Siebenthal Care Home

Type of visit: Case Management - Legal/Non-compliance

A Non- Compliance Conference (NCC) was conducted today July 8, 2026 at 11:30 AM via Microsoft Teams with the Sacramento South Regional Office. The purpose of this Non-Compliance Conference meeting was to discuss Non-Compliance citations issued to the facility. Present in this meeting is Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Lisa Rios, Licensing Program Manager (LPM) Arielle Pascua, Licensing Program Analyst (LPA) Shakaricka Hughes, Licensee/Administrator of Siebenthal Care Home Ermelinda Siebenthal and Elaine Castro. During this virtual meeting, the Non-Compliance Conference process was explained to the licensee. A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and the LIC 9111 was provided to the licensee. On 10/30/2025, the facility attended a Non-Compliance Conference (NCC) to address ongoing compliance concerns, including citations issued between 07/2023 to 6/2025. During that period, the facility received four (4) Type A citations in areas of Incidental Medical and Dental care, Basic services requirements, Administrator qualifications, Health screening, and Criminal record clearance. The facility also received Type B citations in the areas of; Personnel Requirements, Night supervision, Resident appraisal, Reporting requirements, Incidental Medical and Dental Care, Personal Rights, and Postural Supports. On 01/30/2026, the facility successfully completed participation in the Technical Support Program (TSP). Continuation 809-C As part of the conference, the facility agreed to implement corrective actions, including conducting weekly medication log audits, ensuring all staff members are background cleared and properly associated to the facility, providing staff training, ensuring residents are appropriately monitored to prevent elopement, and reporting incidents to appropriate agencies within the required time frame. Since the last Non-Compliance Conference, the facility has continued to demonstrate a pattern of noncompliance. On 03/10/2026, the facility received two (2) Type A citations for violations related to Limitations and Capacity Status, Incidental Medical and Dental Care Services. Additionally, a compliant investigation resulted in a substantiated finding that unlicensed care was being provided in the licensee’s private residence. The facility has stated they will agree to do the following: Attend a vendor training on Resident Assessments, Care plans, and Resident Evictions for all active administrators working inside the facility. The Facility will update LPA on their choice of vendor training by 07/15/2026, and training will be completed no later than 07/31/2026. Update LIC 500 Personnel Report, including additional administrator oversight in the facility weekly. During today’s meeting the facility requested re-engagement of the Technical Support Program (TSP) and currently awaiting contact from a TSP representative. In addition, the Regional Office will continue to conduct unannounced quarterly visits to monitor the above and overall compliance for 12 months from the date of this meeting.the state’s words, verbatim · CDSS document, Jul 8, 2026

Type of visit: Case Management - Other

On 04/27/2026 Licensing Program Analyst (LPA) Shakaricka Hughes conducted an unannounced Case Management Quarterly visit to the facility. LPA met with the facility administrator Ermelinda Siebenthal and explained the purpose of today's visit. The current census is 5 with 1 facility staff present. The following was reviewed during today’s visit; facility staff health screening and criminal record clearances, Incidental medical including staff training on medications, staff training regarding personal rights, dementia, elopement, and reporting requirements. LPA checked Guardian for 5 out of 5 facility staff currently associated with the facility, staff criminal record clearances, and a review of staff records indicated that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. LPA checked facility staff training regarding Medication Administration, Dementia Care, Elopement, and Resident Personal Rights and observed 4 out of 5 staff have completed training. LPA observed a facility staff (S1) who recently began working in the facility and is currently completing hands on training at the facility. LPA checked medication storage and found medication locked in a medication cart and inaccessible to residents in care. LPA reviewed 3 out of 5 residents Medication Administration Record (MAR) and it was observed complete. LPA observed facility records and observed the facility has continued to meet CCLD reporting requirements. No citations were issued during today's visit. An exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 27, 2026

Type of visit: Case Management - Deficiencies

On 3/24/2026 Licensing Program Analyst (LPAs) Shakaricka Hughes and Pang Lee conducted an unannounced visit to the facility. The purpose of the visit was to clear ensure previously cited deficiencies have been corrected. LPAs met with the licensee to review plans of correction. On March 10, 2026 the facility was cited under Title 22 regulation 87204(a) Limitations- Capacity and Ambulatory Status. LPAs toured the facility and observed the current facility census is (6) residents. LPAs did not observe resident (R1) in the facility at the time of the visit. The licensee stated that the resident was sent to the hospital on March 16, 2026 and will not be returning to the facility. An exit interview was conducted, and a copy of this report and POC letter was generated and provided to the facility.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Required - 1 Year

On 3/10/2026 at 10:00 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Hughes met with the facility licensee/administrator Ermelinda Siebenthal. The current census is 7 with 1 facility staff present. This facility is a single story building licensed to serve (6) non-ambulatory residents, however at the time of the visit the facility reported a census of seven (7) residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 111.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the entry way and was last serviced on 01/06/2026. LPA observed the facility has a public telephone in the common area and the facility has the required posters posted. Facility thermostat was observed at 74 degrees Fahrenheit. LPA observed toxins located in the kitchen cabinet and laundry storage cabinet kept locked and inaccessible to residents. LPA observed sharp knives kept locked in the kitchen and inaccessible to residents. Continuation 809-C LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 3 out of 7 residents medications and the medication administration record (MAR) was not complete for one (1) resident. LPA observed the medication administration record for resident (R1) for one (1) medication incomplete for 9 days for the month of March 2026. The first aid kit was checked and contained the required components. LPA requested resident and staff files for review. LPA reviewed 7 out of 7 resident files and they were complete. LPA reviewed 5 staff files, and it was complete. LPA reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. The following documents will be email to LPA by 03/12/2026 (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (3) LIC 610 Current Emergency Disaster Plan (4) Proof of Current Liability Insurance (5) LIC 500 Current Personnel Report As a result of this annual visit, the facility is not in compliance with Title 22 Regulations, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Ermelinda and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Mar 10, 2026

