Santa Fe Home Care IV

Type of visit: Case Management - Deficiencies

On 08/07/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit. The purpose of this visit is to deliver deficiencies observed during the course of the investigation regarding complaint control number 11-AS-20250710130802. LPA met with the House Manager, Nelson Ortega and the purpose of the visit was explained. LPA was granted entry to the facility. Deficiencies observed were as follows: · The licensee did not follow reporting requirements. o On 07/07/2025 the facility staff called 911 for Resident 1 (R1). Paramedics came to the facility and took R1 to the hospital. R1 was released from hospitalization on 07/14/2025. o The licensee did not submit an Unusual Incident/Injury Report (UIR) to the department. · The licensee did not have a doctor’s order for R1’s bed rails. · The licensee did not have a doctor's order for R1’s Hoyer lift. · The licensee did not have a yearly Medical Assessment (Physician’s Report) for R1. o R1’s Physician’s Report was dated 05/24/2024. · The licensee did not have a yearly reappraisal for R1. o R1’s Appraisal/Needs and Services Plan (ANS) dated 03/21/2024, signed by Licensee on 05/12/2024, missing R1’s and resident’s authorized representative signatures. · The licensee did not document/report R1’s change of condition. o According to staff R1’s health had been declining and R1 did not eat much. o R1 was diagnosed with severe malnutrition and oropharyngeal dysphagia according to hospital records from 07/07/2025 to 07/14/2025. On 08/07/206, a walk through of the facility was conducted and the following deficiency was observed: · Vermin were observed in the kitchen and other areas of the facility. Deficiencies are being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. 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, Nelson Ortega.the state’s words, verbatim · CDSS document, Aug 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 24, 2026

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on records reviewed the licensee did not comply with the section cited above in not submitting Unusual Incident/Injury Reports to the department for R1’s hospitalization on 7/7/2025 to 7/14/2025 which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: The house manager has agreed to train staff on reporting requierments. Email trainings to Socorro.Leandro@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(3) · Plan of correction due date: Aug 24, 2026

Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Based on records reviewed the licensee did not have a written order from a physician for R1’s bed rails and Hoyer lift which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: The house manager has agreed to create a plan to maintain a written order for postural supports for all residents in care. Email plan to Socorro.Leandro@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(h)(1-3) · Plan of correction due date: Aug 24, 2026

Reappraisals (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. (2) Documentation of a resident's refusal to receive an annual routine visit, or if applicable, their representative's refusal on their behalf, shall be added to the resident's record. (3) If a resident refuses to receive an annual routine visit, or if applicable, their representative refuses an annual routine visit on their behalf, but later agrees to one, documentation of the annual routine visit shall be added to the resident’s record. This requirement is not met as evidenced by: Based on records reviewed the licensee did not comply with the section cited above in not having a record of R1’s annual routine medical visit / refusal which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: The house manager has agreed to create a plan to ensure that all residents have a documented annual routine medical visit / refusal. Email plan to Socorro.Leandro@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Aug 24, 2026

Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Based on records reviewed the licensee did not comply with the section cited above in not having a record of R1’s yearly appraisal which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: The house manager has agreed to create a plan to ensure that all residents have an updated reappraisal once every 12 months and/or when staff observe a change of condition, whichever occurs first. Email plan to Socorro.Leandro@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Aug 24, 2026

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the licensee did not document R1’s change of condition and did not bring it to the attention of R1’s medical provider and responsible person which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: The house manager has agreed to create a plan to document residents change of condition and bring it to the attention of residents medical provider(s) and reponsible person(s). Email plan to Socorro.Leandro@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(27) · Plan of correction due date: Aug 18, 2026

General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on observations, the licensee did not maintain the kitchen areas free of vermin/insects which posed/poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: The house manager has agreed to increase the number of times the facility gets fumigated and deep clean the kitchen to decrease the amount of vermin in the facility and create a plan to eliminate all vermin from the kitchen areas and maintain the facility free of vermin. Email fumigation contract to come to the facility regularly, email pictures of deep cleaned kitchen, and plan to maintain the facility free of vermin to Socorro.Leandro@dss.ca.gov

Allegation investigated: Staff neglect.

