Silvergate San Marcos Retirement Residence

Type of visit: Required - 1 Year

On May 28, 2026, Licensing Program Analyst (LPA), Aziz Faizi arrived at the facility unannounced to conduct the required annual inspection and met with the Executive Director Joan Rink-Caroll. The facility is licensed for 160 Elderly Adults currently serving 94 eniors. The facility is organized in two (2) detached residential areas for 43 Memory Care residents and 51 Assisted and Independent Living Area residents LPA toured the facility along with the Executive Director Joan Caroll and inspected the facility inside and outside, there were no obstructions or debris to the indoor or outdoor passageways currently at the time of this visit. The facility is a two-story and multi building including a beauty salon, library and wellness center. LPA toured the kitchen and observed the facility has a two-day supply of perishable foods and more than a seven-day supply of non-perishable foods, which are stored in a safe and healthy manner. LPA observed knives and sharp instruments secured in locked kitchen cabinets. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 108.3°F. Fire extinguishers equipped throughout the building are maintained in accordance with the department's safety requirements expiring on 04/25/2027. Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate expiring on 05/01/2027. Continued with 809C LPAs reviewed files for eight (8) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Eight (8) resident files were reviewed and contained all required documentation. All resident medications were securely locked. LPA reviewed medications for residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire/earthquake drill conducted on 05/14/2026 , which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.the state’s words, verbatim · CDSS document, May 28, 2026

Allegation investigated: Facility staff member who is not an appropriately skilled professional removed a fecal impaction from a resident.

On April 15, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Antonine Richard, conducted an unannounced follow-up complaint visit. The LPA met with the Administrator (A1), Joan Rink Carroll, and explained that the purpose of the visit was to correct the wording of the allegation on LIC9099, as stated in LIC802. The investigation consisted of collecting records and observing the facility. On April 7, 2026, the Department obtained various documents, including the Personnel Report LIC 500 (dated 04/07/26), the Resident Roster (dated 04/07/26), the Registered Nursing License dated September 30, 2025, and the Living Nurse Certificates dated June 30, 2026. The department interviewed Administrator A1, an RN, a Licensed Vocational Nurse (LVN), and six residents (R1-R6). Unsubstantiated Allegation #1: Facility staff member who is not an appropriately skilled professional removed a fecal impaction from a resident. The complaint alleged that a resident pressed the call button in the bathroom and required assistance. Facility staff member, who is not an appropriately skilled professional removed a fecal impaction from a resident. On April 7, 2026, the department interviewed the administrator (A1), who denied the allegations and stated that the facility had never experienced such incidents. A1 also stated that no staff member by that name was employed at the facility. During the same investigation, the department interviewed the registered nurse (RN), who clarified that a physician's order is required before a nurse can remove a fecal impaction due to the risks to residents. The RN indicated that if a resident requires this procedure, the facility either contacts the physician or calls the Medical Emergency team for assistance. Additionally, an interview was conducted with the licensed vocational nurse (LVN), who confirmed that a physician's order is indeed required before performing a fecal impaction removal for any resident. If the order is not available, the facility will contact the Medical Emergency team or send the resident to the hospital. The department also interviewed six residents (R1-R6) on April 7, 2026, all of whom denied ever needing this type of procedure and were unaware of any other residents who had undergone it. Furthermore, a review of the facility roster and the Community Care Licensing Division’s Licensing Information System confirmed that no staff members by that name were listed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator Joan Rink-Carroll.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 18-AS-20230413163957

Allegation investigated: Facility staff member who is not an approprieately skilled professional removed a fescal impication from a resident.