Type of visit: Case Management - Other

On 1/26/2026 Licensing Program Analyst (LPA) Shakaricka Hughes conducted an unannounced visit to the facility. LPA met with the facility administrator Ermelinda Siebenthal and explained the purpose of today's visit. The current census is 6 with 1 facility staff present. The following was reviewed during today's visit; facility staff health screening/ criminal record clearance, Incidental medical- staff training on medications, facility partnership with Galt pharmacy regarding Medication training, and accessibility of medication cart. Staff training regarding personal rights, dementia, elopement, reporting requirements LPA checked Guardian for 5 out of 5 staff associated to the facility, staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. LPA checked facility staff training regarding Medication Administration, Dementia care, elopement, and Resident Personal Rights and observed 5 out of 5 staff have completed training. LPA asked the administrator about the facility partnership with Galt pharmacy, administrator stated that the partnership with the pharmacy has started, and that the medication cart has been delivered to the facility. LPA checked medication storage and found medication to be locked away and inaccessible to residents located inside a Medication cart. LPA reviewed 2 out of 6 residents medications and the medication administration record (MAR) was complete. LPA review facility records, and observed the facility has consistently reported concerns, and incidents in the facility on the LIC 624 report. Continuation 809-C LPA provided Title 22 regulation 87628 Diabetes, as the facility has questions regarding residents with Diabetes insulin injections, which will be covered during the next facility training with Galt Pharmacy. LPA explained that the facility is not permitted to perform glucose testing and administration of medications through injections to residents in care unless the administration is through a skilled professional. No citations were issued during today's visit. An exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 26, 2026

Type of visit: Case Management - Other

On 12/30/2025 at 12:30 PM LPA Shakaricka Hughes conducted an unannounced visit to the facility. The purpose of this visit was to conduct a case management visit. LPA met with the facility licensee/administrator Emerlinda Siebenthal. The current census is 6 with 2 facility staff present. During today's visit LPA spoke with the administrator regarding an incident that occurred in the facility on 12/11/2025 regarding a resident (R1) and a visitor to the facility. Administrator stated that R1's visitor was able to be redirected, and able to visit the resident. LPA reviewed the facilities visiting policy in the resident Admissions Agreement with the facility administrator. The facility stated that they will implement additional rules related to visiting in order to ensure the health and safety of all residents in care and facility staff. Administrator stated that the facility staff reviewed previous training related to workplace violence in order to ensure compliance in the facility. Additionally, LPA reviewed new securement physician orders for residents (R1)(R2)(R3) to ensure that residents methods for securement were in compliance with Title 22 regulation 87608 Postural Supports. LPA also requested to review resident LIC 602 Physician's Report to ensure that the use of postural supports was authorized by a physician. However the administrator stated that the LIC 602 for the residents will be updated to include the changes to residents needs, and sent to the LPA for review. No citations were issued. An exit interview was conducted with Emerlinda, and a copy of the LIC 809 was provided to the facility.the state’s words, verbatim · CDSS document, Dec 30, 2025

Type of visit: Case Management - Legal/Non-compliance

A Non- Compliance Conference (NCC) was conducted today October 30, 2025 via Microsoft Teams with the Sacramento South Regional Office. The purpose of this Non-Compliance Conference meeting was to discuss Non-Compliance citations issued to the facility. Present in this meeting is Regional Manager (RM) Stephanie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, Licensing Program Analyst (LPA) Shakaricka Hughes, Licensee/Administrator of Siebenthal Care Home Ermelinda Siebenthal. During this virtual meeting, the Non-Compliance Conference process was explained to the licensee. A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and the LIC 9111 was provided to the licensee. Citations from 07/2023 to 6/2025- Four (4) Type A citations in areas of Incidental Medical and Dental care, Basic services requirements, Administrator qualifications, Health screening, and Criminal record clearance. Type B violations in the areas of; Personnel Requirements, Night supervision, Resident appraisal, Reporting requirements, Incidental Medical and Dental Care, Personal Rights, and Postural Supports. Issues discussed related to the above include: 1. Incidental Medical and Dental Care 2. Criminal Record Clearance Continuation 809-C 3.Administrator Qualifications 4. Staff Training 5. Reporting Requirements The facility has stated they will agree to do the following: 1. Incidental Medical and Dental Care- Implement weekly audits and create electronic files for medications administration logs. The facility stated that a partnering with Galt Pharmacy will assist the facility with hands-on training for staff, including providing a Medication cart to ensure medications are inaccessible to residents in care. Licensee will update the facility Plan of Operation stating changes to Incidental Medical and Dental Care by December 01, 2025. 2. Criminal Record Clearance- Ensure all facility staff are background cleared and associated in Guardian. 3. Staff Training- All facility staff will receive no less than 1 hour of training each 6 months regarding Personal Rights and Dementia Training specifically focused on understanding and managing challenging behaviors and behavioral expressions associated with Dementia. 4. Elopement (AWOL)- The facility will ensure proper monitoring of residents. The method of Monitoring systems used by the facility should be added to the facility Plan of Operation Dementia care plan by December 01, 2025. 5. Reporting Requirements- The facility will implement a system to ensure Special Incident Reports (SIRS) or reported to the appropriate agencies in a timely manner. During today’s meeting it was discussed that the facility has been enrolled in the Technical Support Program (TSP) and currently awaiting engagement from a TSP representative. The Regional Office (RO) will continue to monitor the facilities’ progress. The RO will continue increased monitoring to verify compliance with issues discussed The RO will revisit compliance in 12 months and begin the legal process if facility is not in compliance.the state’s words, verbatim · CDSS document, Oct 30, 2025