On 06/20/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced subsequent complaint investigation visit to deliver an updated complaint investigation report for the allegation listed above. This report supersedes the report dated 01/14/2026. This report has been updated due to provide additional information. This report does not change the findings, the findings remain as “Substantiated”. LPA met with Nelson, and the purpose of the visit was explained. The investigation consisted of the following: On 07/11/2025, a facility tour was conducted, and records were gathered. Facility records were gathered which consisted of Resident Roster dated 06/01/2025 and Personnel Report dated 07/01/2025. Resident 1’s (R1) records were gathered which consisted of Admission Agreement dated 03/11/2020; Physicians Report dated 05/24/2024; Appraisal/Needs and Services Plan dated 05/12/2024; Resident Appraisal dated 03/21/2023; Identification and Emergency Information dated 03/22/2020; Hospital Records dated 07/07/2025 to 07/14/2025; and other pertinent records were provided. Continue to LIC9099-C. Substantiated On 07/23/2025, Staff 1 (S1) to Staff 3 (S3) were interviewed. On 09/26/2025, Staff 4 (S4) and Witness 1 (W1) were interviewed. On 10/14/2025, R1 was interviewed. On 10/15/2025, W1 and Witness 2 (W2) were interviewed. On 01/07/2026, S1 to S3 and Resident 2 (R2) to Resident 5 (R5) were interviewed. Investigation revealed the following: Allegation: “Staff neglect”, it is being alleged that staff neglected R1. Record reviews revealed the following: R1’s records revealed that the licensee did not: document changes in R1’s condition; There were no records of updated yearly Physicians Reports; and Appraisal/Needs and Services Plans. R1’s Admission Agreement dated 03/11/2020 indicated that R1 will receive “B. Basic services at a minimum include: 1. Continuous care and supervision…9. Assistance with personal activities of daily living as follows: toileting, mobility tasks, and other personal care needs”. R1’s Appraisal/Needs and Services Plan (ANS) dated 03/21/2024 does not have R1’s signature nor the resident’s authorized representative signatures; and does not mention incontinence care nor dietary needs. Physicians Report dated 05/24/2024 indicated that R1 was diagnosed/assessed with the following: dementia; motor impairment/paralysis; confused/disoriented; not able to leave the facility unassisted; not able to provide own self-care such as grooming, care for own toileting needs, etc.; non-ambulatory based on both physical and mental condition; weighted 129 pounds; and has a history of bacterial infections. Hospital Records dated 07/07/2026 to 07/14/2026 revealed that R1 was diagnosed with Malnutrition, Urinary Tract Infection, altered mental status, and required medical interventions. Personnel Report dated 07/01/2025 indicates that there were no staff on duty Monday to Sunday from 9:00 PM to 7:00 AM. Interviews revealed the following: On 07/23/2025, S1 indicated that they observed R1’s health on a decline. On 01/07/2026 staff S1 to S3, indicated that R1 would only receive incontinence care before 9:00 PM and after 7:00 AM. Based on records reviewed and interviews conducted 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 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, and a plan of correction was developed. A copy of this report and appeal rights were provided to Nelson.the state’s words, verbatim · CDSS document, Jun 20, 2026 · control 11-AS-20250710130802

Allegation investigated: Staff neglect.

On 01/14/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced subsequent complaint investigation visit regarding the allegation listed above. LPA met with the House Manager, Nelson Ortega, and the purpose of the visit was explained. LPA was granted entry to the facility. Substantiated Investigation consisted of the following: On 07/11/2025, a facility tour was conducted, and records were gathered. Facility records were gathered which consisted of Resident Roster dated 06/01/2025 and Personnel Report dated 07/01/2025. Resident 1’s (R1) records were gathered which consisted of Admission Agreement dated 03/11/2020; Physicians Report dated 05/24/2024; Appraisal/Needs and Services Plan dated 05/12/2024; Resident Appraisal dated 03/21/2023; Identification and Emergency Information dated 03/22/2020; and other pertinent records were provided. On 07/23/2025, Staff 1 (S1) to Staff 3 (S3) were interviewed. On 09/26/2025, Staff 4 (S4) and Witness 1 (W1) were interviewed. On 10/14/2025, R1 was interviewed. On 10/15/2025, W1 and Witness 2 (W2) were interviewed. On 1/7/2026, Staff 2 (S2) to S3 and Resident 2 (R2) to Resident 5 (R5) were interviewed. Investigation revealed the following: Allegation: “Staff neglect”, it is being alleged that staff neglected R1. Personnel Report dated 07/01/2025 revealed the following: there were no staff on duty from 9:00 PM to 7:00 AM. R1’s records reviewed revealed the following: Admission Agreement dated 03/11/2020 indicates that R1 will receive “B. Basic services at a minimum include: 1. Continuous care and supervision…9. Assistance with personal activities of daily living as follows:…toileting…mobility tasks, and other personal care needs”. Physicians Report dated 05/24/2024 indicates that R1 has the following, dementia; motor impairment/paralysis; is confused/disoriented; not able to leave the facility unassisted; not able to provide own self-care such as grooming, care for own toileting needs, etc.; and non-ambulatory based on both physical and mental condition. Based on records reviewed the Licensee did not provide R1 with continuous care and supervision despite R1 requiring continuous care and supervision, due to that, 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 and Chapter 8 are being cited on the attached LIC 9099D. An immediate $500 Civil Penalty is being assessed, please see LIC421IM. An exit interview was conducted, and a plan of correction was developed. A copy of this report and appeal rights were provided to the House Manager, Nelson Ortega.the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 11-AS-20250710130802

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jan 15, 2026

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on record review, R1 required continuous care and supervision, and the licensee did not have staff working between 9 PM to 7 AM thus, staff did not provide R1 with continuous care and supervision, which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: The staff has agreed to re-read CCR87411(a). For residents that quire continuous care and supervision the staff has agreed to provide residents with 24-hour staff continuously working. The licensee will create a plan to provide residents with continuous care and supervision for residents that require it (based on physician’s reports, care plans, admission agreements, observations, etc.). The licensee will email updated LIC500 and plan to Ulysses.Coronel@dss.ca.gov & Socorro.Leandro@dss.ca.gov

Allegation investigated: Resident sustained a fracture due to physical abuse.

