory resident admitted to the facility on 06/01/25. On 06/19/25 and today, LPA observed five (5) non-ambulatory residents (R1 – R4, R6). Deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. An immediate civil penalty of $500 is issued. An exit interview was conducted, plans of correction developed, and a copy of this report and appeal rights was discussed with Administrator Designee Charesa Reyes over the phone. A hard copy of this report was left with Staff Maria Nita.the state’s words, verbatim · CDSS document, Jun 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Jun 25, 2025

(a) All facilities shall maintain a fire clearance approved by... Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance... This requirement was not met as evidence by Based on record review and observation, the facility is approved to serve four non-ambulatory residents. Licensee accepted R2 as the fifth non-ambulatory resident on 06/01/25 without obtaining an appropriate fire clearance. This poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 24, 2025

Plan of correction: The Licensee agree to obtain a fire clearance to increase the non-ambulatory capacity from four to five residents. The Licensee will create a plan, indicating specific steps to be taken by staff, based on the Fire Marshal’s guidance to ensure the residents’ safety.

Type of visit: Case Management - Other

On 06/19/25, Licensing Program Analyst (LPA) Regina Cloyd conducted a Case Management - Other visit at this facility. LPA met with Staff who allowed for entry in this facility. LPA informed Staff the purpose of the visit is to conduct a case management - other visit in association with the noncompliance conference (NCC) with the Licensee on 11/24/2024. Administrator Designee Charesa Reyes joined later. The facility is licensed to serve four (4) non-ambulatory residents and two (2) ambulatory residents age 60 and over. Rooms #1 and #4 are for ambulatory residents and rooms #2 and #3 are for non-ambulatory residents. During today's visit, LPA Cloyd toured rooms one and four and reviewed facility records, three staff records, and six resident records. Deficiencies are being cited based on observations, record reviews, and interviews in accordance with the California Code of Regulations, Title 22, see LIC809D. Civil Penalties will also be issued today. Register of Facility Residents indicated the Resident #1 (R1) is non-ambulatory and lives in room #1 (for ambulatory residents only). R1's medical assessment (03/13/25) reveals resident to be bedridden. LPA observed R1 in hospital bed. Continue to LIC809-C. Register of Facility Residents indicate the Resident #2 (R2) is ambulatory and lives in room #1 (for ambulatory resident only). R2's medical assessment (03/17/25) indicated R2 as non-ambulatory. R2 was admitted to the facility on 03/18/25. LPA observed R2's bed in room #1. Register of Facility Residents indicate that Resident #3 (R3) is non-ambulatory and lives in room #4 (for ambulatory residents only). R3's medical assessment (05/30/25) reveals resident to be non-ambulatory. LPA observed R3 in room #4. R3's Home Health Plan of Care (06/01/25 - 07/30/25) indicate R3 has a stage 3 wound. R3 was admitted to the facility on 06/01/25. As of 06/19/25, the Administrator Designee indicated that the wound is healed and Home Health will send an updated report in a few days. Administrator Designee indicated R3 is not on hospice. The facility did not have an exception request (for prohibited health condition) as specified on 87209 Program Flexibility. Resident #4's (R4) Home Health Medication Profile (05/25/25 - 07/23/25) indicate R4 has a stage 4 ulcer on the right medial heel. R4 was admitted to the facility on 09/28/2017. Wound Specialist/Nurse Practitioner indicated that on 05/05/25, the unstageable wound was open and reclassified as stage 4. As of 06/19/25, the wound is still a stage 4. Administrator Designee indicated that R4 is not on hospice. The facility does not have an exception request (for prohibited health condition) as specified on 87209 Program Flexibility. LPA reviewed three staff records and record review revealed Staff #2 (S2) was at the facility and not associated to the facility. S2 is listed on the Personnel Report dated 06/04/2025. This warrants a $500 civil penalty. See LIC421BG. Continue to LIC809-C. In addition to deficiencies cited, LPA will cite the Administrator (S1) for Administrator Qualifications 87405(d)(2) for not having knowledge and ability to conform to Title 22 Regulations on Limitations - Capacity and Ambulatory Status, Prohibited Health Conditions, and Criminal Record Clearance. LPA reminded the Administrator Designee that a deficiency for Limitations - Capacity and Ambulatory Status was issued on 08/02/2024; therefore, warranting an immediate $250 civil penalty. See LIC421IM. An exit interview was conducted, plans of correction were developed and reviewed, and a copy of this report with appeal rights was provided to the Administrator Designee Charesa Reyes.the state’s words, verbatim · CDSS document, Jun 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(b) · Plan of correction due date: Jun 20, 2025

87204(b) Limitations - Capacity and Ambulatory Status (b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. This requirement was not met by evidence of: During record review, interviews, and observation, R1, R2, and R3 are non-ambulatory and live in ambulatory rooms (#1 and #4). This poses a potential safety risk to residents in care. This is a repeated violation issued on 08/02/2024.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: The Licensee wil email evidence of corrections to regina.cloyd@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87615(a)(1) · Plan of correction due date: Jun 24, 2025

87615(a)(1) Prohibited Health Conditions (a) Persons who require health services for or have a health condition including... shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met by evidence: During record review and interviews, R3 and R4 have stage 3 injuries upon admission/retention. The facility does not have a program exception request as specified in 87209 Program Flexbility. This poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: The Licensee will email a plan of correction to regina.cloyd@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jun 24, 2025

87355(e)(3) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement was not met as evidence by: Record review of Guardian revealed that Staff #2 (S2) was not associated to the facility. This poses a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: The Licensee will email plan of correction to regina.cloyd@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(2) · Plan of correction due date: Jun 24, 2025

Administrator - Qualifications and Duties (d) The administrator shall have... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidence by: Based on interviews and record review, the Administrator (S1) was cited for Regulations on Limitations - Capacity and Ambulatory Status, Prohibited Health Conditions, and Criminal Record Clearance. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: The Licensee will email plan of correction to regina.cloyd@dss.ca.gov by the POC due date.

Allegation investigated: Staff did not provide an itemized receipt to resident for care services rendered

On June 4, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted a complaint visit regarding the above allegation. LPA Lee met with Charesa Reyes Administrator designee, and explained the reason for the visit. LPA spoke with Licensee Angelique Gradney via telephone who stated that Charesa will be the point person to provide any information needed for the investigation. The investigation consisted of the following: On June 4, 2025, LPA obtained and reviewed the following: staff roster (date 4/1/25), resident's roster (dated 6/1/25), Resident Appraisal for R1 (dated 3/12/25), Need and Services Plan for R1 (dated 3/12/25), Physician's Report for Residential Care for the Elderly (RCFE) for R1(dated 3/10/25), R1" signed personal rights LIC 613C (dated 3/12/25), signed Consent to a Medical Examination form (dated 3/12/25), Admission Agreement (dated 3/12/25), LPA reviewed R1 file. LPA conducted 1 staff interview—Administrator Designee (A1). page 1 of 2 Substantiated Investigation revealed the following: Allegation: Staff did not provide an itemized receipt to resident for care services rendered. The complaint alleges that "R1 paid a total amount of $10,500.00 for 1 ¾ months stay (3/12/25-5/3/25) and never received an itemized receipt for care services rendered." On 6/4/25 at 10:42am, LPA interviewed Administrator Designee (A1), Charesa Reyes who did not deny the allegation. A1 admitted that R1 was not provided an itemized receipt for her stay at the facility (3/12/25-5/3/25). Based on LPAs interview and the review of records, 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 Copy of appeals rights and report provided to Charesa Reyes, Administrator Designee. Page 2 of 2 Investigation revealed the following: Allegation: Staff did not conduct a proper assessment of resident The complaint alleges that that R1 never got an assessment. On 6/4/25 at 10:42am, LPA interviewed Administrator Designee (A1), Charesa Reyes who denied allegation stating that R1 received a proper medical assessment including residential appraisal and Need and Services Plan. On 6/4/25, LPA reviewed Physician's Report for Residential Care for the Elderly (RCFE) for R1(dated 3/10/25), Resident Appraisal for R1 (dated 3/12/25), Need and Services Plan for R1 (dated 3/12/25). The medical assessment LIC 602 was completed signed and dated. Based on the information gathered, there is insufficient evidence to support the stated allegation. Although the allegation 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 UNSUBSTANCIATED. There were no deficiencies cited during today's visit. Exit interview conducted and report provided to Charesa Reyes, Administrator Designee. Page 2 of 2the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 11-AS-20250528092349

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a)(3) · Plan of correction due date: Jun 11, 2025

87208 (a)(3) Plan of Operation The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. (3) Statement of admission policies and procedures regarding acceptance of persons for services. This requirement was not met as evidenced by Based on record review and interviews, the licensee did not follow the payment provision section of their Plan of Operation by not providing R1 with an itemized receipt and billing statement upon receipt of payment which poses a potential Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 4, 2025

Plan of correction: Administrator designee will submitt a written plan to LPA Deborah.Lee@dss.ca.gov via email by POC date 6/11/25 indicating how they will ensure future compliance of providing itemized receipts for residents upon receipt of payments.

