Serra Mesa Guests Home III

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit for a required Annual Inspection. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Nestor Landas. Administrator Evelyn Salazar later joined the visit. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, ages 60 and over. The facility has an approved hospice waiver for four (4), and bedridden waiver for one (1).. During today’s inspection, there were a total of five(5) residents in care. LPA, accompanied by Nestor, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. (Cont. on LIC 809-C) (Cont. from LIC 809) No pools or bodies of water were observed on the premises. Per Nestor, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) and emergency flashlights were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed staff and resident records. The reviewed files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Evelyn Salazar, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 15, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Director, Evelyn Salazar. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, ages 60 and over. The facility has an approved hospice waiver for four (4), and bedridden waiver for one (1). During today’s inspection there were 6 (six) residents in care. LPA and Director, Evelyn Salazar toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Director, Evelyn Salazar, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Director, Evelyn Salazar to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 6, 2025

Allegation investigated: Facility did not seek resident timely medical attention.

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced complaint visit to deliver findings regarding the above mentioned allegations. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Joy Singson, Caregiver. During today’s visit, LPA observed residents in care and interviewed residents and staff. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the facility did not seek timely medical attention. Interviews and review of medical records revealed that Resident 1 (R1) had an unwitnessed fall at the facility, which resulted in them sustaining a broken femur, and the facility failed to seek timely medical. Interviews and documents reviewed revealed that between October 11, 2023, and October 18, 2023, hospice and facility staff stated R1 would complain of leg pain, but the pain R1 expressed was similar to the pain they have had since the beginning of admission and interviews revealed they didn’t think it was anything serious Substantiated Interviews revealed that R1 remained at Serra Mesa Guest Home III for a week with noticeable pain and significant signs of bruising without being assessed and being seen by a competent doctor to rule out any internal injuries that could not be seen. Interviews revealed that on October 11, 2023, around 4:30 am, R1 rolled out of bed and onto their knees with staff assisting R1 back to the bed shortly after. Interviews and record review revealed that the hospice nurse came to examine R1 around 12:30 PM and stated that R1 showed no signs of pain and had no visible bruising. Interviews revealed between October 11, 2023, and October 16, 2023, that hospice staff and staff stated R1 would complain of leg pain but again the pain they expressed was similar to the pain R1 had since the beginning of admission. Interviews revealed that facility staff and hospice staff stated R1 started showing some visible signs of purple discoloration on their lower extremities hours after the fall and through the date of October 16, 2023. Interviews revealed that staff administered Tylenol to help with the pain from the date of the fall up until R1 went to the hospital. On October 14, 2023, interviews with staff revealed they noticed R1 showing different signs of pain with facial grimaces and contacted hospice. Interviews with hospice staff stated there were no new onset signs of pain and continued administering Tylenol. On October 16, 2023, hospice and staff stated R1 still was showing signs of pain, this time with groaning sounds, and decided to contact R1's son regarding administering morphine to R1 for pain. Interviews revealed the son refused the morphine and preferred R1 get X-rays before giving R1 any narcotics. Interviews revealed that on October 17, 2023, an in-house X-ray technician went to the facility to take X-rays of R1's legs, and on October 18, 2023, results came back stating R1 had a broken leg femur. Interviews revealed that on October 18, 2023, R1 was transported to Kaiser Hospital and did not return to the facility due to the son’s wishes for R1 not to return. Based on the information collected during the investigation, there is enough evidence to support the allegation of the facility failing to seek timely medical; therefore, the allegation is deemed Substantiated. The allegation is valid because the preponderance of the evidence standard has been met. This report has been discussed and a copy was provided to Joy Singson, Caregiver at the conclusion of the visit. S1 stated that during the NOC shift, R1 was restless and the only resident who wouldn’t sleep through the night. Interviews with S1 stated that on October 11, 2023, during their NOC shift, they stayed with R1 by the bedside most of the night. Interviews with S1 revealed that their shift was due to end, and they left R1's room for about 15 minutes to change another resident’s diaper. Interviews revealed S1 stated when they came back to R1's room, S1 found R1 on their knees next to the bed. Interviews revealed that S1 and S2 both assessed R1 and that R1 complained of no pain and had no visible injuries or bruising. Interviews revealed that staff notified the administrator, and the administrator contacted the hospice care agency and R1's family around 7 am. Interviews and record review revealed that the hospice nurse came to examine R1 around 12:30 PM and also stated that R1 showed no signs of pain and had no visible bruising. Interviews revealed between October 11, 2023, and October 16, 2023, that hospice and staff stated R1 would complain of leg pain, but the pain they expressed was similar to the pain R1 had since the beginning of admission. Interviews revealed that the facility staff and hospice staff stated R1 had started showing some visible signs of purple discoloration on their lower extremities hours after the fall and through the date of October 16, 2023. Interviews revealed that staff administered Tylenol to help with the pain. On October 14, 2023, interviews with staff revealed that is when they noticed R1 showing different signs of pain with facial grimaces and contacted hospice. Interviews with Hospice stated there were no new onset signs of pain and continued administering Tylenol. On October 16, 2023, hospice and staff stated R1 still was showing signs of pain, this time with groaning sounds, and decided to contact R1's son to see if it was okay to administer morphine to R1 for pain. Interviews revealed the son refused the morphine and stated that he preferred moving forward with x-rays before giving R1 any narcotics. On October 17, 2023, an in-house X-ray technician went to the facility to take X-rays of R1's legs, and on October 18, 2023, results came back stating R1 had a broken leg femur. Interviews revealed that the hospice agency provided the transportation and transported R1 to Kaiser Hospital. Interviews revealed that R1 was a fall risk, and Serra Mesa Guest Home had preventative measures to protect R1 from falling, such as a half-bed rail, bed alarms, fall mats, and low-level mattresses. Interviews revealed that facility staff were instructed to check on R1 every two hours and reposition R1. Interviews revealed R1 did not have one one-on-one care at the facility, and staff were not required to stay at their bedside through the night but did so to provide extra support and company for R1. It was alleged that the facility did not follow reporting requirements. Interviews revealed that the facility staff provided the documents showing that they reported the incident to Community Care Licensing (CCL) and that the incident report revealed the incident regarding R1. Based on the information collected during the investigation, there is not enough evidence to support the allegation of neglect to resident resulting in serious bodily injury and facility did not follow reporting requirements; therefore, the allegation is deemed Unsubstantiated. This report has been discussed and a copy was provided to Joy Singson, Caregiver at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 08-AS-20231023085742