On 01/07/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced subsequent complaint investigation visit regarding the allegation listed above. LPA met with the House Manager, Nelson Ortega, and the purpose of the visit was explained. LPA was granted entry to the facility. Unsubstantiated Investigation consisted of the following: On 07/11/2025, a facility tour was conducted, and records were gathered. Facility records were gathered which consisted of Resident Roster dated 06/01/2025 and Personnel Report dated 07/01/2025. Resident 1’s (R1) records were gathered which consisted of Admission Agreement dated 03/11/2020; Physicians Report dated 05/24/2024; Appraisal/Needs and Services Plan dated 05/12/2024; Resident Appraisal dated 03/21/2023; Identification and Emergency Information dated 03/22/2020; and other pertinent records were provided. On 07/23/2025, Staff 1 (S1) to Staff 3 (S3) were interviewed. On 09/26/2025, Staff 4 (S4) and Witness 1 (W1) were interviewed. On 10/14/2025, R1 was interviewed. On 10/15/2025, W1 and Witness 2 (W2) were interviewed. On 1/7/2026, Resident 2 (R2) to Resident 5 (R5) were interviewed. Investigation revealed the following: Allegation: “Resident sustained a fracture due to physical abuse.” Interviews conducted with R1 to R5 revealed the following: 3 out of 5 residents denied the allegation and 2 out of 5 resident interviews were inconclusive. Interviews conducted with S1 to S4 revealed the following: 4 out of 4 staff denied the allegation. Interviews conducted with W1 to W2 revealed the following: 2 out of 2 witnesses denied the allegation. R1’s records reviewed revealed the following: there were no hospital records, Unusual Incident Reports, nor a history of Adult Protective Services (APS) reports indicating that R1 has been physically abused in the facility. Observations on 07/11/2025 and 01/07/2026 revealed the following: there were no physical altercations nor abuse observed in the facility. Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. 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 unsubstantiated. No citations were provided. An exit interview was conducted, and a copy of this report was left with the Caregiver, Resti Saragih.the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 11-AS-20250710130802

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

On 12/10/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator, Angelique Gradney. The purpose of the visit was explained, and the LPA was allowed entry to the facility. This facility is licensed to serve 6 non-ambulatory adults ages 60 and above, of which 2 may be bedridden. The facility has a hospice waiver for 6 residents. Bedroom #3 is cleared for 1 bedridden client. A total of 6 residents are currently residing in this facility. The facility paid their Annual Licensing Fees today. Facility Layout: The facility is a two-story house located on a main street. The first floor consists of 3 resident bedrooms; 2 full bathrooms; 1 great room which consists of a kitchen area, dining room area, office space, and living room area; 1 attached garage with a laundry area. The second floor consists of 3 staff bedrooms and 1 full bathroom. Outside, there is a front yard and back yard patio area with shaded seating; and there is a storage room. Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there are no security bars or weapons on the premises. Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to residents in care. There is fire extinguisher in the kitchen and it was last serviced on 02/13/2025. Great Room / Community Space: There is a landline telephone, fax machine, and a videoconferencing device in the office area. There are games/activity work (i.e. board games and books) for residents in the living room area. Resident Bedrooms: 3 out of 3 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Bathrooms: Toilets, showers, and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries are accessible to residents. Medications: were inaccessible to residents in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. 6 out of 6 Medication Administration Records (MARs) were reviewed. Nonprescription (PRN) medication was documented but it did not include the resident’s response to the medication. 1 out of 6 residents were being provided with insulin injections by facility staff (this resident is currently taking insulin pills, according to staff resident injected themselves through their assistance). Garage: has a laundry area, staff break room area, and holds extra facility supplies. Supplies such as, blankets, towels, pillowcases, cleaning supplies, incontinent care need supplies, etc. Miscellaneous: Documents are posted as mandated. Last fire drill was conducted on 10/2/2025. The last Annual Fire Inspection by the Torrance Fire Department was conducted on 2/14/2025. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. The facility liability insurance is current. Fumigators come to the facility once a month and provide services. 5 staff records were reviewed, 5 out of 5 staff records had required documentation. Night staff are on call / live in and according to staff they are only paid during the times they work for example if a resident requires assistance than the night staff will assist a resident. 6 resident records were reviewed, 6 out of 6 resident records had required documentation. Physicians Report for the Resident 1 to Resident 6 indicate the following: Resident 1 – Nonambulatory Resident 2 – Severe Cognitive Impairment; Comorbidities; Unstageable heel pressure ulcer; Incontinent; Motor Impairment/Paralysis; Requires Continuous Bed Care; History of Skin Condition or Breakdown; Needs Assistance with Activities of Daily Living (ADL); Nonambulatory Resident 3 – Dementia; Diabetes; Treatment - Insulin PEN; Severe Late Onset Alzheimer’s Dementia; Hearing Loss; Incontinent; Requires Assistance with Repositioning and Transferring; Not able to: bathe self, dress/groom self, manage own toileting needs; Disorientation; Lack of Impulse Control; Expressions of Frustration; Patient bed bound; Not able to Manage own medications; Bedridden Resident 4: Sepsis/UTI; Mild Cognitive Impairment; Confused Disoriented; At Risk if Allowed Direct Access to Personal Grooming and Hygiene Items; Not able to care for own toileting needs Resident Appraisal 10/31/2025: Needs special observation/night supervision Resident 5: Multiple diagnosis; Mild Cognitive Impairment; Bowel & Bladder Impairment; Confused/Disoriented; Sundowning Behavior; Not able to care for Self-Care includes toileting needs and self-grooming Resident 6: Dementia; Hypertension; Incontinent Urinary; Requires Supervision; Motor Impairment/Paralysis - Weakness; Requires Continuous Bed Care; History of Skin Condition or Breakdown; At Risk if Allowed Direct Access to Personal Grooming and Hygiene Items; Not able for Self-Care including toileting, bathing, grooming Technical violations are being provided regarding emergency quarterly drills. Deficiencies are being cited based on observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. Violations regarding PRN medications, injections, and night staff. 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 Administrator, Angelique Gradney.the state’s words, verbatim · CDSS document, Dec 10, 2025