Allegation investigated: Resident sustained bed sores due to staff neglect. Staff hit resident. Staff are not safeguarding resident's personal belongings. Staff are not providing adequate food service to residents. Staff did not provide resident with a 60day rent increase notice. Staff are threatening resident. Staff did not ensure resident's wheelchair was in good repair.

**This report supersedes the previous report dated 2/16/24 to correct the order of pages for the complaint report. ** On 3/7/25, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced subsequent complaint visit to amend the complaint to correct the order of the pages. LPA was met by Christian Espino, Caregiver, and the purpose of the visit was explained. On 02/16/2024 at 08:08 am Licensing Program Analyst (LPA) David España conducted an unannounced complaint investigation visit for the allegation listed above. LPA met with Administrator, Catherine Espino and the purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access. Page 1 of 6 Unsubstantiated The investigation consisted of the following: An initial complaint visit was completed by LPA David España on 02/16/2024. A subsequent visit was completed by LPA Perry Scott on 3/7/2025. On 02/16/2024 LPA requested copies of the following: Resident's medical records, including diagnosis and treatment of pressure sores. Documentation of care provided by appropriately skilled professionals. Records of staff training on pressure sore prevention and care. Resident's care plan and daily care logs. Incident reports. Staff disciplinary records. Resident's medical records documenting any injuries. Facility policies on abuse prevention and reporting. Resident's personal property inventory. Facility policies on safeguarding residents' belongings. Staff training records on resident rights and property protection. Any reports of missing items. Meal plans and menus. Food service logs. Dietary requirements for residents. Staff training records on food service and nutrition. Copies of rent increase notices. Facility policies on rent increases and notifications. Resident's admission agreement. Communication logs with residents or their representatives. Facility policies on resident rights and staff conduct. Maintenance logs for resident mobility devices. Inspection records for wheelchairs and other mobility devices. Resident's care plan addressing mobility needs. Staff training records on equipment maintenance and safety. LPA España interviewed Resident 1- Resident 3 (R1-R3) and Staff 1 - Staff 4 (S1-S4). Investigation revealed the following: Allegation #1: Resident sustained bed sores due to staff neglect. On 02/16/2024, LPA España interviewed Resident 1 - Resident 3 (R1-R3) regarding the allegation. Of those interviewed, 1 of 3 residents stated they had no bed sores, the other two did not answer the question. On 02/16/2024, LPA España interviewed Staff 1-Staff 4 (S1-S4). 3 out of 4 staff disagreed with the allegation of neglect leading to bed sores. On 2/16/2024 LPA Espana reviewed records for four facility residents and found no indication of any residents being treated for bedsores. Page 2 of 6 Continued On LIC9099-C Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Allegation #2: Staff hit resident. On 02/16/2024 LPA España interviewed Resident 1 - Resident 3 (R1-R3). Of those interviewed, 3 out of 3 residents denied the allegation. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). 3 out of 4 staff members denied the allegation. On 02/16/2024 LPA España reviewed facility records and found no Unusual Incident/ Injury regarding staff hitting residents. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Allegation #3: Staff are not safeguarding resident's personal belongings. On 02/16/2024 LPA España interviewed Resident 1 - Resident 3 (R1-R3). Of those interviewed, 2 out of 3 denied the allegation. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, 2 out of 4 denied the allegation and the other two indicated they had insufficient knowledge to answer, as they were newer employees to the facility. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Page 3 of 6 Continued On LIC9099-C Allegation #4: Staff are not providing adequate food service to residents. On 02/16/2024 LPA España noted that the facility had a weeks’ worth of non-perishables and two days’ worth of perishable food items. A review of the weekly menu shows residents receive three meals and snacks daily. On 02/16/2024 LPA España observed residents eating a breakfast of toast, jam, and eggs, which aligned with the posted weekly menu. On 02/16/2024 LPA España interviewed Resident 1 - Resident 3 (R1-R3). Of those interviewed 2 out of 3 denied the allegation. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, 4 out of 4 denied the allegation. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Allegation #5: Staff did not provide resident with a 60-day rent increase notice. On 02/16/2024 LPA España reviewed facility records and observed a rate increase notice dated 60 days before the effective date. Interview with Administrator Catherine Espino revealed that facility is supposed to provide increase notices to residents in writing. Administrator also added that it is part of the admissions contact which is signed by residents and families. On 02/16/2024 LPA España interviewed Residents 1-3 residents (R1-R3). Of those interviewed, 2 out of 3 were aware of a rent increase, but only one spoke about when it was received, stating they had only recently been told, but that family would know more. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, one denied the allegation and the other three were unaware of rent increases. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Page 4 of 6 Continued On LIC9099-C Allegation #6: Staff are threatening resident. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, 4 out of 4 denied the allegation, with one adding that such behavior is not tolerated and is a personal rights violation. On 02/16/2024 LPA España interviewed Residents 1-3 residents (R1-R3). Of those interviewed, 2 out of 3 denied the allegation while one did not answer the question. LPA España facility records and found no incidents reports for the 30-day period reviewed related to any threats. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Allegation #7: Staff did not ensure resident's wheelchair was in good repair. On 02/16/2024, LPA España reviewed facility records which show that three resident use wheelchairs for mobility. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, 4 out of 4 reported no issue with resident’s wheelchairs. Interview with Administrator Catherine Espino revealed that most of the time medical equipment is provided by home health and any issues are reported to them. Further, S1-S4 stated that residents have no problems using or accessing their wheelchair in the facility. LPA interviewed the Administrator who stated that the facility’s best practices for wheelchair maintenance are as follows and staff ensures the wheelchairs are in good repair: The facility implements a regular cleaning schedule, wiping down the wheelchair with a damp cloth weekly to remove dirt and debris. Page 5 of 6 Continued On LIC9099-C Perform weekly brake checks to ensure they are operating properly and engaging/releasing correctly. Inspect tire pressure regularly and adjust as needed, rechecking brake function after any pressure changes. Train staff on basic wheelchair inspection and maintenance procedures to identify problems early. Keep a maintenance log to track regular upkeep and any repairs needed. On 02/16/2024 LPA España interviewed residents 1-3 residents (R1-R3). 2 out of 3 residents stated staff were good at moving bedridden and wheelchair-using residents. 2 out of 3 residents see other residents being moved throughout the day but couldn't specify how often. 2 out of 3 residents stated that other residents who can't walk are moved regularly with staff help. 2 out of 3 residents stated that staff move these residents, and they are seen in different locations during the day. 2 out of 3 residents stated residents who can't walk are moved regularly with staff help. 2 out of 3 residents stated staff move residents, and they are seen in different locations during the day. LPA reviewed documentation of resident council meetings or other forums where residents may have voiced concerns. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. Based on interviews, observations, and records reviewed, there is insufficient evidence to support the allegations that 1. "Resident sustained bed sores due to staff neglect," 2. "Staff hit resident. 3."Staff are not safeguarding resident's personal belongings," 4."Staff are not providing adequate food service to residents," 5. "Staff did not provide resident with a 60-day rent increase notice," 6. "Staff are threatening resident," and 7. "Staff did not ensure resident's wheelchair was in good repair." Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore all allegations are Unsubstantiated. There were no deficiencies issued. An exit interview was conducted, and a copy of this report provided to Christian Espino, Caregiver. Page 6 of 6the state’s words, verbatim · CDSS document, Mar 7, 2025 · control 11-AS-20240209103510