Type of visit: Case Management - Incident

On 9/30/2025 at 11:10 AM Licensing Program Analyst (LPA) Shakaricka Hughes conducted an unannounced visit to the facility. The purpose of the visit to was follow-up on a incident that occurred at the facility on August 19, 2025. LPA spoke with facility administrator Lita Siebenthal. The current census is 6 with 2 facility staff. On August 19, 2025 LPA Shakaricka Hughes received an email from the facility regarding residents in the facility being handled aggressively while being on a walk around the facility. The report was witnessed by an individual outside of the facility. LPA spoke with facility administrator regarding facility staff (S1), returning to work in the facility. Administrator stated that facility staff has been on leave from the facility pending review of the incident by CCLD. Administrator has provided a correction plan for facility staff (S1), and has re-trained all facility staff with a training course provided by CCLD Violence in the Workplace and has also conducted various trainings with an outside training vendor. LPA has referred the facility to the Technical Support Program (TSP) for additional assistance to ensure the facility meets licensing requirements. Additionally, LPA discussed with the administrator how the facility will ensure the health and safety of all residents in care. Administrator has provided a statement via email stating how the facility will prevent incidents from happening in the facility. CCLD South Sacramento RO has scheduled a Non Compliance Conference with the Licensee/Administrator to discuss methods to ensure the facility remains in compliance with Title 22 regulations. An exit interview was conducted with Licensee/Administrator Lita, and a copy of this LIC 809 report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 30, 2025

Type of visit: Case Management - Incident

On 9/2/2025 at 12:50 PM Licensing Program Analyst (LPA) Shakaricka Hughes conducted a case management visit to the facility regarding an incident that occured on 8/19/2025. LPA met with facility administrator Ermelinda. The current census is 6 with 2 facility staff. LPA conducted an interview with a witness of the incident, who confirmed observing the incident and reported that facility staff were acting aggressively toward residents. Additional interview with the facility administrator confirmed that the incident was not observed by the administrator, but information was obtained through witness and staff reports and video recordings obtained from the witness. The facility reported the incident to CCL LPA Hughes, documented the incident, corrective actions were implemented including the suspension of facility staff (S1) pending the outcome of the investigation of the incident. There were no deficiencies observed or cited during today's case management visit. An exit interview was conducted with facility administrator Ermelinda, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 2, 2025

Allegation investigated: Staff are inappropriately restraining a resident in care. Staff are forcing residents to drink water.

On 7/29/2025 at 12:00 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced complaint visit. LPA Hughes met with caregiver Ermelinda Siebenthal and explained the purpose of the visit. The current census is 6 with 2 facility staff. Staff are forcing residents to drink water It was alleged that staff are forcing residents to drink 2 to 4 metal cups of water before they are able to leave the table. This investigation consisted of facility observation, and interviews with staff and residents. On 7/1/2025 LPA Hughes conducted a visit to the facility, upon observation of the facility residents were seen sitting at the kitchen table having lunch. Interview with 3 out of 5 residents indicated that they had no concerns regarding being required to drink water. Additionally, an interview with 2 out 3 facility staff indicated that residents are required to consume water as part of their daily routine. Continuation 9099-C Substantiated Interview with S1 confirmed that residents, “have too drink water” without additional explanation on why residents are required and cannot choose whether they want to drink water. This was observed not in compliance with Title 22 regulation 87468.2(a)(3) Additional Personal Rights of Residents in Privately operated facilities.The facility did not ensure that residents in care were protected from coercion. Interviews and observations revealed that staff were requiring residents to drink a specific amount of water determined by the facility, and residents were reportedly not permitted to leave the table until they had complied. Staff are inappropriately restraining a resident in care It was alleged that staff inappropriately restrained a resident in care. Staff were observed tying an apron around the waist of a resident in care. This investigation consisted of facility observations, interviews with staff, and records review. On 7/1/2025 LPA Hughes conducted an unannounced facility visit and observed resident (R3) sitting at the dining table having lunch, with a helmet on their head. On 7/25/2025 LPA Gould conducted an unannounced facility visit, and observed two gait belts on the kitchen table, per LPA Gould, interview with 1 out of 1 facility staff indicated the belts are used for R1 and R3 to secure the residents to the kitchen table chairs. Facility staff demonstrated how the Gait belts are used on LPA Gould, while sitting at the kitchen table, securing the LPA to the kitchen chair. On 7/29/2025 LPA Hughes conducted an interview with facility administrator, administrator stated that gait belts are used to guide the residents. Resident (R3) wears a gait belt whenever she is unsteady. A review of resident (R3) LIC 603A Resident Appraisal indicates that resident’s ambulatory status and functional capabilities do not require the use of assistive devices such braces or crutches. However, R3 has a physician’s order on file indicating the use of a gait belt for assistance with mobility/transfers with staff support. The order does not specify the use of a gait belt for the purpose of securing the resident to a chair. This was observed not in compliance with Title 22 regulation 87608(a)(5) Postural Supports. The facility did not ensure that residents in care were assisted in a manner that upholds their personal rights, including freedom from being physically restrained or tied. As a result, these allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Lita S and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 27-AS-20250623163519