Type of visit: Required - 1 Year

On 12/05/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD), Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced annual inspection visit. The purpose of the visit was explained, and the LPA was allowed entry to the facility. A physical plant tour was conducted and records were reviewed. Due to time constraints, LPA was unable to complete annual inspection. An exit interview was conducted and a copy of this report was provided to Administrator, Angelique Gradney.the state’s words, verbatim · CDSS document, Dec 5, 2025

Type of visit: Case Management - Other

On 11/14/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit. The purpose of the visit was explained, and the LPA was allowed entry to the facility. A physical plant tour was conducted. No citations were provided. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 14, 2025

Type of visit: Case Management - Other

On 08/29/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit. The purpose of the visit was explained, and the LPA was allowed entry to the facility. This facility is licensed to serve 6 non-ambulatory adults ages 60 and above, of which 2 may be bedridden. The facility has a hospice waiver for 6 residents. Bedroom #3 is cleared for 1 bedridden client There are currently 4 residents in the facility. Today’s unannounced case management visit focused on physical facility plant. Facility Layout: The facility is a two-story house located on a main street. The first floor consists of - 3 resident bedrooms; 2 full bathrooms; 1 great room which consists of a kitchen area, dining room area, office space, and living room area; 1 attached garage with a laundry area. The second floor consists of - 3 staff bedrooms and 1 full bathroom. Outside - There is a front yard and back yard patio area with shaded seating. Outside Grounds: were toured no bodies of water were observed, there are no security bars or weapons on the premises. Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to residents in care. There is a fire extinguisher in the kitchen area, and it was last serviced on 02/13/2025. At 1:42 PM the dining room area measured 96.44 degrees Fahrenheit; Resident 1 was sitting at the dining room table. There is a wall thermometer near the dining table, and it measured around 94 degrees Fahrenheit from 1:34 PM to 1:45 PM. There was a fan pointing to Resident 1. There was a portable cooler in the dining room area. Community Indoor Space: There is a landline telephone and videoconferencing device in the office area. There are games/activity work (i.e. board games, books, magazines) for residents in the living room area. Resident Bedrooms: 3 out of 3 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. At 1:40 PM resident bedroom # 3 measured 94.28 degrees Fahrenheit; Resident 2 was sleeping in the room; there was a fan on in the room. At 1:43 PM resident bedroom # 1 measured 93.74 degrees Fahrenheit; Resident 3 was sleeping in the room; there was a fan on in the room. Bathrooms: Toilets and sink faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. Bathroom 2 shower head was in disrepair. The hot water temperature in the downstairs bathroom between resident bedroom #1 and resident bedroom #2 measured 135.5 degrees Fahrenheit. Medications: were inaccessible to residents in care. Garage: is used as a storage area for live-in staff, residents, and extra facility supplies such as bed linens, toiletries, cleaning supplies, food, and etc. Miscellaneous: Smoke and carbon monoxide detectors were in compliance and operational. Technical advisories are being provided regarding: keeping outside walkways free of obstruction; keeping upstairs walkways free of obstruction; keeping garage free of obstructions and clutter. Deficiencies are being provided based on observations in accordance with the California Code of Regulations, Title 22, see LIC809D. Violations regarding hot water temperatures and indoor facility temperatures. 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, Nelson Ortega.the state’s words, verbatim · CDSS document, Aug 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Aug 30, 2025

Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above. Hot water temperature measured 135.5 degrees Fahrenheit. This violation poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: The House Manager, Nelson Ortega, has agreed to decrease the hot water temperature and create a plan to ensure that hot water temperatures are maintained at 105 to 120 degrees Fahrenheit. Proof of correction will be emailed to Socorro.Leandro@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(b)(2) · Plan of correction due date: Aug 30, 2025

Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above. Facility indoor temperatures measured 96.44 F, 94.28 F, and 93.77 F. This violation poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: The House Manager, Nelson Ortega, has agreed to decrease indoor facility temperatures via providing more fans, coolers, etc. to residents and maintain indoor facility temperatures at 78 F to 85 F. And create a plan to ensure that residents do not dehydrate, overheat, become heat exhausted, etc. Proof of correction will be emailed to Socorro.Leandro@dss.ca.gov

Allegation investigated: Staff made inappropriate comments towards resident Staff are not providing adequate food service to resident Staff did not safeguard resident's peresonal belongings Staff did not ensure resident received a copy of admissions agreemen Staff did not ensure the shower was not slippery Staff do not allow resident out of his room