Type of visit: Case Management - Health Checks

On 09/26/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a Case Management visit at this facility. LPA met with caregiver Christian Espino who allowed for entry in this facility. LPA informed Espino the purpose of the visit is to conduct a health and safety check in association with the annual inspection visit conducted on 08/02/24. In the annual inspection conducted on 08/02/24, Licensing Program Analyst (LPA) Regina Cloyd observed (2) out of the (4) residents did not occupy the proper rooms for non-ambulatory or/ambulatory. Resident #1 who is non-ambulatory was in an ambulatory room. Resident #3 is ambulatory and was in a non-ambulatory room. The facility was not compliant and was issued a citation under Title 22 Regulation 87204(b). LPA Dabuet conducted a health and safety check and observed Resident #1 now resides in a non-ambulatory room #2. Resident #3 is no longer a resident at the facility. During the inspection, LPA Dabuet reviewed Resident #1 and Resident #2 Physician's Report LIC 602A (dated: 02/22/22 and 02/16/23). Resident #1 (R1) is non-ambulatory requires continuous bed care, is bladder/bowel impairment, and requires assistance with toileting needs. According to the LIC 500 Personnel Report (dated: 02/01/24) and staff #1's interview, no staff worked after 8:00 pm until 7:00 am. It was revealed that there are no night-shift workers at the facility to provide the services necessary to meet resident needs. Based on observations, interviews, and record reviews, a preponderance of evidence standard has been met. The facility did not have night shift worker to provide services necessary to meet resident needs. Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 809-D. An exit interview was conducted with Christian Espino, and a hard copy of the report along with appeal rights.the state’s words, verbatim · CDSS document, Sep 26, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 10, 2024

87411 - Personnel Requirements - General (a) Facility personnel shall...be sufficient in numbers...to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary..The licensing agency may require...staff..needs of the particular residents, the extent of services provided...adequate services. This has not been met as evidenced by: Based on record review/interview (R1) requires continious bed care who is bladder/bowel incontinent. Facility did not have a night staff to meet (R1)'s needs after 7pm. This violation which poses a potential health and safety to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Licensee/Administrator have agreed to hire an overnight staff in order to attend to residents' needs while in care. Administrator will send an updated LIC500 to LPA Dabuet, via email, at Ernand.Dabuet@dss.ca.gov

Type of visit: Required - 1 Year

On 08/02/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff Christian Espino. Backup Administrator Catherine Espino joined us later. This facility is licensed to serve 6 adults ages 60 and above, of which 2 may be non-ambulatory residents. Rooms 1 & 4 are for ambulatory residents. Rooms 2 & 3 are for non-ambulatory residents. A total of 4 residents are currently residing in this facility, of which 2 are ambulatory and 2 is non-ambulatory. The facility is a one-story house located on a residential street. The home consists of 4 resident bedrooms, 2 staff bedrooms, 1 ensuite bedroom (bedroom is connected to its own bathroom), 1 bathroom, 1 toilet room, 1 living room, 1 kitchen/dining/tv room, 1 attached garage, and front and backyard patio areas have shaded seating. Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Resident bedrooms had the required furniture and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Continue to LIC809-C. Resident bathrooms were checked. Grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, and hot water temperature properly measured at 105.2 degree F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced August 11, 2023 was observed in the kitchen area. Staff tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional. 5 staff records were reviewed, 5 out of 5 staff records had required criminal record clearances or criminal record exemptions. 4 resident records were reviewed and, 4 out of 4 residents' records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed. Deficiencies are being cited based on LPA observations in accordance with the California Code of Regulations, Title 22, see LIC809D. LPA Cloyd observed vermin in the kitchen cabinet near the cereal and on the baseboard in the dining room. Continue to LIC809-C. LPA Cloyd observed a nonambulatory resident #2 in an ambulatory room #1. An exit interview was conducted, plans of correction developed, and a copy of this report and appeals was discussed and left with Backup Administrator Catherine D Espino.the state’s words, verbatim · CDSS document, Aug 2, 2024

Allegation investigated: Illegal Eviction

On 05/19/24, Licensing Program Analyst (LPA) Ernand Dabuet made a subsequent unannounced visit to this facility and was greeted by caregiver staff #1 (S3) Christian Espino. LPA Dabuet met with Anqelic Gradney who was able to present for this visit. LPA explained the purpose of today’s visit is to gather information for the allegation mentioned above and deliver findings. The investigation consisted of the following: (LPA) Dabuet requested copies of files for resident #1 (R1)’s Admissions Agreement (dated: 08/10/23), Physicians Report LIC 602A (dated: 08/30/23), Register of Facility Residents LIC 9020 (dated: 02/01/24), and other documents associated with the complaint. Interviews were staff #1-#2 (S1-S2), and resident #1 (R1). A Collateral visit to Golden Senior Assisted Living II. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Illegal Eviction. It is alleged that resident #1 (R1) was illegally evicted from this facility. The complainant reported (R1) was admitted at Kaiser Permanente on 06/12/24 due to concerns with wounds. (R1) was evaluated, treated, and deemed safe for discharge. (R1) was not found to require a higher level of care. The hospital wound care specialist and Registered Nurse determined no infection, and the wounds were not open and appeared to be healing. The complainant reported the administrator declined to accept (R1) back to the facility and stated (R1) required a higher level of care due to the wounds. According to resident #1 (R1)’s Admissions Agreement (dated: 08/10/23), (R1) was admitted to Santa Fe Home Care effective 08/10/23. Physicians Report LIC 624A (dated: 08/30/23) is non-ambulatory unable to self-care and requires assistance with assisted daily living (ADL). (R1) was under home health care for wound care with Human Touch Home Health Care from (May 2023 through October 2023). An Unusual Incident Report LIC 624 (dated: 06/17/24) indicated nurse from Quality Home Health reported that (R1) has a bed sore and recommended that (R1) be evaluated at the hospital due to the bed sore and high level of care. (R1) was transported and admitted to Kaiser Permanente Medical Center Emergency Department on 06/12/24 for a wound problem. Kaiser Permanente medical records (dated: 06/19/24) revealed that sores were cleaned and treated with no indication of Stage 3 or 4 pressure injuries that are classified as a prohibited health condition and that (R1) would require a higher level of care. (R1) was authorized discharge with home health assistance by the hospital. Investigation revealed (R1) was discharged on 06/14/24 from the hospital and was admitted to Golden Senior Assisted Living II and not Santa Fe Care Homes. (R1) was admitted to Golden Senior Assisted Living II on 06/14/24. On 06/17/24, (R1) was transported and readmitted to Kaiser Permanente Medical Center Emergency Department and has remained at the hospital waiting for discharge. On 06/17/24 between 03:00 pm – 03:14 pm, the Department interviewed resident #1 (R1) verified being admitted at Golden Assisted Living and not Santa Fe where (R1) preferred to reside. (Evaluation Report continues LIC 9099-C) (R1) claimed not to have agreed with management for this move. (R1) is unaware of why (R1) was sent back to the hospital and why (R1) has not been released back to the facility. (R1) claimed the bed sores were healing and verified that (R1) was on home health for wound care. On 06/19/24 between 10:30 am – 12:00 pm, the Department interviewed (2) out of (2) staff #1 - #2 who verified the reason for (R1) requiring medical emergency assistance at Kaiser Permanente Medical on 06/12/24 and 06/17/24. (S1) claimed that (R1) needed wound assessment for (R1)’s bedsores. (S1) claimed that (R1) required a higher level of care but did not receive medical evaluation from the hospital that (R1) had prohibited health conditions that would prevent (R1) to return at Santa Fe Care Home. (S2) indicated that (R1) exhibited contentious behavior that law enforcement was dispatched on 06/16/24, and it was deemed that (R1) required psychological assessment at the hospital. (S2) claimed that (R1) exhibited challenging behaviors in the past at Santa Fe Care Homes and that (R1) would benefit from a skilled nursing facility. (S2) expressed that (R1) had received an Eviction Notice from Santa Fe Home but was not able to provide a copy of the notice sent to Community Care Licensing for approval. (S2) had refused to accept (R1) to return to the facility based on the conditions for eviction that (R1) requires a higher level of care. Medical records indicated (R1) psychiatric behavior is normal. On 06/19/24 between 10:30 am – 12:00 pm, the Department interviewed (2) out of (2) residents #2 - #3 at Golden Assisted Living both verified that (R1) did not cause any disruption at the facility and did not observe (R1) in exhibited unsafe behavior toward staff or residents. Based on the information provided the facility failed to provide to (CCL) confirmation receipt that an Eviction Notice was sent. The El Segundo Regional Office (CCL) had no records on file. The facility failed to follow up with (CCL) for approval as written in Title 22 Regulations Section 87224 Eviction Procedures. (S1-S2) failed to follow up and contact the Department to inform an Eviction Notice was issued to (R1). (S2) failed to provide a copy of the notice. Interviews and records reviews support the above allegation. Based on the Department's observation and interviews, records reviews, and analysis, the preponderance of evidence standard has been met, therefore the allegation of “Illegal Eviction" is Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D. An exit interview was conducted with Anqelic Gradney. The Rights were discussed with Anqelic Gradney and a copy of Appeals Procedures for Licensees was provided, as well as a copy of this report.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 11-AS-20240617085500

