Sapphire Sunset

Type of visit: Required - 1 Year

On 7/31/26, Licensing Program Analyst (LPA) Kyle Wellington arrived unannounced to conduct an annual inspection. LPA was greeted and granted entry by Caregiver, Marife Balabag, who was informed of the purpose of the visit. LPA met with Administrator (Admin), Daphne Drapeau, who arrived shortly thereafter and was also informed of the purpose of the visit. The census at the facility is six (6) residents. LPA received a staff and resident roster from Admin. LPA toured the inside and outside of the facility with Admin. LPA conducted an observation and record review for the inspection. Facility Overview: Facility is a one story house with five (5) resident bedrooms, two (2) resident bathrooms, kitchen, dining room, family room, laundry room, office, staff room and attached garage. There are no pools, bodies of water or firearms at the facility. Facility has a rock cascading waterfall in the backyard that does not pose a safety risk to residents in care. Facility has a fire clearance for six (6) non-ambulatory adults of which six (6) may be bedridden. Facility was granted a hospice waiver for six (6) residents.. Infection Control: LPA observed hand sanitizers and soap dispensers throughout the facility. Cleaning equipment and additional cleaning supplies were kept in the locked garage and available for regular facility maintenance. LPA reviewed the facility’s infection control plan which met the department’s requirements. Physical Plant: LPA observed the inside and outside of the facility to be clean, safe and well kept. The floors, windows and doors were clean and well maintained. The living room and dining room furniture was in good repair. The residents’ bedrooms were neat, organized and contained the required bedding, lighting and furniture. Bathrooms were clean, tidy and had paper towels, soap, grab bars and non-slip floors in the showers. Extra linen and towels were kept in closets in the hall. Laundry equipment appeared to be in good working condition. Laundry supplies were kept in the locked laundry room. One (1) fire extinguisher was charged and last tested on 7/25/26. LPA tested one (1) of the smoke and carbon monoxide detectors and found them to be hard-wired and operational. The backyard was free of hazards and contained outdoor furniture and shaded area for the residents. Kitchen/Food Service: LPA observed the kitchen to be sanitary, organized, and well maintained. The kitchen had the ability to prepare and store food in a safe and clean environment. Kitchen appliances appeared to be in good working condition. All sharp objects were kept in a locked drawer in the kitchen inaccessible to residents. Cleaning supplies were kept in a locked cabinet under the kitchen sink inaccessible to residents. Facility has over a two day supply of perishable foods and over a seven day supply of non-perishable foods. Care & Supervision: LPA observed one (1) staff and six (6) residents at the facility during the inspection. Facility has sufficient staff to supervise the residents. Administration: LPA observed facility sketch, emergency and disaster plan, personal rights, resident bill of rights, complaint procedures and long-term care ombudsman information posted in the hall near the kitchen. Admin holds a current Administrator Certificate, CPR/First Aid Certificate and a Criminal Record Clearance. Record Review and Resident/Staff Files: LPA reviewed the records of three (3) resident files and two (2) staff files. Staff have a a CPR/first aid certificate, criminal record clearance and are associated with the facility. The files contained all the required documentation and paperwork. The staff and client files were kept on an ipad that is locked and inaccessible to unauthorized individuals. Health Related Services/Incidental Medical Services: LPA observed clients' medications were centrally stored in the locked office inaccessible to residents. First aid kit was kept in the locked office and it contained all the required items. LPA reviewed three (3) residents' medications to the facility’s medication log to make sure all medication was accounted for and dispensed correctly. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan. It is current and up to date. Fire drills are done quarterly and last done on 3/24/26. Facility's property and liability insurance is current and expires on 3/20/27. All facility exits had signage and were clear of obstructions. No deficiencies were cited during this visit. An exit interview was conducted with Administrator, Daphne Drapeau and a copy of this report was given to Administrator, Daphne Drapeau.the state’s words, verbatim · CDSS document, Jul 31, 2026