On 08/22/2025, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Santa Fe Home Care IV Facility and was greeted by Manager Rodolfo Lozada (S1). LPA Calderon spoke to S1 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 allegations. The investigation consisted of the following: LPA Calderon interviewed Manager (S1), Staff (S2-S3), resident (R1-R4). LPA Calderon obtained the following records: The Physician report (dated 05/21/2025), the Needs and Service plan (dated 06/11/2025), Incident reports (dated 07/17/2025 and 08/13/2025), the Admission Agreement (dated 06/05/2025), Providence Hospital record (dated 08/14/2025), MYO Management nurse notes (dated 08/01/2025), Martin Luther King Hospital record (dated 04/18/2025) for R1. LPA Calderon obtained the facility 2-week meal plan and pictures of residents being served and eating meals. LPA Calderon toured the facility with S1. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff made inappropriate comments towards residents. This complaint alleged that staff called R1 inappropriate names. LPA Calderon toured the facility and did not witness any negative interactions between staff and residents. Records review indicate the following: The Physician report indicates that R1 is aggressive with staff and has cognitive issues. The Needs and Service plan indicates that R1 can communicate R1 needs and is not conserved. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 moved to a new facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff made inappropriate comments towards residents” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are not providing adequate food service to residents. This complaint alleged that staff did not feed R1. LPA Calderon toured the facility and did not witness any negative interactions between staff and residents. LPA Calderon inspected the kitchen and noted 2 day and 7-day supply of food for residents to eat. LPA Calderon reviewed the 2-week meal plan for residents and obtained pictures of R1 eating food. LPA Calderon noted staff serving breakfast to residents in care and making lunch. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 moved to a new facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff are not providing adequate food services to residents” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff did not safeguard residents’ personal belongings. This complaint alleged that staff stole R1 clothes. LPA Calderon toured the facility and did not witness any negative interactions between staff and residents. LPA Calderon inspected residents’ rooms and noted personal space for residents’ belongings. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 moved to a new facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff did not safeguard residents’ personal belongings” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff did not ensure residents received a copy of the admission agreement. This complaint alleged that staff did not give a copy of the admission agreement to R1. LPA Calderon toured the facility and did not witness any negative interactions between staff and residents. Records review indicate the following: Reviewed the admission agreement. R1 signed the agreement, and a copy was saved in residents facility file. The Physician report indicates that R1 is aggressive with staff and has cognitive issues. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 moved to a new facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not ensure resident received a copy of admission agreement” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff did not ensure the shower was not slippery. This complaint alleged that staff did not ensure that the shower was safe. LPA Calderon toured the facility and did not witness any negative interactions between staff and residents. LPA Calderon inspected the facility 2 bathrooms and noted that there were grab bars and skid pads on the floor. LPA Calderon noted that the two bathrooms were working correctly. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 moved to a new facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff did not ensure the shower was not slippery” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff do not allow resident out of his room. This complaint alleged that staff did not allow R1 out of R1 room. LPA Calderon toured the facility and did not witness any negative interactions between staff and residents. LPA Calderon noted residents coming and going from the residents’ rooms. Records review indicate the following: Reviewed pictures of R1 out of R1 room eating at the dining room table. The Physician report indicates that R1 is aggressive with staff and has cognitive issues. Interviews indicate the following: 3 out of 3 staff deny the allegation. R1 could not be interviewed as R1 moved to a new facility. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff do not allow resident out of his room” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Manager Rodolfo Lozada (S1).the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 11-AS-20250814144437

Allegation investigated: Residents needs are not being met.

On 07/30/2025, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Santa Fe Home Care IV Facility and was greeted by Administrator Angelique Gradney (S1). LPA Calderon spoke to S1 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. The investigation consisted of the following: LPA Calderon interviewed Administrator (S1), Staff (S2-S4), resident (R1-R5), witness (W1). LPA Calderon obtained the following records: Physician report (dated 05/25/2025), Needs and Service plan (dated 06/11/2025), Incident reports (dated 06/26/2025 to 07/17/2025), Admission Agreement (dated 06/05/2025) for R1. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Residents’ needs are not being met. This complaint alleged that staff are not taking care of R1 wounds and needs. LPA Calderon toured the facility and did not witness any negative interactions between staff and residents. LPA Calderon noted the facility was clean. R1 took LPA Calderon to bathroom 1 to inspect as R1 believes the shower is for children. LPA Calderon did not notice any issues with the bathroom and the shower worked properly. Records review indicate the following: The Physician report indicates that R1 is aggressive with staff and has cognitive issues. The Needs and Service plan indicates that R1 can communicate R1 needs and is not conserved. The Incident reports indicate that R1 refuses to take a shower, change R1 clothes, or allow staff to take care of R1 leg wounds. The incident reports indicate that R1 refuses to be taken to the hospital or treat R1 left leg. R1 refuses to be seen by a doctor and will not go to the hospital for evaluation. Interviews indicate the following: 4 out of 4 staff deny the allegation. W1 indicates that R1 refuses to shower or change R1 clothes. W1 indicates that R1 refuses to be seen by a doctor or be taken to the hospital. R1 indicates that R1 does not need any help from staff and R1 does not need to be taken to the hospital for any reason. R1 indicates that R1 does not have any wounds and does not need to take a shower. R1 indicates that the facility provides meals and medication. 2 out of 3 residents deny the allegation. 4 out of 5 residents could not answer any questions. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Residents needs are not being met” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Angelique Gradney (S1).the state’s words, verbatim · CDSS document, Jul 30, 2025 · control 11-AS-20250724160158

Allegation investigated: Staff do not provide adequate food service. Staff do not ensure resident has access to a bathroom. Staff do not safeguard resident's' personal property.