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(b) · Plan of correction due date: Jun 21, 2024

87224(b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good safety... mental and/or physical health or safety of others in the facility. Use. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or… This requirement is not met as evidenced by: Based on interviews and record reviews. The facility failed to properly inform CCLD of an Eviction for (R1) and failed to provide evidence of notice submitted. The notice is not valid unless CCLD approves. This violation posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jun 19, 2024

Plan of correction: Licensee is to review Title 22 Regulation Section 87244 and resubmit a written statement to CCL to indicate it was reviewed and understood. Licensee will readmit (R1) back at the facility or submit a Plan to the Department on how to be in compliance with Title 22 Regulaitons by POC must be sent by fax to 424-544-1016 by 06/21/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(1)(2) · Plan of correction due date: Jun 28, 2024

87405 Administrator – Qualifications and Duties (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on interviews and record reviews. The licensee evicted (R1) illegally without proper consent from CCL. This violation posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jun 19, 2024

Plan of correction: Licensee is to review Title 22 Regulation Section 8405 and resubmit a written statement to CCL to indicate it was reviewed and understood and submit by POC must be sent to LPA Dabuet at fax to 424-544-1016 by 06/21/24.

Allegation investigated: Staff did not ensure that resident exited the facility supervised

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Wednesday, June 19, 2024, Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met Licensee Angelique Gradney. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: Interviews were conducted with staff members 1-2 (S1-S2) and residents 1-2 (R1-R2). LPA Bunker was unable to interview residents 3-4 (R3-R4) due to their non-verbal status. S1-S2 stated residents are provided with care and supervision 24 hours a day, 7 days a week, 365 days a year. S1-S2 noted the facility has a live-in staff that is always on duty. S1-S2 and R1-R2 confirmed that this is not a locked facility and that residents are permitted to go out into the community. S1-S2 stated on Friday, June 7, 2024, resident signed out to go for a walk at 2:00 P.M., and returned at 2:10 P.M. The following morning, on Saturday, June 8, 2024, a neighbor came knocking on the front door and ringing the doorbell. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 The neighbor reported that one of their residents was outside by himself and threw a dirty adult diaper into her front yard, as well as into another neighbor's front yard. S1-S2 stated residents have personal rights and that staff could not have prevented the resident from leaving the diaper behind. However, staff is willing to dispose of the diaper and ensure the neighbor that such incidents do not occur in the future. Staff 2 Christian Espino and LPA Bunker toured the entire facility to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. No signs of neglect or abuse were observed during today's visit. LPA Bunker requested and reviewed residents' records, including sign-in/out log sheets, incident report, admission agreements, appraisal & needs service plans, physician's reports, progress notes, I.D., and emergency information. Licensee Angelique provided LPA Bunker with copies of supporting documents. Allegation: Staff did not ensure that resident exited the facility supervised Interviews with Staff 1-2 (S1-S2) and residents 1-2 (R1-R2) revealed that residents are allowed to exit the facility unsupervised as this is not a locked facility. S1-S2 and R1-R2 stated residents sign in and out and are allowed to go into the community when they leave the facility. S1-S2 stated staff are trained and competent to provide care and supervision to meet the resident's needs. S1 stated staff is receiving ongoing training. S1-S2 and R1-R2 stated staff are always aware of residents' whereabouts when a resident leaves the facility. They also stated that residents always wear shoes and do not go outside barefoot. S2 stated he never told the neighbor that residents are not allowed outside by themselves. S2 stated he mentioned that the resident has PTSD and is a war veteran. S2 stated he never told the neighbor resident was aggressive. S1-S2 stated this is a 24-hour care facility that operates, 7 days a week, 365 days a year 24 hours a day, ensuring that residents are never left at the facility alone without supervision. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Investigation revealed the following: Staff 1-2 (S1-S2) stated as a 24/7 operation, staff is available around the clock, every day of the year, guaranteeing that residents are never left unattended Residents 1-2 (R1-R2) stated staff is always available to assist residents and they were happy living at the facility. S1-S2 and R1-R2 stated staff is providing comfortable accommodations for the residents. S1-S2 stated their staff is a dedicated team providing the necessary care and supervision to ensure the safety of all residents. Staff stated that since the resident had signed out, they were unaware of the incident involving the dirty adult diaper and had no control over the resident's actions. S1-S2 reported counseling the resident and explaining throwing diapers in the neighbor's yard is unacceptable. The resident explained that he couldn't find a trash can but agreed to use the facility's trash can in the future. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation 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 deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to the Licensee/Administrator Angelique Gradney. There were no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 11-AS-20240611161313

Allegation investigated: Staff neglected resident resulting in resident sustaining pressure injuries. Staff neglected resident resulting in dehydration. Staff neglected resident resulting in malnutrition. Staff left resident soiled for an extended period of time.

Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by a caregiver (S2: Christian Espino). LPA conducted a risk assessment before entering the facility and observed the COVID-19 protocol. S2 informed LPA that the facility has no COVID cases nor do residents or staff have symptoms. The purpose of today’s visit is to conduct a subsequent visit to deliver the findings about the above-mentioned allegation(s). LPA contacted Administrator Angelique Gradney who could not be present for this visit, authorized Christian Espino to sign for this complaint report. The investigation consisted of the following: A 24-hour visit for health and safety check of residents in care was conducted by LPA Jeremiah Randle on 10/25/22. LPA was met by Staff #1 (S1: Rey Malit, Caregiver); as the Administrator (A1: Angelique Gradney) and Asst. Administrator (A2: Catherine Espino were unavailable. LPA conducted a tour of the facility’s physical plant and spoke to residents in care (R1-R3) and observed them sitting in the common areas with no signs of distress. (Evaluation Report continues LIC 9099-C) Unsubstantiated LPA requested pertinent documents related to the above-mentioned allegation(s): facility staff roster & work schedules (September 2022), residents’ roster (October 2022), weekly menu and photos of meals (October 2022), facility staff in-service training records (dated 07/05/22) regarding Care for Dementia, Direct Care staff, and Personal Rights; Resident #1’s face sheet, admission agreement (dated 08/30/22), physician’s report (dated 08/26/22), appraisal/needs and services plan (dated 08/30/22), medication records (09/29/22), Allied Hospice Care records (dated 09/28/22), hospice flow chart with sign-in/sign-out sheet (dated 09/29/22, 09/30/22, 10/19/22), and Kaiser Permanente Medical Nutritional Therapy Assessment (dated 10/24/22). This complaint investigation was referred to the California Department of Social Services (CDSS), Community Care Licensing Division (CCLD), Investigations Bureau (IB) and assigned to Investigator Laura Garcia. It included a review of Resident #1’s medical records from Kaiser Permanente Medical Center (dated 10/21/22); interviews with facility staff (A1, S1), residents (R1 – R3), witnesses (W1 – W5) from local law enforcement agency (Torrance Police Dept), hospital personnel (Kaiser Permanente), and hospice staff (Allied Hospice Care). After several attempts to contact Witness #3 (Palliative Physician), Witness #4 (KP Physician), and Witness #5 (Kaiser Permanente Social Worker); to date, no contact was made possible. Attempted interviews with residents (R1 – R3) were not possible due to their cognitive disorders and inability to answer questions. Resident #4 was unavailable for an interview due to their hospitalization. INVESTIGATION REVEALED THE FOLLOWING: Regarding Allegation #1: this investigation revealed that Resident #4 belonged to a Permanent Housing Program for the Elderly under Kaiser Permanente. The resident was under hospice care (effective 09/28/22); specifically for palliative care and comfort while at the facility. Resident #4 was medically re-assessed by the registered nurse (Witness #1) who visited the facility every other day and would evaluate Resident #1 for any type of food/fluid intake. RN suggested to facility staff to continue offerings of liquids and meals; of which, facility staff complied with the hospice nurse’s directives. Based on the evidence gathered and interviews conducted, and records reviewed, although the allegation 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 of NEGLECT/LACK OF SUPERVISION: Staff neglected resident resulting in resident sustaining pressure injuries is found to be UNSUBSTANTIATED. (Evaluation Report continues LIC 9099-C) Regarding Allegation #2: this investigation revealed facility staff were instructed to provide adequate liquids despite Resident #4 having difficulty swallowing. Specific instructions were given by Witness #1 to offer the resident nutritional liquids. Facility staff were instructed to immediately inform the hospice nurse (Witness #1) of any change of condition in the resident. Facility staff were aware of Resident #4’s decreased intake of fluids and to prevent dehydration, they would consult with Witness #1 for other nutritional liquid options. Resident #4 would self-induce regurgitation behaviors right after ingesting liquids; and, facility staff would re-direct the resident’s behaviors. During Witness #1’s evaluation visits with Resident #4, the Hospice RN would observe facility staff offer the resident nutritional fluids throughout the day. Based on the evidence gathered and interviews conducted, and records reviewed, although the allegation 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 of NEGLECT/LACK OF SUPERVISION: Staff neglected resident resulting in dehydration is found to be UNSUBSTANTIATED. Regarding Allegation #3: this investigation revealed facility staff were instructed to provide adequate food despite Resident #4 having difficulty swallowing food. Specific instructions were given by Witness #1 to offer the resident nutritional foods. Facility staff were instructed to immediately inform the hospice nurse (Witness #1) of any change of condition in the resident. Facility staff were aware of Resident #4’s decreased intake and to prevent malnutrition, they would consult with Witness #1 for other nutritional options. Resident #4 would self-induce regurgitation behaviors and bring out undigested food after ingestion; and, facility staff would redirect the resident’s behaviors. During Witness #1’s evaluation visits with Resident #4, the Hospice RN would observe facility staff offer the resident nutritional meals throughout the day. Based on the evidence gathered and interviews conducted, and records reviewed, although the allegation 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 of NEGLECT/LACK OF SUPERVISION: Staff neglected resident resulting in malnutrition is found to be UNSUBSTANTIATED. Regarding Allegation #4: this investigation revealed that Resident #4 was presented to the ER at Kaiser Permanente South Bay Hospital by Witness #2 (responsible person/family member) and admitted on 08/15/22. At that time, Resident #4 was observed to be covered in feces and urine per Witness #5 Resident #4 was discharged on 09/29/22 back to the facility. (Evaluation Report continues LIC 9099-C) Interview conducted of Asst. Administrator (A2) indicated that Resident #4’s under hospice care, specifically for palliative care and comfort through Kaiser Permanente’s Housing Program for homeless, elderly residents. During Witness #1’s evaluation visits with Resident #4, facility staff would act accordingly and immediately tend to the resident’s needs. Witness #1 stated that Resident #4 would pick themself to defecate, and facility staff would immediately clean the resident’s feces off their person and bed rails. Witness #1 observed facility staff to provide the appropriate level of care for Resident #4 and denied neglect or lack of care on their behalf. Witness #2 (responsible person/family member) did not address areas of concern to facility staff regarding Resident #4 being left soiled for an extended period during their visits to the facility. Based on the evidence gathered and interviews conducted, and records reviewed, although the allegation 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 of NEGLECT/LACK OF SUPERVISION: Staff left resident soiled for an extended period of time is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to caregiver (Christian Espino).the state’s words, verbatim · CDSS document, Jun 8, 2024 · control 11-AS-20221024135727

Allegation investigated: Staff did meet resident's dietary needs.

On 04/17/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Caregiver Carmelita Bonifacio. and explained the purpose of the visit. LPA spoke with Administrator Angelique Gradney over the phone. The investigation consisted of the following: During today’s investigation, LPA toured the kitchen area, conducted record review, and interviewed residents and staff. Continue to LIC9099-C. Unsubstantiated The investigation revealed the following: Regarding the allegation "Staff did meet resident's dietary needs,” it is being alleged that although staff has been informed multiple times that R1 does not eat pork, staff is serving pork to R1. Interviews conducted indicate the following: staff is aware of the dietary needs of the residents and considers the religious background and food habits of R1. LPA observed R1 eating beef, mash potatoes with gravy, and diced apples for lunch. Physician Report and Preplacement and Resident appraisals reveal that R1 is on a special diet and does not eat pork. LPA observed a photo of the meal that R1 stated was pork but confirmed it to be chicken adobo. Based on the interviews, record review, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. An exit interview was conducted, and a copy of the Complaint Report was provided to Caregiver Carmelita Bonifacio.the state’s words, verbatim · CDSS document, Apr 17, 2024 · control 11-AS-20240409084401

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility staff did not assist resident with arranging transportation to medical appointments.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Santa Fe Home Care Homes facility on 03/06/2024 and was greeted by Administrator Nelson Ortega (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation and conducted an in-person interview with Administrator Nelson Ortega (A1). The investigation consisted of the following: LPA Calderon interviewed Administrator (A1), Staff (S1-S3), resident (R1-R4) and witness (W1-W3). These interviews were conducted on 03/06/2024. LPA Calderon obtain and reviewed the following: Physician’s report (dated 09/20/2023) Vehicle transportation logs (date 01/17/2024, 02/07/2024 and 02/08/2024, doctors’ appointment (date 02/07/2024 to 05/15/2024), admission agreement (date 09/20/2024) for R1. The investigation revealed the following: Substantiated Regarding Allegation #1: Facility staff did not assist residents with arranging transportation to medical appointment. This complaint alleged staff did not arrange transportation for R1 doctor’s appointment. LPA Calderon interviewed with A1. A1 states that staff does help R1 make doctors’ appointments with the VA hospital. A1 states that R1 did not have an appointment with the VA and no transportation was made. A1 states that staff do keep records of residents’ transportation requests. LPA Calderon interviewed staff (S1-S3). Two out of three staff state that staff do not set up transportation for residents in care. S3 states that S3 does arrange transportation for R1 and S3 did not know R1 had a doctor’s appointment on 02/26/2024 and 02/28/2024. LPA Calderon interviewed residents (R1-R4). R1 states that staff did not arrange transportation for R1 doctors’ appointments, and he missed the doctors’ appointments on 02/26/2024 and 02/28/2024. Three out of four residents state that staff do help them with transportation requests. S4 could not answer any questions due to health conditions. LPA Calderon interviewed witness (W1-W3). W1 states that W1 sets up transportation request for VA hospital but does not request transportation request. W1 states that the request is made by facility staff. W2 states that their records do not show any transportation request from facility for 02/26/2024 and 02/28/2024. W3 states that R1 did have a doctor’s appointment for 02/26/2024 and 02/28/2024 and was a no show for appointments. LPA Calderon reviewed R1 admission agreement (date 09/20/2023), section #7 states “plan, arrange or book for an approved non-emergency medical transportation provider to medical and dental appointments. Reviewed transportation schedule for R1. Schedule suggest that R1 had appointments for 02/07/2024, 02/08/2024, 02/26/2024, 02/28/2024, 03/27/2024 and 05/15/2024. Reviewed transportation log notes (date 01/17/2024, 02/07/2024 and 02/08/2024), log notes support R1 appointment schedule for doctors’ appointments. Based on LPA Calderon observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegations “facility staff did not assist resident with arranging transportation to medical appointments” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are cited on the attached LIC 9099D. An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Administrator Nelson Ortega (A1).the state’s words, verbatim · CDSS document, Mar 6, 2024 · control 11-AS-20240227140101

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(8) · Plan of correction due date: Mar 15, 2024

87208 Plan of Operation (8) Transportation arrangements for persons served who do not have independent arrangements. This requirement was not met as Based on interviews and records reviews, the facility staff failed to provide transportation to resident in care. This violation poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Administrator will provide training to staff regarding schedualing residents doctors appointments and email LPA Calderon with proof of training by POC date.