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(3) · Plan of correction due date: Aug 1, 2025

87468.2 Additional Personal Rights for all Residents in Privately operated Facilities.(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights.(3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, as citizens and as residents of the facility. Residents shall be free from interference, coercion... This requirement was not met as evidenced by: Licensee did not ensure that residents in care were protected from coercion being required to drink a specific amount of water.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Licensee will ensure that the facility is in compliance with Title 22 regulation 87468.2(a)(3). Facility will ensure that residents in care are supported in maintaining adequate hydration while respecting their right to choose when and how much water to consume. Licensee will review the regulations, and provide LPA Hughes with a letter of understanding of the regulation by 08/01/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(5) · Plan of correction due date: Aug 1, 2025

87608 Postural Supports.(a)Based on the individual's preadmission appraisal..(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This requirement was not met as evidenced by: Licensee did not ensure that residents in care were assisted in a manner that upholds their personal rights, including freedom from being physically restrained or tied.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Licensee will ensure that the facility is in complaince with Title 22 regulation 87608(a)(5). Facility will ensure that residents in care are assisted in a manner that upholds their personal rights. Additionally, Licensee will ensure the use of assistive devices will be used in the manner, instructed by physician orders only. Licensee and facility staff will review regulations regarding Postural support and conduct training with facility staff on the proper use of assistive devices. Licensee will provide LPA Hughes with a letter of understanding of the regulation by 08/01/2025.

Allegation investigated: ) Staff gave resident medication that was not prescribed to that resident resulting in hospitalization 2) Staff handled resident in a rough manner resulting in a broken nose 3) Staff did not allow resident to visit/contact family. 4) Staff did not allow resident to leave the facility. 5) staff verbally abused residents 6) Staff financially abused residents 7) staff left residents unsupervised 8) staff forces residents to eat even when they don't want to.

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Siebenthal Care Home RCFE on 7/25/25 at 1:15pm to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Licensee, Lita Siebenthal and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA contacted the Reporting Party (RP) and all co complainants regarding the allegations. LPA conducted interviews with current staff members and any staff members present while at the location in Fort Bragg, CA. LPA was unable to interview the alleged victim as LPA does not know their current whereabouts and no current information was provided to LPA by A1. Report continued on LIC 9099-C Unsubstantiated LPA was unable to interview one of the alleged victims as they passed away prior to being interviewed by LPA. LPA was unable to conduct meaningful interviews with current residents as all residents currently in placement are not cognitively able to respond to interview questions. Per statements obtained from the RP, the hospital could not perform any tests that would indicate resident received a medication not prescribed for them. LPA could not interview this resident as they had passed away prior to being interviewed. Additionally, all staff interviewed denied providing any insulin or medications that would explain low blood sugar upon admission. LPA was unable to obtain any corroborating statements or documentation to support the allegation. LPA is unable to corroborate the allegations of physical, financial or verbal abuse. LPA obtained text messages between one of the co-complainants and the licensee, LPA observed no reported concerns from the co-complainant regarding physical, verbal or financial abuse documented in the text communications between the licensee/facility staff and the co-complainant. LPA observed documentation that R2 had a fall and broken nose prior to being accepted to the facility. Per interviews with facility staff R2 had a nose bleed that could not be stopped and staff applied appropriate pressure to the site to ensure the bleeding stopped and when it was not, they transported R2 to the hospital for evaluation. All co-complainants interviewed, indicated the only evidence was statements obtained form R2 while at the dentist and hospital. Per R2's authorized representative, R2 is diagnosed with dementia and was diagnosed at the hospital with UTI. All staff members denied any abuse or witnessing abuse. LPA asked R2's authorized representative for any documentation or paperwork provided to R2 or them for selling R2's property and Authorized representative has not provided any evidence to LPA and that is not reflective of the text messages observed between facility staff and the authorized representative. Regarding the final allegations of residents being left unsupervised, Resident not able to contact family and residents being forced to eat food when they do not want to are also unsubstantiated. LPA has not been able to obtain any evidence or statements corroborating the allegations. While one co-complainant observed some residents in the car while licensee was at the dentist with R2, they could not confirm whether there was another staff member present in the car with residents providing supervision. Staff members denied leaving any residents unsupervised. Staff members denied restricting phone conversations or contact with family members. Report continued on LIC 9099-C2. Again LPA was unable to obtain any evidence or corroborating statements from co-complainants or witnesses that residents are forced to eat at times when they do not want. All residents who current reside in the facility have a diagnosis of dementia and may need frequent reminders. Staff members denied the allegations and no other evidence has been obtained or provided to corroborate the allegations. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of (Personal Rights, physical abuse) are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 25, 2025 · control 27-AS-20241015163935