On 07/23/25 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted a subsequent visit to deliver complaint findings. LPA met with (S1) Nelson Ortega as the purpose of today’s visit was explained. The investigation consisted of the following: On 7/10/25 LPA Villegas obtained copies of the staff and resident rosters, and copies of the following documents for Resident #1 (R1) emergency ID form, admission agreement dated: 6/5/25, Preplacement appraisal dated: 06/11/25, Physicians report dated: 5/21/25, needs and service plan dated 6/11/25, theft and loss policy and procedures dated 6/5/25, diaper change log for June-July 2025, communication log/staff notes dated 6/26/25, and a copy of an inventory list dated 6/5/25. On 7/11/25 from 10:14 am-10:45 am LPA conducted Interviews with staff #1-2(S1-S2). On 7/10/25 at 10:45 am LPA conducted tour of the facility, and on 7/10/25 from 11:30 am-12:04 pm interviews were conducted with resident #1-3 (R1-R3). On 7/10/25 LPA contacted witness 1-3 (W1-W3). On 07/23/25 LPA obtain copy of the June 2025 and July 2025 Medication Administration record for R1. Unsubstantiated The investigation revealed the following: Allegation: Staff do not provide adequate food service. It is being alleged that a resident in care is not receiving good nourishment at the facility. On 7/10/25 from 10:14 am-10:45 am LPA conducted Interviews with S1-S2 regarding the allegation above, 2 of 2 staff denied the allegation. Per 2 of the 2 staff interviewed, residents in care obtain 3 meals a day with snacks in between, residents are provided with additional food servings upon request. Additionally, staff have observed that R1 has been hesitant to accept nourishment, expressing feelings of mistrust and concerns about potential harm. On 7/10/25 from 11:30 am-12:04 pm interviews were conducted with resident #1-3 (R1-R3), 2 of 3 residents interviewed denied the allegation above, and did not report any concerns about the food being provided. 1 of 3 residents interviewed acknowledged the concerns raised and mentioned that the quality of the meals does not seem to meet expectations, implying that some of the items may not be as authentic as expected initially. On 7/10/25 LPA was unable to interview R4-R6 due to communication barriers. On 7/10/25 LPA conducted telephone interviews with W1-W3 regarding the allegations above, 3 of 3 witnesses interviews reported having no concerns about the food being provided at the facility. On 7/10/25 at 10:45 am LPA conducted tour of the facility, LPA observed the facility kitchen to have 2 refrigerators: 1 stores protein, 1 stores vegetables, milk, and juice. There is 1 pantry filled with canned goods, there was also fresh fruit observed. On 7/16/25 LPA conducted a review of staff notes dated 6/26/25, LPA documented that R1 has indicated a reluctance to accept nourishment. Allegation: Staff do not ensure resident in care has access to a bathroom. It is being alleged that facility staff are denying R1 access to the bathroom. On 7/10/25 from 10:14 am-10:45 am LPA conducted Interviews with S1-S2 regarding the allegation above, 2 of 2 staff denied the allegation. Per 2 of the 2 staff interviewed, there is only 1 resident in care that uses the bathroom independently and reports that resident has not been denied access to the bathroom. Additionally, staff members have indicated that a plumber has been requested to visit the facility several times each week to address ongoing issues with toilet drainage. On 7/10/25 from 11:30 am-12:04 pm interviews were conducted with resident #1-3 (R1-R3), 2 of 3 residents interviewed denied the allegation above, and reported that staff assist with incontinent needs. 1 of the 3 residents interviewed acknowledged the concern raised and mentioned experiencing difficulty accessing the bathroom, with staff citing hygiene issues as the reason for this restriction. On 7/10/25 LPA was unable to interview R4-R6 due to communication barriers. On 7/10/25 LPA conducted telephone interviews with W1-W3 regarding the allegations above, 3 of 3 witnesses interviewed reported having no concerns about toileting needs being met. On 7/22/25 LPA conducted a review of R1’s physicians report, per physician’s report R1 is able to care for R1’s toileting needs. Allegation: Staff do not safeguard resident's' personal property It is being alleged that facility staff have taken R1's shoes and clothes. On 7/10/25 from 10:14 am-10:45 am LPA conducted Interviews with S1-S2 regarding the allegation above, 2 of 2 staff denied the allegation. Per 2 of the 2 staff interviewed, R1 does not allow staff near R1 belongings and R1 refused to sign an inventory log upon admission. Per staff, R1 has reported items missing that were later found under R1’s bed. On 7/10/25 from 11:30 am- 12:04pm interviews were conducted with resident #1-3 (R1-R3), 2 of 3 residents interviewed denied the allegation above. 1 of the 3 residents interviewed confirmed the allegation above, per resident the facility staff allow people into the facility therefore the staff is responsible for items going missing. On 7/10/25 LPA was unable to interview R4-R6 due to communication barriers. On 7/10/25 LPA conducted telephone interviews with W1-W3 regarding the allegations above, 3 of 3 witnesses interviewed reported having no concerns about the allegation above. On 7/16/25 LPA conducted a review of inventory logs dated 6/5/25, per log R1 refused to complete the inventory log upon admission. On 7/16/25 LPA conducted a review of staff notes dated 6/26/25, per staff notes R1 accused staff of stealing belongings, R1 does not want staff to touch or arrange belongings, shoes reported stolen were under R1’s bed. On 7/22/25, LPA reviewed R1's physician's report and Preplacement appraisal. It was noted in the preplacement appraisal that R1 is facing challenging behaviors related to major neuro cognitive disorders (NCD). 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 allegations are unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 11-AS-20250707125908