Allegation investigated: Resident sustained bed sores due to staff neglect Staff hit resident Staff are not safeguarding resident's personal belongings Staff are not providing adequate food service to residents Staff did not provide resident with a 60day rent increase notice Staff are threatening resident Staff did not ensure resident's wheelchair was in good repair

**This report supersedes the previous report dated 2/16/24 to correct the order of pages for the complaint report. ** On 3/7/25, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced subsequent complaint visit to amend the complaint to correct the order of the pages. LPA was met by Christian Espino, Caregiver, and the purpose of the visit was explained. On 02/16/2024 at 08:08 am Licensing Program Analyst (LPA) David España conducted an unannounced complaint investigation visit for the allegation listed above. LPA met with Administrator, Catherine Espino and the purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access. Page 1 of 6 Unsubstantiated The investigation consisted of the following: An initial complaint visit was completed by LPA David España on 02/16/2024. A subsequent visit was completed by LPA Perry Scott on 3/7/2025. On 02/16/2024 LPA requested copies of the following: Resident's medical records, including diagnosis and treatment of pressure sores. Documentation of care provided by appropriately skilled professionals. Records of staff training on pressure sore prevention and care. Resident's care plan and daily care logs. Incident reports. Staff disciplinary records. Resident's medical records documenting any injuries. Facility policies on abuse prevention and reporting. Resident's personal property inventory. Facility policies on safeguarding residents' belongings. Staff training records on resident rights and property protection. Any reports of missing items. Meal plans and menus. Food service logs. Dietary requirements for residents. Staff training records on food service and nutrition. Copies of rent increase notices. Facility policies on rent increases and notifications. Resident's admission agreement. Communication logs with residents or their representatives. Facility policies on resident rights and staff conduct. Maintenance logs for resident mobility devices. Inspection records for wheelchairs and other mobility devices. Resident's care plan addressing mobility needs. Staff training records on equipment maintenance and safety. LPA España interviewed Resident 1- Resident 3 (R1-R3) and Staff 1 - Staff 4 (S1-S4). Investigation revealed the following: Allegation #1: Resident sustained bed sores due to staff neglect. On 02/16/2024, LPA España interviewed Resident 1 - Resident 3 (R1-R3) regarding the allegation. Of those interviewed, 1 of 3 residents stated they had no bed sores, the other two did not answer the question. On 02/16/2024, LPA España interviewed Staff 1-Staff 4 (S1-S4). 3 out of 4 staff disagreed with the allegation of neglect leading to bed sores. On 2/16/2024 LPA Espana reviewed records for four facility residents and found no indication of any residents being treated for bedsores. Page 2 of 6 Continued On LIC9099-C Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Allegation #2: Staff hit resident. On 02/16/2024 LPA España interviewed Resident 1 - Resident 3 (R1-R3). Of those interviewed, 3 out of 3 residents denied the allegation. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). 3 out of 4 staff members denied the allegation. On 02/16/2024 LPA España reviewed facility records and found no Unusual Incident/ Injury regarding staff hitting residents. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Allegation #3: Staff are not safeguarding resident's personal belongings. On 02/16/2024 LPA España interviewed Resident 1 - Resident 3 (R1-R3). Of those interviewed, 2 out of 3 denied the allegation. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, 2 out of 4 denied the allegation and the other two indicated they had insufficient knowledge to answer, as they were newer employees to the facility. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Page 3 of 6 Continued On LIC9099-C Allegation #4: Staff are not providing adequate food service to residents. On 02/16/2024 LPA España noted that the facility had a weeks’ worth of non-perishables and two days’ worth of perishable food items. A review of the weekly menu shows residents receive three meals and snacks daily. On 02/16/2024 LPA España observed residents eating a breakfast of toast, jam, and eggs, which aligned with the posted weekly menu. On 02/16/2024 LPA España interviewed Resident 1 - Resident 3 (R1-R3). Of those interviewed 2 out of 3 denied the allegation. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, 4 out of 4 denied the allegation. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Allegation #5: Staff did not provide resident with a 60-day rent increase notice. On 02/16/2024 LPA España reviewed facility records and observed a rate increase notice dated 60 days before the effective date. Interview with Administrator Catherine Espino revealed that facility is supposed to provide increase notices to residents in writing. Administrator also added that it is part of the admissions contact which is signed by residents and families. On 02/16/2024 LPA España interviewed Residents 1-3 residents (R1-R3). Of those interviewed, 2 out of 3 were aware of a rent increase, but only one spoke about when it was received, stating they had only recently been told, but that family would know more. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, one denied the allegation and the other three were unaware of rent increases. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Page 4 of 6 Continued On LIC9099-C Allegation #6: Staff are threatening resident. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, 4 out of 4 denied the allegation, with one adding that such behavior is not tolerated and is a personal rights violation. On 02/16/2024 LPA España interviewed Residents 1-3 residents (R1-R3). Of those interviewed, 2 out of 3 denied the allegation while one did not answer the question. LPA España facility records and found no incidents reports for the 30-day period reviewed related to any threats. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Allegation #7: Staff did not ensure resident's wheelchair was in good repair. On 02/16/2024, LPA España reviewed facility records which show that three resident use wheelchairs for mobility. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, 4 out of 4 reported no issue with resident’s wheelchairs. Interview with Administrator Catherine Espino revealed that most of the time medical equipment is provided by home health and any issues are reported to them. Further, S1-S4 stated that residents have no problems using or accessing their wheelchair in the facility. LPA interviewed the Administrator who stated that the facility’s best practices for wheelchair maintenance are as follows and staff ensures the wheelchairs are in good repair: The facility implements a regular cleaning schedule, wiping down the wheelchair with a damp cloth weekly to remove dirt and debris. Page 5 of 6 Continued On LIC9099-C Perform weekly brake checks to ensure they are operating properly and engaging/releasing correctly. Inspect tire pressure regularly and adjust as needed, rechecking brake function after any pressure changes. Train staff on basic wheelchair inspection and maintenance procedures to identify problems early. Keep a maintenance log to track regular upkeep and any repairs needed. On 02/16/2024 LPA España interviewed residents 1-3 residents (R1-R3). 2 out of 3 residents stated staff were good at moving bedridden and wheelchair-using residents. 2 out of 3 residents see other residents being moved throughout the day but couldn't specify how often. 2 out of 3 residents stated that other residents who can't walk are moved regularly with staff help. 2 out of 3 residents stated that staff move these residents, and they are seen in different locations during the day. 2 out of 3 residents stated residents who can't walk are moved regularly with staff help. 2 out of 3 residents stated staff move residents, and they are seen in different locations during the day. LPA reviewed documentation of resident council meetings or other forums where residents may have voiced concerns. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. Based on interviews, observations, and records reviewed, there is insufficient evidence to support the allegations that 1. "Resident sustained bed sores due to staff neglect," 2. "Staff hit resident. 3."Staff are not safeguarding resident's personal belongings," 4."Staff are not providing adequate food service to residents," 5. "Staff did not provide resident with a 60-day rent increase notice," 6. "Staff are threatening resident," and 7. "Staff did not ensure resident's wheelchair was in good repair." Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore all allegations are Unsubstantiated. There were no deficiencies issued. An exit interview was conducted, and a copy of this report provided to Christian Espino, Caregiver. Page 6 of 6 This page intentionally left blank INTENTIONALLY LEFT BLANK This page intentionally left blank Documentation of resident council meetings or other forums where residents may have voiced concerns. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. Regarding the allegation: Staff did not ensure resident's wheelchair was in good repair. Investigation consisted of the following: On 02/16/2024, LPA España observed residents and confirmed residents to have a wheelchair. On 02/16/2024, LPA España interviewed 4 out of 5 staff who stated that residents have no problems using or accessing their wheelchair in the facility. LPA España interviewed 4 out of 5 staff who stated staff are expected to move residents every few hours. LPA España interviewed 3 out of 4 residents stated staff were good at moving bedridden and wheelchair-using residents. 3 out of 4 residents see other residents being moved throughout the day but couldn't specify how often. 3 out of 4 residents stated that other residents who can't walk are moved regularly with staff help. 3 out of 4 residents stated that staff move these residents, and they are seen in different locations during the day. 3 out of 4 residents stated residents who can't walk are moved regularly with staff help. 3 out of 4 residents stated staff move residents, and they are seen in different locations during the day. LPA interviewed the Administrator who stated that the facility’s best practices for wheelchair maintenance are as follows and staff ensures the wheelchairs are in good repair: The facility implements a regular cleaning schedule, wiping down the wheelchair with a damp cloth weekly to remove dirt and debris.LIC 9099C Continued Perform weekly brake checks to ensure they are operating properly and engaging/releasing correctly. Inspect tire pressure regularly and adjust as needed, rechecking brake function after any pressure changes. Train staff on basic wheelchair inspection and maintenance procedures to identify problems early. Keep a maintenance log to track regular upkeep and any repairs needed. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. Investigation consisted of the following: On 02/16/2024, LPA España interviewed 3 out of 4 residents. LPA España interviewed 3 out of 4 residents who stated that staff are expected to move residents every few hours. 3 out of 4 residents stated that staff are good at moving bedridden and wheelchair-using residents. 3 out of 4 residents stated they (resident) see other residents being moved throughout the day but couldn't specify how often. Based on interviews, observations, record reviewed there is insufficient evidence to support the allegations that 1. "Resident sustained bed sores due to staff neglect," 2. "Staff hit resident. 3."Staff are not safeguarding resident's personal belongings," 4."Staff are not providing adequate food service to residents," 5. "Staff did not provide resident with a 60-day rent increase notice," 6. "Staff are threatening resident," and 7. "Staff did not ensure resident's wheelchair was in good repair." Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. There were no deficiencies issued. An exit interview was conducted and a copy of this report provided to Christian Espino, Caregiverthe state’s words, verbatim · CDSS document, Feb 16, 2024 · control 11-AS-20240209103510