Allegation investigated: Staff did not ensure that resident's dietary needs were met Staff spoke inappropriately to resident Staff not accommodating residents needs

On 7/17/2025 at 12:45 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to the facility to conduct a complaint visit. LPA met with administrator Lita Siebenthal and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 6. A brief interview with conducted with Lita Siebenthal. Allegation: Staff did not ensure that resident's dietary needs were met It was alleged that staff did not ensure that resident's dietary needs were met. This investigation consisted of interviews with residents and care, records review, and facility observations. On 5/7/2025 LPA’s Pang Lee and Shakaricka Hughes conducted an unannounced facility visit. Interview with 2 out of 5 residents indicated that residents have no concerns about their dietary needs not being met. Additionally, a review of resident (R2) LIC 602A Physician’s report indicates that R2 has a diabetic diet. A review of the facilities meal menu provided was sufficient in meeting the dietary needs of resident (R2). Continuation- 9099-C Unsubstantiated On 7/17/25 LPA Hughes conducted a follow-up facility visit and observed the facility refrigerator 2-day perishables food supply. Two-day perishables in the facility refrigerator were observed pre-made with dates on the containers; food was observed appropriate for residents with specific dietary needs. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time. Allegation: Staff spoke inappropriately to resident It was alleged that staff spoke inappropriately to resident. This investigation consisted of interviews with witnesses, facility staff and residents. On 4/29/2025, during a visit to the facility witness (1) stated that they observed an interaction between facility administrator and resident (R2) stating that facility administrator spoke inappropriately to resident (R2). Additionally, interview with R2’s private caregiver reflected that there were no concerns of staff speaking inappropriately to residents in care. Interview with 1 facility staff indicated that, staff have not spoken to residents inappropriately and have not witnessed other staff speak to residents inappropriately. Interview with resident (R2) reflected no concern with facility staff speaking inappropriately themselves or other residents in care. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time. Staff not accommodating residents needs It was alleged that staff are not accommodating residents needs. This investigation consisted of interviews with facility staff and residents. On 7/1/2025 LPA Hughes conducted a follow-up visit to the facility. Interview with residents in care reflected that 3 out of 5 residents in care have no concern with staff not accommodating the needs of residents in care. On 7/17/2025 LPA Hughes conducted a follow-up visit and observed facility staff assisting residents with seating for lunch. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Resident (R2) had (1) medication that was signed off as administered but the medication could not be located in the facility, R2’s Centrally Stored Medication Destruction Record (CSMDR) could not be located in the resident’s medication log. Resident (R3) had inconsistencies in the start date and amount of medication on hand. Interview with facility staff revealed that there were known discrepancies in medication administration, which had not been addressed or corrected at the time of the facility observation. This allegation was observed not in compliance with Title 22 regulations 87465(a)(6) Incidental Medical and Dental Care. The facility did not ensure that an accurate record of residents medication was maintained at the facility. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Lita Siebenthal and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 27-AS-20250506081827

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Jul 24, 2025

Incidental Medical and Dental Care 87465. (a) A plan for incidental medical and dental care shall be developed by each facility.(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained..This requirement was not met as evidenced by: Licensee did not ensure that a accurate record of resident's medication were accurately maintained in the facility. R1,R2,R3 medication logs were not accurately recorded, CSMDR record was missing from R2 resident medication log, including inconsistencies in the start date and amount of medication on hand.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Licensee will ensure that the facility is in compliance with Title 22 regulation 87465 Incidental Medical and Dental Care. Licensee will ensure resident medication logs and CSMDR are accurately recorded and available. Licensee will provide a signed statement... of understanding and provide proof of training related to Incidental Medical and Dental Care to LPA Hughes by 7/24/2025.

Type of visit: Case Management - Deficiencies

On 7/17/2025 Licensing Program Analyst Shakaricka Hughes conducted an unannounced visit to the facility. The purpose of the visit was to conduct a case management of deficiencies inside the facility. LPA Hughes met with facility administrator Lita Siebenthal. LPA Hughes conducted an tour of the facility, including the facilities kitchen area. Upon observation of the kitchen area LPA observed the facilities 7-day non-perishable food supply contained expired canned and dry goods. LPA Hughes explained to the administrator that expired food perishable and non-perishable can pose an immediate health and safety risk to residents in care. Administrator stated that the expired food will be disposed of by the end of the day 7/17/2025. Per California Code of Regulations, Title 22, the following deficiency is cited. An exit interview was conducted with administrator Lita and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Jul 18, 2025

87555 General Food Service Requirements. (b) The following food service requirements shall apply. (8) All food shall be of good quality. Commercial foods shall be approved by appropriate... Food in damaged containers shall not be accepted, used or retained. This requirement was not met as evidenced by: Licensee did not ensure that 7-day perishables dry and canned goods were of good quality. LPA Hughes observed canned and dry goods in the kitchen cabinet expired. Administrator agreed that expired canned goods and dry foods should be disposed of immediately.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Licensee will ensure that the facility is in compliance with Title 22 regulation 87555(b)(8). Licensee will ensure all food supply within the facility shall be of good quality. Licensee will discard of expired food supply by 7/17/2025. Licensee will write a statement of understanding of the regulation and provide the statement to LPA Hughes by 7/18/2025.