Allegation investigated: Staff did not ensure resident's incontinence needs were being met, Staff did not respond to resident’s calls for assistance. Staff did not provide adequate food service to resident

On May 28, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted a complaint visit regarding the above allegations. LPA Lee met with Nelson Ortega, House Manager, and explained the reason for the visit.Subsequently, the Administrator Virginia Asis arrived to assist with visit. The investigation consisted of the following: On May 28, 2025, LPA and House Manager conduct tour of faciltiy, LPA obtained and reviewed the following: staff roster (4/21/25), resident's roster (dated 4/20/25), Appraisal/Need and Services Plan for R1 (dated 5/17/25), Physician's Report for Residential Care for the Elderly (RCFE) for R1(dated 5/16/25), Staff trainings: Appropriate care of Resident personal hygiene (dated 12/2/24 ), Grooming (dated 5/13/25), Cleanliness (5/13/25), Personal Rights of Residents (dated 5/13/25) and Elder Abuse (dated 11/25/24). LPA observed food supply and facility menu.LPA reviewed (R2-R5) files. LPA conducted 2 staff interviews (S1- S2), Administrator (A1), and 3 resident interviews (R2-R4 ). Page 1 of 4 Unsubstantiated Investigation revealed the following: Allegation: Staff did not ensure resident's incontinence needs were being met The complaint alleges that during the period of 5/17/25 - 5/18/25 the staff “were not changing and cleaning R1.” On 5/28/25 at 11:56 am, LPA interviewed Administrator (A1) who denied allegation stating that staff tends to all residents’ incontinent needs, "they are always changed when they need to be and the staff constantly check to see if the resident needs changing." A1 further stated that “As long as they are wet, the staff will change them at once.” Lastly, A1 informed LPA that the staff checks the residents every hour. On 5/28/25, between 9:30am and 1:00pm, LPA interviewed 2 staff (S1-S2)regarding the allegation and (2) out of (2) staff denied the allegation stating; residents are changed on a regular basis, and they are check often and changed at least 4 times a day depending on the need. (2) out of (2) staff stated that they have adequate training on how to care for residents who are incontinent. On 5/28/25, between 1:00pm and 2:00pm, LPA interviewed 3 Residents (R2-R4)). R1 and R5 could not be interviewed as R1 no longer resides at the facility and R5 is nonverbal. Of those interviewed, 3 out of 3 residents denied the allegation, stating that staff change them on a regular basis, and they are never left wet for a long period of time. On 5/28/25, LPA reviewed staff training regarding care for incontinent residents, which indicates that they have knowledge of how to care for residents who are incontinent. Based on the information gathered, there is insufficient evidence to support the stated allegations Page 2 of 4 Allegation: Staff did not respond to resident’s calls for assistance The complaint alleges that R1 “called for assistance, and no one came.” On 5/28/25 at 11:56 am, LPA interviewed Administrator (A1) who denied allegation stating that "when resident called for assistance, there was a staff right there to assist R1." On 5/28/25, between 9:30am and 1:00pm, LPA interviewed 2 staff (S1-S2) regarding the allegation and (2) out of ( 2) staff denied the allegation stating R1’s needs were tended to when R1 called for assistance. On 5/28/25, between 1:00pm and 2:00pm, LPA interviewed 3 Residents (R2-R4) who denied allegation. (3) out of (3) residents stated that whenever they would call staff, they responded immediately. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff did not provide adequate food service to resident The complaint alleges that “during that time R1 was at the facility, R1 was only fed sandwiches” On 5/28/25, at 11:56 am, LPA interviewed Administrator (A1) who denied allegation stating they provide adequate food that is nutritious to the residents. On 5/28/25, between 9:30am and 1:00pm, LPA interviewed 2 staff (S1-S2) regarding the allegation and (2) out of (2) staff denied the allegation, stating that they serve adequate and nutritious food and that at no time was any resident served only sandwiches for a meal. On 5/28/25, between 1:00pm and 2:00pm, LPA interviewed 3 Residents (R2-R4) who denied allegation. (3) out of (3) residents stated that they are served nutritious food and they are never served "just sandwiches." Additionally, 3 out of 3 residents stated that they get enough to eat at the facility. On 5/28/25, between 11:00 and 12:00pm, LPA observed food service and the facilities food supply. LPA observed an ample supply of food for the residents in care. Page 3 of 4 Based on the information gathered, there is insufficient evidence to support the stated allegation. Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. There were no deficiencies cited during today's visit. Exit interview conducted and report provided to Nelson Ortega, House Manager Page 4 of 4the state’s words, verbatim · CDSS document, May 28, 2025 · control 11-AS-20250519111719