On April 7, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced follow-up complaint visit. The LPA met with the Administrator (A1), Joan Rink Carrol, and Bardiago Evelina, Registered Nurse (RN). And explained the purpose of the visit was to investigate the allegation mentioned above. The investigation consisted of collecting records and observing the facility. The Department obtained various documents, including the Personnel Report LIC 500 (dated 04/07/26), the Resident Roster (dated 04/07/26), the Registered Nursing License dated September 30, 2025, and the Living Nurse Certificates dated June 30, 2026. The department interviewed Administrator A1, an RN, a Licensed Vocational Nurse (LVN), and six residents (R1-R6). Unsubstantiated Allegation #1: A facility staff member who is not an appropriately skilled professional removed a fiscal impact from a resident. The complaint alleged that a resident pressed the call button in the bathroom and required assistance. A staff member at the facility, who lacked proper training, reportedly removed a fecal impact from a resident. On April 7, 2026, the department interviewed the administrator (A1), who denied the allegations and stated that the facility had never experienced such incidents. A1 also stated that no staff member by that name was employed at the facility. During the same investigation, the department interviewed the registered nurse (RN), who clarified that a physician's order is required before a nurse can remove a fecal impaction due to the risks to residents. The RN indicated that if a resident requires this procedure, the facility either contacts the physician or calls the Medical Emergency team for assistance. Additionally, an interview was conducted with the licensed vocational nurse (LVN), who confirmed that a physician's order is indeed required before performing a fecal impaction removal for any resident. If the order is not available, the facility will contact the Medical Emergency team or send the resident to the hospital. Report Continued on LIC9099C The department also interviewed six residents (R1-R6) on April 7, 2026, all of whom denied ever needing this type of procedure and were unaware of any other residents who had undergone it. Furthermore, a review of the facility roster and the Community Care Licensing Division’s Licensing Information System confirmed that no staff members by that name were listed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator Joan Rink-Carroll.the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 18-AS-20230413163957

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to obtain signatures on an amended report. During today’s visit, LPA was greeted by the Lead Front Desk Receptionist Edgar Baltazar, identified herself and met with Administrator Rink-Carroll and discussed the purpose of the visit. During today’s visit, LPA obtained Administrator's signature on an amended version of a report originally delivered on August 14, 2024. An exit interview was conducted with Administrator Rink-Carroll a and a copy of this report and the Licensee Appeal Rights (LIC 9058 3/22) were provided.the state’s words, verbatim · CDSS document, Aug 22, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Case Management (CM) visit. LPA identified herself and was granted entry by Edgar Baltazar, concierge. LPA met with Joan Rink-Carroll, Director, and discussed the purpose of the visit. During today’s visit, LPA requested and obtained staff records, and provided the facility the Plan of Correction (POC) clearance letter for a CM visit conducted on 3/25/24. There were no deficiencies observed or cited during today’s visit. An exit interview was conducted with Joan Rink-Carroll, Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Aug 21, 2024

Allegation investigated: Resident's money was stolen while in care.

Licensing Program Analyst (LPA) Debbie Correia conducted a follow up visit to conclude a complaint investigation. The LPA identified herself and was greeted by Front Desk Receptionist Daisy Olvera and met with DRC Navarette and disclosed the purpose of the visit. The Department’s investigation consisted of facility and resident record reviews, interviews conducted with staff, residents and an outside source. It was alleged that Resident's 1 (R1’s) money was stolen while in care. A resident records review revealed R1 was admitted to the facility on August 10, 2019. Further review of R1’s facility records revealed the facility only covered theft or loss of personal belongings up to $200 and encouraged residents to seek personal insurance for any items that exceeded the property value covered by the facility. Resident records also revealed R1 declined to provide the facility with a list of their personal belongings. Interviews conducted with the Administrator and Staff 1 (S1) revealed R1 had suspected Staff 2 (S2) had taken their money. The Administrator encouraged R1 to file a police report, notified the appropriate parties, and conducted an internal investigation. Interviews and facility records reviews revealed the internal investigation did not yield evidence to support the allegation. Interviews conducted with facility staff revealed S2 resigned from the facility approximately 2 years ago. This is an amended version of the original report delivered on August 14, 2024. [Continued on LIC 9099C] Unsubstantiated [Continuation of LIC 9099] Additional interviews conducted with Residents in care revealed no corroborating evidence. On December 2, 2020, an outside source records review revealed R1 filed a police report indicating the theft of cash from their apartment at the facility occurred between November 18 and November 29, 2020. The records also revealed R1 admitted to leaving their apartment unlocked at times. An outside source interview revealed the investigation with the Sheriff Department was suspended due to having no leads, R1 would leave their apartment unlocked, there are no surveillance cameras, and approximately 81 staff members employed at the facility during the time of the alleged theft. Due to lack of evidence the finding for the above-mentioned allegation was determined to be unsubstantiated. This finding means although the allegation may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violation occurred. (See LIC 811 for confidential names) LPA Correia conducted an exit interview with DRC Naverrete. At the time of the exit was conducted with DRC Navarrete was notified a copy of the Complaint Investigation Reports (LIC 9099) and Licensee Rights (LIC9058 01-2016) will be provided at the conclusion of the visit. Signature on this report acknowledges receipt of the documents. This is an amended version of the original report delivered on August 14, 2024.the state’s words, verbatim · CDSS document, Aug 14, 2024 · control 08-AS-20201204154620