Type of visit: Required - 1 Year

On 7/15/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Caregiver, Marife Balabag who was informed of the purpose of the visit and has a criminal record clearance. LPA met with Administrator, Daphne Drapeau who was already present and also informed of the purpose of the visit. The facility has a fire clearance to serve six (6) non-ambulatory/bedridden elderly residents. The facility also has an approved hospice waiver for six (6) but LPA was informed none of the current residents are receiving hospice services at the facility. During today's visit, there was two (2) staff and six (6) residents present. LPA toured the facility with the administrator and observed the facility is made up of a one-story home with five (5) resident bedrooms, two (2) bathrooms, a kitchen, dining area, living room, medication room, laundry room, staff room, and attached garage. Resident bedrooms had the required bedding, furniture, and lighting. Bathrooms had grab bars and non-skid mats in the showers. The facility has a cascading rock waterfall feature installed on their landscape in the backyard. However, the waterfall feature is not a fishpond, wading pool, hot tub, swimming pool or anything close to larger bodies of water that may pose a risk to residents in care. Indoor and outdoor pathways were free of obstruction. Outside shaded seating is available for the residents in care. The facility met Departmental requirements for a two-day supply of perishable foods and seven-day supply of non-perishable foods. Medications are secured in the locked medication room. Administrator tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted near the kitchen last serviced on 6/25/2025. The facility's certificate of liability insurance expires on 12/12/2025. Administrator showed LPA the residents' digital records which had Departmental required documentation. LPA reviewed the facility's Emergency Preparedness Training noting the facility's last emergency disaster drill was conducted on 6/30/2025. Long Term Care Ombudsman's contact information, residents' personal rights, emergency disaster plans, complaint procedures, and facility sketch are visibly posted on the hallway wall leading to the living room. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to the administrator.the state’s words, verbatim · CDSS document, Jul 15, 2025

Allegation investigated: Resident sustained multiple injuries due to lack of supervision by facility staff Resident went missing due to lack of supervision by facility staff

Licensing Program Analyst (LPA), Janette Romero arrived unannounced to the facility to deliver findings of an investigation into the allegations listed above. LPA met with Administrator, Daphne Drapeau and explained the purpose of the visit. Regarding the allegations “Resident sustained multiple injuries due to lack of supervision by facility staff” and “Resident went missing due to lack of supervision by facility staff”, it was alleged that staff failed to provide supervision for Resident #1 (R1) who was then found on the concrete, face down injured by a street sweeper at approximately 4:45 AM on August 24, 2022. The investigation consisted of records review, interviews, and observations. Unsubstantiated Licensee denied having any knowledge of previous elopement behavior for R1 prior to admission. On December 14, 2022, Department staff observed the facility to be equipped with audible door alarms at the front door, the back French doors leading to the backyard, as well as R1’s bedroom doors leading to the outside. Interview with S1 revealed they did not hear any door alarms on the morning of the incident. A review of Emergency Medical Services (EMS) records revealed they were dispatched at 4:54 AM on August 24, 2022 and responded to the area of 1850 El Norte Parkway in San Marcos, which was one half mile from the facility. EMS observed R1 to have facial trauma, laceration above the left eye, swollen and bloody lip, laceration to the bridge of the nose, and skin tears to both hands and R1 reported to EMS they had too much to drink. R1 was then transported to the hospital. A review of R1’s hospital records dated August 24, 2022 revealed R1 had an odontoid fracture, multiple rib fractures, multiple old fractures of the right clavicle, left scapula, left pubic ramus, and T9 vertebral body, and lacerations to the left hand and face. Although the allegations may have happened or are valid, records reviewed indicated R1 was able to leave the facility unassisted and did not require overnight supervision. Therefore, there is no preponderance of evidence to prove the alleged violations did or did not occur. The allegations are unsubstantiated. An exit interview was conducted, a copy of this report was provided along with Confidential Names list (LIC 811). A review of R1’s Admission Agreement indicated R1 was admitted to the facility April 6, 2022. A review of R1’s Physician’s Report dated January 17, 2022 indicated the categories ‘confused/disoriented’, ‘aggressive behavior’, ‘wandering behavior’, ‘sundowning behavior’, ‘able to follow instructions’, ‘able to leave the facility unassisted’, and ‘able to dress/groom self’ were marked as yes. A review of R1’s Preplacement Appraisal dated March 7, 2022 revealed R1 exhibited short term memory loss, enjoyed smoking outdoors, wandered back and forth in the yard while smoking, avoids front door, did not exhibit exit seeking behavior, can communicate care needs, was aware of surroundings, awake by 9:00 AM, asleep by 10:00 PM, did not have sleep disturbances as long as bedtime medications are taken, and did not require special observation/night supervision due to confusion/forgetfulness/wandering. R1’s Individual Service Plan dated March 3, 2022 revealed R1 was a risk for fall/injury secondary to their diagnosis. The Pre-Placement Appraisal, Physician’s Report, and Individual Service Plan did not indicate R1 had any elopement behavior. Interview with facility Staff #1 (S1) indicated they were sole staff on duty the night of August 23, 2022 into the morning of August 24, 2022. S1 reported their normal routine is to check on the residents twice during the night, once at 1:00 AM and then again sometime between 3:30 AM and 4:30 AM. S1 reported R1 went to bed between 7:00 PM and 8:00 PM on the night of August 23, 2022 after taking their medications and was acting fine and normal. S1 reported they checked on R1 at 4:30 AM on the morning of August 24th and observed R1 to be sleeping. S1 reported R1 frequently smoked in the backyard but had never left the property before. S1 reported that at 8:00 AM on the morning of August 24th they went to R1’s room and after discovering R1 was missing they had observed the backyard gate on the north side of the property partially open. Interviews were conducted with separate relevant parties and those parties reported the following timelines obtained by their interviews with S1: one relevant party reported S1 told them S1 had checked on R1 between 4:30 AM and 5:30 AM. Another relevant party reported S1 told them R1 went to bed between 9:00 PM and 10:00 PM and that S1 had checked on R1 at 3:00 AM and again between 4:30 AM and 5:00 AM.the state’s words, verbatim · CDSS document, Nov 4, 2024 · control 18-AS-20220826154813