Allegation investigated: Neglect/Lack of Supervision: 1) Resident sustained unexplained injuries while in care. 2) Facility is retaining a resident with a higher level of care need.

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Siebenthal Care Home RCFE on 4/24/25 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Licensee, Ermelinda Siebenthal and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, the department was unable to corroborate the allegations. The department obtained and reviewed all records from the facility for alleged victim R1 (see confidential names list, LIC 811 dated 4/24/25) and reviewed medical records provided by the hospital. The department has verified the extensive bruising are a result of reported falls and the alleged victims medication which made R1 susceptible to bruising. The department has reviewed R1's fall history and the bruising is consistent with reported falls that ocurred at the facility. Additionally, there were reported concerns for pressure injuries observed on R1. Report continued on LIC 9099-C. Unsubstantiated The department conducted interviews with facility staff and R1's home health providers and all parties interviewed denied the allegations. Home health nurse interviewed denied witnessing pressure injuries on R1 while in their care at the facility. The department has also reviewed R1's medical and facility records to ensure there are no diagnosis or observations that would indicate R1 would require a higher level of care. Resident file review and staff interviews did not indicate R1 was in need of a higher level of care. All staff interviewed provided statements they were able to meet R1's care needs. Interviews with R1's authorized representative did not produce any additional concerns as family members interviewed approved of the care and supervision provided to R1 while in their care. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Neglect/lack of supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 27-AS-20241123150713

Type of visit: Case Management - Deficiencies

On 1/17/25 Licensing Program Analyst (LPA) Kevin Gould conducted a case management inspection to address reporting of incidents to the department. LPA met with administrator Ermelinda Siebenthal and together discussed the report. LPA conducted an inspection to obtain additional medical records and any related incident reports for a former resident. LPA obtained hospice records and obtained and incident report dated 9/26/24. LPA had no record or receiving this incident report and it was confirmed by a staff member through fax transmission logs and email history that the incident report dated 9/26/24 regarding fall and injury of former resident was not provided to the department in the time frame required by title 22 regulations. Per California Code of Regulations, Title 22, the following deficiency is cited. Exit interview conducted and a copy of this report was left at the home.the state’s words, verbatim · CDSS document, Jan 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Jan 31, 2025

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... Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met as evidenced by and incident report obtained from the facility dated 9/26/24 was never submitted to the department as confirmed by facility staff which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 17, 2025

Plan of correction: Licensee has agreed to provide a written plan of correction stating an understanding of reporting requirements and specific time frame for reporting. Facility will also provide a step by step plan for reporting incidents to the department.

Type of visit: Required - 1 Year

On 1/17/25 at 1:00pm Licensing Program Analyst (LPA) Kevin Gould arrived at Siebenthal Care Home RCFE for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Ermelinda Siebenthal and together conducted a tour of the home. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 111 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report and LIC 9020 client roster. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 17, 2025

Allegation investigated: ) Staff yells at the residents. 2) Staff threatens the residents 3) staff hit a resident. 4) staff tie doors closed to prevent residents from leaving bedrooms.

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Siebenthal Care Home RCFE on 12/11/24 at 1:00pm to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Licensee, Ermelinda Siebenthal and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA Gould conducted interviews with four staff members (see confidential name list LIC-811 dated 12/11/24) Who all denied the above allegations. No staff interviewed witnessed any staff member yell at, threaten, or hit residents in care. LPA contacted the authorized representatives for all residents. LPA was able to conduct phone interviews with two of the five authorized representatives and both denied any concerns regarding the allegations and provided statements they are satisfied with the care their family receives. Report continued on LIC 9099-C. Unsubstantiated LPA attempted to interview all residents, only two residents were able to provide statements to LPA as all residents in care have a diagnosis of dementia. The two residents interviewed expressed to LPA they are happy in the home and treated with kindness and respect. The two residents interviewed denied being hit, yelled at or threatened by any staff member. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of (indicate the complaint allegation) are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. LPA conducted a walk through of the facility on multiple occasions and at different times and did not observe any devices, equipment, ropes or other items that could be used to secure bedrooms and lock residents in their bedrooms. No staff member was able to corroborate the allegation and provided statements they have never witnessed the bedroom doors being locked or secured by other means. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 11, 2024 · control 27-AS-20240719112743

Type of visit: POC

On 12/11/24 Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced POC inspection at Siebenthal Care Home to ensure previously cited deficiencies have been corrected. LPAs met with the licensee to review plans of correction. LPA observed staff are present at the facility and are in process of competing Medications training. Licensee was able to provide LPA with documentation of scheduled training with a RN and is scheduled to be completed on 12/17/24. Licensee has sent LPA first week of Medication administration records for all residents and will continue to provide to LPA weekly to ensure completeness of medication administration documentation and will continue to send weekly until February 10th 2025. POC letters generated and provided to the Licensee. Exit interview conducted and a copy of this report were left at the facility.the state’s words, verbatim · CDSS document, Dec 11, 2024

Allegation investigated: Medications: 1) Staff is mishandling the residents medications 2) Staff is inappropriately administering medication Neglect/Lack of Supervision: 1) Staff did not provide adequate care and supervision to a resident.