Allegation investigated: Staff did not safeguard resident's personal belongings.

On 02/07/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegations. LPA met with Caregiver LaVisitacion Carbonell and explained the purpose of the visit. Assistant Administrator Rodolfo "Ninyo" Lozada arrived 20 minutes later. The investigation consisted of the following: During today’s investigation, LPA interviewed 4 out of 4residents and 4 staff which included the Assistant Administrator and (3) caregivers. LPA reviewed the resident records and staff training records. Continue to LIC 9099-C. Substantiated The investigation revealed the following: Regarding the allegation "Staff did not safeguard resident's personal belongings," interviews conducted indicated the following: three out of four staff interviews agreed with the allegations. Over the phone, S4 confirmed with the Assistant Administrator that the allegation occurred. The Assistant Administrator asked S3 if the allegation occurred and S3 admitted to throwing contents away and apologized. Resident interviews conducted indicated the following: one out of four residents stated that their personal items are not protected, two out of four residents stated that their personal items are protected, and one out of four residents was unable to answer the question. Record reviews indicate that three out of four residents had a blank safeguards for property/valuables document on file with signature. Record reviews indicate that three out of three caregivers received training on residents’ rights. Regarding the allegation “Staff did not safeguard resident's personal belongings," based on interviews and observation, the preponderance of evidence has been met therefore the allegation is Substantiated. Deficiencies were issued. An exit interview was conducted and plans of correction developed. A copy of this report and appeals rights was reviewed with Assistant Administrator Rodolfo "Ninyo" Lozada and left with Caregiver Dominador "David" Bonifacio. The investigation revealed the following: Regarding the allegation Staff are threatening resident," interviews conducted indicated the following: one out of four residents agreed with the allegation, three out of four residents disagree with the allegation, and three out of three staff members disagreed with the allegation. Record reviews indicate four out of four residents have a signed admission agreement which includes the eviction procedure. Based on the interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was reviewed with Assistant Administrator Rodolfo "Ninyo" Lozada and left with Caregiver Dominador "David" Bonifacio.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 11-AS-20240205141144

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Feb 22, 2024

Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents'... personal property and valuables which have been entrusted to the licensee or facility staff. The...resources. This requirement was not met as evidenced by: Based on observations and interviews, the facility staff placed R1's personal property into the trash can without R1's permission.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: The licensee will develop a plan of correction by the POC due date to ensure that all staff take appropriate measures to safeguard residents' personal property and valuables.

Allegation investigated: Facility staff does not provide resident with adequate amounts of food.

** This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 1/24/24. On 1/24/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Rey Malit, Housekeeper and Angelique Gradney, Director was called. LPA explained the purpose of today’s visit and LPA was granted entry. The investigation consisted of the following: On 1/24/24 LPA reviewed resident files and toured the facility. LPA reviewed copies of the following records: Staff Roster, resident files, resident MAR, Admission Agreement, ID and Emergency information, resident appraisal, Preplacement Appraisal, Appraisal Needs and Services, medical record of outpatient medications, copy of weekly menu’s. The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Facility staff does not provide resident with adequate amounts of food Resident is concerned that meal portion amounts are too small. Resident also states that the food is good in quality just not enough food. Resident states that’re working out and wants to be fit, but occasionally wants more food. Resident states that he is given extra food sometimes, but not all of the time. LPA observed vegetables being prepped for daily soup which is on the menu for the day. LPA observed that some of the residents had soul food containers brought in from family. During interviews LPA learned that a majority of the meals are Filipino based meals. LPA discussed with the Administrator to consider revising the weekly menu to represent all residents in care. On 1/24/24 LPA Shirley conducted interviews with both staff and residents. LPA interviewed staff, staff 1 – staff 2 (S-1 – S-2). LPA asked staff, “Does staff provide residents with adequate amounts of food?” Of those interviewed 2 out of 2 answered yes. LPA interviewed residents 1 – resident 4 (R-1 – R-4). LPA asked residents, Do you feel like you are getting adequate amounts of food? Of those interviewed, 3 out of 4 answered, yes. Based on information gathered, the department did not find sufficient evidence to support allegations "Facility staff does not provide resident with adequate amounts of food,” therefore the allegation is Unsubstantiated. Allegation: Facility staff mismanages resident’s medication It is being alleged that staff is mismanaging medication. LPA Shirley conducted a review of resident’s service file including Medication Administration Records (MAR). Records revealed that there are two medications listed on MAR with initials for administering medication. Upon review of medications, LPA was not able to locate either medication in the medication basket. LPA observed another prescribed medication in the basket but medication is not listed on MAR. According to the information gathered and the acknowledgment declaration from staff, there is sufficient evidence to support the allegation mentioned above. Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8, therefore this allegation is Substantiated. Deficiencies are issued and an exit interview is conducted Nelson Ortega, Administrator's designee. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 24, 2024 · control 11-AS-20240116161744

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(e) · Plan of correction due date: Feb 7, 2024

Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement was not met as evidenced by: Based on interviews and records reviews, the facility staff failed to make accurate records for prescribed medications for residents. Staff failed to refill prescriptions on file. Staff failed to list all medications on the MAR. This violation poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: Licensee will submit plan informing the department medication training has been peformed with all staff. A written proof of correction must included date, time and particpants names. Correction must be submitted by due date: 02/07/24 to LPA's email: felisa.shirley@dss.ca.gov

Allegation investigated: Staff does not ensure resident health care needs are being met.