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Janette Romero arrived unannounced to the facility to conduct a case management visit to address a deficiency observed during the investigation of complaint control number 18-AS-20220826154813. LPA met with Administrator, Daphne Drapeau. On August 24, 2022 at approximately 8:00 AM, Resident #1 (R1) was discovered missing from the facility. An interview conducted with Staff #1 (S1) revealed they immediately contacted Licensee, Ali Naghibi to inform them of the missing resident rather than call local law enforcement. Furthermore, phone records reviewed revealed R1’s responsible party was not notified R1 was missing until 9:32 AM. A further review of phone records revealed local law enforcement still had not been contacted by 10:39 AM. An interview with San Diego County Sheriff's Department staff revealed a call was finally received from the facility at 11:12 AM to report R1 missing. Therefore, the facility failed to contact R1’s responsible party and local law enforcement to report R1 was missing in a timely manner. The following deficiency was cited per Title 22, Division 6 of the California Code of Regulations on the attached LIC809-D. An exit interview was conducted, and a copy of this report was provided along with Appeal Rights as well as Confidential Names list (LIC 809).the state’s words, verbatim · CDSS document, Nov 4, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Nov 11, 2024

The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by: The licensee did not ensure 911 was contacted immediately after staff discovered R1 was missing at 8:00 AM. Based on interviews conducted and records reviewed, local law enforcement was not contacted until 11:12 AM. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 4, 2024

Plan of correction: Administrator Drapeau stated the facility will conduct a staff refresher training regarding 'Incidental Medical and Dental Care'. Proof of correction will be submitted to LPA by close by of business on 11/11/2024.

Type of visit: Required - 1 Year

On July 31, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator. The facility file review was conducted at the Regional Office and additional records were reviewed on site. LPA Mixson toured the facility along with the Administrator, and made observations. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. Physical Plant: The facility phone number is (760) 233-0302 and it is operable. LPA Mixson observed the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguisher. LPA Mixson observed required postings such as "If you See Something, Say Something" and the "Personal Rights." The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. The residents and staff files were electronic and were reviewed online. Files are inaccessible to residents in care. Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply on hand. The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. Care & Supervision: Facility has sufficient staff on site currently there are two staff on site. Records Review: LPA Mixson reviewed resident and staff files, conducted staff interviews and resident interviews. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted, and a copy of this report was discussed and given to the Administrator, Ali Naghibi.the state’s words, verbatim · CDSS document, Jul 31, 2024