Type of visit: Required - 1 Year

On 10/03/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manager Nelson Ortega. LPA explained the purpose of today’s visit. Ortega contacted the administrator Virgina Asis who later was present during the visit. The facility is licensed to operate for (6) non-ambulatory of which (2) maybe bedridden elderly adults ages 60 and above. Currently, the facility has no hospice resident in care. The facility is approved for (6) hospice residents. The facility consists of two (2) floor levels: the first floor consists of (3) resident bedrooms all of which are shared rooms, (2) restrooms, kitchen, dining room, living room, and attached 2 car garage. The second floor consists of 3 bedrooms occupied by staff. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 114.8 degrees F. A comfortable temperature of 77 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguisher were charged. The facility has conducted emergency fire drills on 04/06/24. A review of the Medication Administration Record (MAR) was observed to be maintained in order. (Evaluation Report continues LIC 809-C) LPA observed First Aid Kit was maintained. A working landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 08/19/23 through 08/19/24. The facility is current with CCLD annual license dues. An audit of residents #1-#4 (R1-R4) service files and staff #1-#4 (S1-S4) personnel files. The facility has the current administrator's certification on file for Virginia Asis #7010477740 Expiration 09/08/25. DEFICIENCIES: Non-operable smoke detector in resident room #1. Disinfectant Spray left out on top of kitchen trash bin accessible to resident in care. No window screen for resident room #2. Staff #1 and #2 did not have direct care training completed. Staff # 2 and #4 did not have current CPR/First Aid completed. Resident #3 not on hospice care had full extended bed rails without physician's prescription. Facility had no night "awake" staff for (3) out of (4) residents diagnosed with Dementia. Civil Penalties issued for repeat violations. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 809-D). An exit interview conducted with Nelson Ortega, a copy of report and appeal rights 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) are cleared. *the state’s words, verbatim · CDSS document, Oct 3, 2024

Allegation investigated: Saff are not allowing resident to have visitors

On 01/25/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met with House Manager, Nelson Ortega, and the purpose of today's visit was explained. During today's visit, LPA toured the facility, received documents pertinent to the investigation, interviewed Staff (S1-S4), interviewed Residents (R1-R4), and Resident's POA. Documents received and reviewed are the Admission Agreement (12. Facility Visiting Policy), resident Identification and Emergency Information, Visitor Logbook, and Prevention, Containment, Mitigation Measures for Coronavirus Disease 2019 (Covid-19). The investigation revealed the following: Continued on LIC9099-C Unsubstantiated Allegation: Saff are not allowing resident to have visitors. The allegation alleges that the staff are sick and not allowing visitors to visit Residents during the weeks of 01/07/24 to 01/20/24. During file review, LPA reviewed the Visitor Logbook that show visitors during the weeks of 01/07/24 to 01/20/24. During interviews with Staff (S1 and S2), two (2) out of two (2) stated during those dates’ residents had a cough and a fever. S1 stated the families were notified, residents were tested for Covid-19, and we were isolating until residents had a second negative Covid-19 test to make sure. Additionally, S1 stated once residents were tested negative, we let families know and they had visitors. When visitors came, we did let them know if their resident was sick but we never denied entry. Staff S1, additionally stated, some of the resident’s families dropped items off for the resident. S1 stated the only visiting restrictions we have is for Resident R2 who has a visitor list that the Responsible Party has listed of who is able to visit R2 and if they are not on the list R2’s Responsible Party will inform staff a visitor is coming, including friends, family, and medical providers. During interviews with Residents (R1-R4), four (4) out of four (4) stated they have been informed of the Visitor Policy, have no concerns regarding the Visitor Policy, and have had no issues with friends, family, or medical providers visiting. R1 and R3 stated there were a few days they did not have visitors due to a cough and fever and they made sure it was not Covid-19, and visitors came after that. Continued on LIC9099-C LPA spoke with R3’s Responsible Party, who stated they have no concerns regarding the Facility Visiting Policy, and that staff called and informed them R3 was sick and kept them posted on testing, R3’s condition, and ensured they were able to speak on the phone. Additionally, R3’s Responsible Party stated staff informed them when R3 was confirmed not to have Covid-19 and when they were able to return for visiting. LPA reviewed the Facility Visiting Policy (#12 in the Admission Agreement) that states the hours and protocol of visiting. Upon review of the Prevention, Containment, Mitigation Measures for Coronavirus Disease 2019 (Covid-19) that states on number 7. “We will be restricting individuals who have respiratory Symptoms or potential Covid-19 exposure out of an abundance of caution…” During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated. During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with House Manager, Nelson Ortega, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 25, 2024 · control 11-AS-20240122091659

Type of visit: Required - 1 Year

On 12/28/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Nelson Ortega/Caregiver and later Virgina Asis/Designee Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) non-ambulatory elderly adults ages 60 and above and approved hospice waiver for (6). (2) May be bedridden. Bedroom #3 is cleared for (1) bedridden client. The home consists of two (2) floor levels: the first floor consists of (3) resident bedrooms all of which are shared rooms, (2) restrooms, kitchen, dining room, living room, and attached 2 car garage. The second floor consists of 3 bedrooms occupied by staff. LPA Iniguez toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (3) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #1, #2, and #3. smoke and carbon monoxide combo are all operable conditions. The water temperature ranged from 102.5F° – 118.2F°. The room temperature ranged from 76F° – 78F°. Evaluation Report continues on LIC 809-C LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. Working landline phones are available on-site. LPA reviewed (3) residents' service files (R#1-R#3) and (3) staff personnel files (S#1-S#3). Medication Administration Records (MAR) were maintained in order. First AID lit was checked. Last fire disaster drill was on: None. Licensee will email copy of liability insurance to LPA. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview conducted with Ortega Nelson /Caregiver and a copy of the appeal rights were given at the time of the visit.the state’s words, verbatim · CDSS document, Dec 28, 2023