On 01/10/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial complant investigation visit at the facility. LPA was greet by care staff Rey Melit who contacted administrator Angelic Gradney by telephone. LPA explained the purpose of the visit is investigate on the allegation mentioned above. Investigation consisted of the following: A review of resident and staff roster. A review of resident #1-#4 (R1-R4) service files including Centrally Store Medications and Medication Administration Records. Copies of (R1's) Admission Agreement, ID & Emergency Info, Resident Appraisal, Physicians Report , and other records associated with the nature of his complaint. A tour of the faciliy was performed. (Evaluation Report continues LIC 9099) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff does not ensure resident health care needs are being met. It is alleged that the facility does not ensure resident health care needs are being met. Resident #1(R1)'s healthcare needs are not being met, according to the complainant. The complainant did not provide further details on the matter and was not available for further statements. On 01/10/24 from 11:15 am to 12:13 pm, the Department interviewed (3) out of (4) residents #1-#3 all verified their healthcare needs were being met. (R1-R3) all verified to have received adequate care and supervision to maintain physical, mental, or emotional well-being. (R1-R3) verified medication administration by staff is received daily and timely. On 01/10/24 from 10:31 am - 3:02 pm, the Department conducted a review of all resident service files including Medication Administration Records (MAR). Records revealed the facility failed to maintain an accurate (MAR) for January 2024. (R1-R4) all had prescribed medication and "pro re nata" (PRN). (R1) had two (2) PRN, (R2) had (1) PRN, (R3) had (2) and (R4) had (2) PRN, and (3) non-prescribed medications that were not documented in medication record. The non-prescribed medications not issued by a primary care physician were Fluticasone and Synthroid for (R4). At 10:31 am - 10:41, staff #2 (S2) was interviewed. (S2) admitted to have failed to keep accurate records of resident's medications. (S1-S2) recognized that by not maintaining accurate records endangers residents' health and the needs are not being met. (R4) was present at the facility but was not available for an interview during this investigation visit. According to the information gathered and the acknowledgment declaration from staff, there is sufficient evidence to support the allegation mentioned above. Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8, Deficiencies are issued and an exit interview is conducted with Rey Melit. A copy of this report and appeal rights were provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * INVESTIGATION REVEALED THE FOLLOWING: Allegation #2: Staff does not assist residents with incidental medical needs. The details of this complaint reported that resident # 1 (R1) was being denied a care provider. The complainant did not provide further details on the matter and was not available for further statements. On 01/10/24 from 10:31 am - 12:47 pm, the Department interviewed (3) out of (3) staff #1 -#3 all verified that all residents were being assisted with incidental medical needs. (S1) stated that resident (R1-R3) are independent and make their own medical or dental appointments. (R3) is currently on home health assistance three days a week and is being assisted by facility staff as well. According to (S1-S3), (R1 and R3) medical providers are through the Department of Veterans Affairs (VA). (S1) claimed (R1) makes all the medical appointments directly with the (VA). The (VA) notifies the Santa Fe home care office one week in advance and the office staff will generate a written confirmation to the facility with details of the upcoming appointment. The notice includes all the pertinent information such as date, time, place, transportation company, and VA coordinator information. The facility staff acts as a liaison between the resident and the medical provider. (S1) stated the facility staff has never been denied care assistance to (R1). Additional care assistance such as home health would have to be authorized by (R1's) medical physician at the VA. On 01/10/24 from 11:15 am - 12:13 pm, the Department interviewed (3) out of (4) residents #1-#3 all verified are capable of handling their own incidental medical needs. (R1-R3) stated that they had no issues or concerns getting assistance with help with medication or physician care. (R1) claimed (R1) was not denied a care provider. (R1) claimed not to have problems contacting (VA) physicians for medical appointments and that the facility ensures that (R1's) appointments are maintained in order. (R1) stated in an interview conducted by Licensing Program Analyst (LPA) Socorro Leandro on 12/21/23, was asked about Incidental Medical/Dental Care and if needed medical assistance do I get it? (R1) stated my answer has not changed, it still a "YES". (R4) was present at the facility but was not available for an interview. On 1/10/24 from 1:10 pm - 2:40 pm, the Department interviewed (2) out (2) family representative witness #1-#2 (W1-W2) who were complimentary of staff and that the facility provided adequate care and supervision. (W1-W2) stated residents are assisted with incidental medical needs. (Evaluation Report continues LIC 9099-C) Based on the information provider, an inspection of the facility, observation, interviews, and analysis of service records, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. An exit interview was conducted with Rey Melit, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 10, 2024 · control 11-AS-20240103085600

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d)(3) · Plan of correction due date: Jan 11, 2024

Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication... facility staff designated by the licensee shall be permitted to assist... the resident with self-administration...(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement was not met as evidenced by: Based on interviews and records reviews, the licensee failed to make accurate records for prescribed & PRN medications from 01/01/24 - 01/10/24. (see LIC9099-C) for full details. This violation poses a immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Licensee will submit plan informing the department what steps will take in effect in order to prevent documentation and medication errors from occurring. Proof of correction must be submitted by due date: 01/11/24 to LPA's email: ernand.dabuet@dabuet@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(e) · Plan of correction due date: Jan 24, 2024

Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement was not met as evidenced by: Based on interviews and records reviews, the licensee maintained non-prescribed medications for (R3). This violation poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Licensee will submit plan informing the department medication training has been peformed with all staff. A written proof of correction must included date, time and particpants names. Correction must be submitted by due date: 01/24/24 to LPA's email: ernand.dabuet@dabuet@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 12/27/2023 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Christian Espino /Administrator. LPA explained the purpose of this visit. During this visit LPA observed that designee administrator was covering for administrator. During this visit LPA observed that designee did not have the qualifications specified in Sections 87405(d)(1) through (7). Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. (See D page for details) An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Christian Espino/Administrator.the state’s words, verbatim · CDSS document, Dec 27, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(1)(7) · Plan of correction due date: Jan 5, 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 as evidenced by: Based on observations and interviews LPA did not observed administrator designee having the qualifications stated on regulation 87405(d)(1)(7). This poses a potential risk to health and safety of residents in care.the state’s words, verbatim · CDSS document, Dec 27, 2023

Plan of correction: Administrator will choose another designee to conduct administrator duties while she is out of the facility. Once Administrator chooses another designee, she will send the required documentation to LPA via email before POC due date.

Type of visit: Case Management - Annual Continuation

On 12/27/2023, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced continuation Required – 1 Year Inspection to the above-named facility and met with the House Manager / Caregiver Rey Malit. LPA explained the purpose of the visit to the House Manager. Deficiencies & Civil Penalties are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D pages and LIC421IM pages. Civil Penalties Regarding: Fire Clearance Building Permit Violations Regarding: CCR 87309(a) CCR 87411(f) CCR 87202(a)(2) HSC 1569.605 CCR 87303(a) CCR 87303(e)(6) CCR 87305(a) CCR 87307(a)(3)(D) CCR 87307(a)(3)(D) CCR 87468(d) HSC 1569.319(a) CCR 87219(i) CCR 87555(b)(27) CCR 87465(h)(5) HSC 1569.695(a) An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the House Manager.the state’s words, verbatim · CDSS document, Dec 27, 2023

Type of visit: Annual/Random

On 12/21/2023 at around 8:10 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the House Manager / Caregiver Rey Malit. LPA explained the purpose of the visit and was accompanied by the House Manager inside and outside the facility during this inspection. This facility is licensed to serve 6 adults ages 60 and above, of which 2 may be non-ambulatory residents. Rooms 1 & 4 are for ambulatory residents. Rooms 2 & 3 are for non-ambulatory residents. A total of 4 residents are currently residing in this facility, of which 2 are ambulatory, 1 is non-ambulatory, and 1 is bedridden. The Annual Licensing Fees are current. The facility is a one story house located in a residential street. The home consists of 4 resident bedrooms, 2 staff bedrooms, 1 ensuite bedroom (bedroom is connected to its own bathroom and a non-staff member is currently residing in the bedroom), 1 bathroom, 1 toilet room, 1 living room, 1 kitchen/dining/tv room, 1 attached garage, front and backyard patio areas have shaded seating. The home has a total of 7 bedrooms and 2 full bathrooms. Due to time constraints the LPA was unable to complete todays visit. An exit interview was conducted and a copy of this report was left with the House Manager.the state’s words, verbatim · CDSS document, Dec 21, 2023