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Siebenthal Care Home RCFE on 12/5/24 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Licensee, Ermelinda Siebenthal and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. LPA reviewed medication administration records for three (3) of the five (5) current resident's in care. LPA observed staff who administer medications are signing off medications administered prior to the medications being given to the resident. LPA observed one medication for R1 that is ordered to be administered every other day, documented as being administered daily. R1 has been over-medicated for the medication Ferosul as medicaion order is for every other day and is documented as adminstered daily. Report Continued on LIC 9099-C. Substantiated LPA observed and received statements from staff member of combining prescription medication contents from older prescriptions to new bottles. LPA observed medications marked as administered for R2 not present at the facility. LPA also observed insulin medication for R2 not refrigerated as directed prior to first use. Additionally, LPA reviewed current staff schedule and observed the Licensee scheduled for 122 hours for the week of December 1st through the 7th with assigned overnight care duties. LPA reviewed resident records and pre-placement appraisals and needs and services and observed three of the five files reviewed included documentation of needed overnight supervision as a result of residents diagnosis of dementia. LPA and Licensee discussed the overnight shift duties and licensee did provide statements to LPA that there are times where there is no awake overnight care staff on duty. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of medications and neglect/lack of supervision is substantiated. The following deficiencies are cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 27-AS-20240719112743

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 6, 2024

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA reviewed of three resident medication administration records which documented medications that had not yet been given to the residents which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: Licensee has agreed to conduct medication training for all staff members who assist with medication administration. medication administration records will be emailed to LPA weekly for review for the next three months.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(1)(a) · Plan of correction due date: Dec 6, 2024

Incidental Medical and Dental Care: The preservation of medicines requires refrigeration, if the resident has no private refrigerator. This requirement was not met as evidenced by LPA observations of insulin medication not stored in a refrigerator prior to first use as directed on the prescription directions which poses an immediate health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: Licensee has agreed to conduct medication training for all staff members who assist with medication administration and obtain a lock box to ensure medications are stored in fridge and inaccessible to residents in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Dec 6, 2024

Incidental Medical and Dental Care: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by LPA review of centrally stored medications and statements obtained from staff member that they have transferred medications from one prescription container to another which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: Licensee has agreed to conduct medication training for all staff members who assist with medication administration. medication administration records will be emailed to LPA weekly for review for the next three months. (Mondays)

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Dec 6, 2024

Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by LPA review of R1's medication administration records which showed documentation of a medication ordered to be given every other day is documented as being administered to R1 daily which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: Licensee has agreed to conduct medication training for all staff members who assist with medication administration. medication administration records will be emailed to LPA weekly for review for the next three months.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4)(A) · Plan of correction due date: Dec 13, 2024

In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement was not met as evidenced by LPA observations of staff schedule and statements obtained form the licensee that there are times where there is not an awake staff member on duty which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: Licensee is in process of hiring an overnight shift staff member and will provide documentation of staff member start date by the POC due date.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: POC

On 10/30/24 Licensing Program Analysts (LPAs) Kevin Gould and Holly Williams conducted an unannounced POC inspection to ensure previously cited deficiencies have been corrected. LPAs met with the licensee to review plans of correction. LPA observed the facility staff is in process of obtaining criminal records clearances and health screening/TB tests as LPAs observed scheduled appointments for health screaming and actions taken to complete criminal record clearances. LPA Gould has not received written plans of correction for health screening and criminal record clearances, an extension was granted to the licensee to complete the written plans of correction by 10/31/24. LPA has not received an LIC 200 and supporting documents to appoint a new administrator who is pending certification so LPA can expedite the administrator approval and ensure there is a certified administrator for the facility. An immediate civil penalty was issued for failure to correct the plan of correction. Exit interview conducted and a copy of this report and appeal rights are left at the facility.the state’s words, verbatim · CDSS document, Oct 30, 2024

Type of visit: Case Management - Deficiencies

On 10/23/24 at 9:20am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to address deficiencies observed regarding facility staff and resident records maintained by the facility. LPA met with the licensee and together discussed LPA's observations. LPA identified missing/incomplete records observed and provided licensee with ample time to locate items requested and identified as missing in resident and staff files. LPA observed the following: There is currently not a certified administrator associated to the facility. The licensee (S1) has completed all required hours for recertification but has not yet submitted the documents to be recertified. LPA observed there is a pending initial administrator certificate for the other licensee (S2). Although the licensee claims they are renewing the administrator certificate, could not provide LPA with the most recent certificate and the documents submitted did not identify the certificate number for S2 and did not include an expiration date. Additionally, LPA reviewed all staff files and observed the facility did not follow title 22 regulations in 2017 when they hired a 17 year old caregiver identified as S3. Upon additional file reviews for staff member LPA observed S2, S4, S5 and S6 did not have current health screening or TB test on file. LPA also observed that S6 also does not have a criminal record clearance despite working at the facility since 4/28/24. S7 must obtain a criminal record clearance and be associated to the facility prior to being present in the facility or working with residents. Report continued on LIC 9099-C LPA reviewed all five current resident files and one former resident file. LPA observed all residents placed at the facility have a diagnosis of dementia per their physician's report (LIC 602) LPA observed two of the current residents did not have a current 602 as they were over a year old. Per the California Codes of Regulations, Title 22, the following deficiencies are cited during today's inspection. An immediate civil penalty has been issued as one of the staff members present does not have a criminal record clearance. Exit interview conducted and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Oct 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Oct 24, 2024

Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. This requirement was not met as evidenced by statements from S1 regarding S6's working at the facility since April 2024 without a criminal record clearance which poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 23, 2024

Plan of correction: Licensee has agreed to ensure S6 has a criminal record clearance prior to working again in the facility and has agreed to provide a written plan of correction indicating the steps facility will take to ensure the violation does not reoccur.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Oct 25, 2024

Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section... this requirement was not met as evidenced by: LPA observations there is no current certified administrator and the administrators whose certificate expired has yet to submit documents for renewal which poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 23, 2024

Plan of correction: Licensee has agreed to submit documentation of all required training to the Administrator Certification Bureau by the POC due date ad submit an LIC 200 and all supporting documents to appoint staff member with a pending certification. once completed, LPA will request an expedited certification of the identified staff member.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(f) · Plan of correction due date: Oct 24, 2024

Personnel Requirements - General: All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall test, performed bya be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents wich poses an immediate health, safety or personal rights risk to residents incare.the state’s words, verbatim · CDSS document, Oct 23, 2024

Plan of correction: Licensee has agreed to ensure all identified staff without documentation of a health screening or TB test to be scheduled immediately and will submit a written report indicating the steps facility will take to ensure the violation does not reoccur.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: Nov 8, 2024

Care of Persons with Dementia: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by LPA observations that two of the five resident's in placement did not have an annual 602 and needs and services plan updated annually pre regulations which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 23, 2024

Plan of correction: Licensee has agreed to have all physician reports and needs and services plans updated for the identified residents by the POC due date.

Allegation investigated: Staff physically abused residents. Staff verbally abused residents. Staff withheld food from resident. Staff did not allow resident to have a personal cell phone. Staff did not assist resident with scheduling requested medical appointments.

On 6/18/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to complete and delivery findings for a complaint investigation received on 4/18/24. LPA met with Administrator Ermerlinda Siebenthal and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on records review, and staff and resident interviews, there is insufficient evidence to substantiate the allegations mentioned above. LPA interviewed six (6) residents. Two residents were unable to corroborate due to their diagnosis of dementia. 4 out of 6 residents stated that they were unaware of any verbal or physical abused from staff. Residents reported that they have access to food and telephone. One resident reported that they have a personal cell phone. Residents also corroborated that staff assisted with scheduling medical appointments and provide transportation. As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of the report was provided to Administrator Ermerlinda Siebenthal. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 18, 2024 · control 27-AS-20240418145238

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 year Annual Inspection Visit. LPA met with Administrator and explained purpose of visit. The facility has an approved hospice waiver for two. LPA and administrator inspected physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature measured at 113.8 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers were inspected on 1/16/2024. Smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to clients. LPA reviewed Fingerprint clearance and associations to the facility. Common touch surfaces are cleaned after each use. Fire drill last conducted on 12/12/2023. LPA reviewed three resident and two staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete. LPA requested the following updated documents to be submitted via email to community care licensing by February 12, 2024: LIC 308, LIC 500 - Personnel Report, Liability insurance Certificate, and Administrator Certificate. ruth.wallace@dss.ca.gov Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted with administrator. A copy of this report and LIC 811(Confidential Names) was left with administrator at the facility.the state’s words, verbatim · CDSS document, Feb 3, 2024

Allegation investigated: Staff did not provide adequate supervision to the residents

Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to commence a complaint investigation with the allegation above. LPA met with Administrator Ermerlinda Siebenthal and explained the purpose of the visit. Based on the interviews conducted and reviewed of records, it was learned that on 12/8/23 resident (R1) and (R2) AWOL'd out of the side gate of the facility without staff knowledge. It was learned that R1 and R2 Physician’s Report prohibited resident from leaving the facility unsupervised due to Dementia diagnosis. The administrator corroborated that she noticed the residents were not on the facility premises and proceed to search the neighborhood. R1 and R2 were found without any visible injuries and bought the residents back to the facility. It was determined that due to lack of supervision, resident R1 and R2 left the facility unsupervised on 12/8/2023. Continued on 9099-C Substantiated As a result of this investigation, LPA finds the allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. CIVIL PENALTIES ARE ASSESSED IN THE AMOUNT OF $500 today for immediate violations. Exit interview conducted, a copy of this report, LIC 9099-D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 27-AS-20231208140918

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Dec 13, 2023

Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services:...(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidence by: Based on interviews and record review, the facility did not comply with section cited above in 1569.312(d). R1 and R2 AWOL'D from facility. The LIC 602 states the resident was not allowed to leave the facility unassisted. This poses an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Dec 12, 2023

Plan of correction: Licensee agrees to conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. A statement of correction will be submitted by plan of correction date of 12/13/2023 via email to LPA Tung Truong. Proof of staff training for the cited section will be completed and a signature sheet of all staff who attended will be submitted to LPA after training is finished. Immediate civil penalty of $500.00 is assessed for health and safety deficiency.