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jul 23, 2025

A plan for incidental medical care shall be developed by each facility. The plan shall encourage routine medical care and provide for assistance in obtaining such care by... The licensee shall arrange or assist in arranging for medical care appropriate to the conditions and needs or residents... This requirement was not met as evidenced by: Based on interviews and records review, the licensee delayed medical attention for 1 of 6 residents (R1) that expressed pain for 7 days which posed an immediate health, safety or personal risk to persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2025

Plan of correction: Administrator agreed to have all staff attend a training on Timely Medical Attention for Residents in care. Proof of training will be provided by POC due date of 07/23/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was met by Caregivers, Danilo Samonte and Joy Singson. Licensee, Evelyn Salazar, arrived later and LPA discussed with Ms. Salazar, the purpose of the visit. All staff present possessed a current criminal record clearance. Salazar is the Certified Administrator for the facility. LPA conducted a tour of the facility, both inside and outside. There were two (2) staff members to provide for the residents in care. The residents all stated that they were treated with dignity by facility staff and produced no concerns in their interviews. The facility is operating in accordance with their fire clearance. The smoke and carbon monoxide alarms were present. Caregiver, Samonte stated that there are no firearms stored on the premises. The facility thermostat read at 77.0 degrees F. Hot water temperatures measured 111.3- and 111.7-degrees F in the resident bathrooms and 113.4 at the kitchen sink. Each toilet and bathtub/shower had grab bars for resident use and each bathtub/shower had nonskid mats or strips. Each resident room had sufficient lighting. The facility exceeded the minimum of one (1) week of nonperishable foods and a minimum of two (2) days of fresh perishable foods. Medications are centrally stored and secured in the kitchen. Facility records were also reviewed. The disaster plan was available in the hallway by the kitchen and was updated April 17, 2024. On 1/27/2024, facility coordinated a fire/earthquake drill per the facility log. Staff records were reviewed and indicated current training including, medications and prohibited conditions. Review of Resident records indicate that in each of the files reviewed, there is a current Medical Assessment, and an Admission Agreement. Ms. Salazar provided the declaration sheet for the facility's current liability insurance. The coverage amounts, meet minimum requirements as required, and expires on 03/28/2025. Licensing and infection control postings were prominently placed. [Continued on LIC8090-C] [Continued from LIC-809] No deficiencies were cited during today’s inspection. An exit interview was conducted, and a copy of this report was provided to Ms. Salazar, and she was provided a copy of the Licensee/Appeal rights (LIC9058 01/16). Ms. Salazar’s signature on this form, acknowledges receipt of these rights.the state’s words, verbatim · CDSS document, Apr 17, 2024