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On May 08, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Director of Resident Care, (DRC), Ada Navarrete. The facility file review was conducted in the Regional Office and additional forms were requested and reviewed on site. The facility is licensed for 160 Elderly Adults (740) and is currently serving 81 Seniors. LPA Mixson toured the facility along with the DRC and inspected the facility inside and outside, there were no obstructions or debris to the indoor or outdoor passageways currently at the time of this visit. The facility is a two-story and multi building located at 1550/1560 Security Place San Marcos, CA. 92078 Physical Plant: The facility phone number is (760) 744-4484 and it is operable. The LPA observed a sampling of the residents’ bedrooms, and those observed were equipped with required furniture as per Title 22. LPA Mixson inspected a sampling of the 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 extinguishers. The LPA observed required postings such as "If you See Something, Say Something" the "Personal Rights" and the Ombudsman postings, and the DRC knows their Ombudsman personally. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit. Medications Were stored and locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident at the time of this visit. The overall facility is clean, the furniture is in good condition. The facility heating system and other appliances were operable currently at the time of this visit, and there were safety lights for night. 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 sharps are locked. Care & Supervision: Facility has sufficient staff, 110 staff on site at the time of this visit, and 81 residents. Records Review: The LPA reviewed resident and staff files, conducted staff and resident interviews. Previous Community Care Licensing forms were reviewed. 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 reviewed given to the Director of Resident Care, Ada Navarrete.the state’s words, verbatim · CDSS document, May 8, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Case Management visit to deliver an amended report for a visit conducted on 03/25/2024 and to clear the plan of correction (POC). LPA identified herself and was granted entry by Edgar Baltazar, Lead Concierge. LPA met with Joan Rink-Carroll, Director, and Ada Navarrete, Director of Resident Care and discussed the purpose of the visit. During today’s visit, LPA obtained the Director’s signature on the amended report LIC809 dated 03/25/2024 and deficiencies were issued on the attached LIC809-D. The deficiency was deemed cleared during the visit. An exit interview was conducted with Joan Rink-Carroll, Director, and Ada Navarrete, Director of Resident Care, to whom a copy of this report, the amended deficiency page of the report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Mar 29, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 26, 2024

INCIDENTAL MEDICAL & DENTAL CARE - “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…” This requirement is not met as evidenced by: Based on outside source records and interviews, on 04/20/20, the licensee, did not call 911 for 1:79 residents in care until two (2) hours after R1 sustained an unwitnessed fall. R1, who has a history of traumatic injury to the head, sustained an acute subdural hematoma caused by blunt head trauma from a fall which later resulted in death. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: The Facility will corrdinate a date of training with their local Fire Department within the next 24 hours and submit a letter to LPA with the date of all staff training to be conducted by 3/26/2024. Facility will submit all staff training documents regarding emergency assessments by 4/16/2024. This is an amended version of the original report created on 03/26/2022. This POC was cleared while at the facility.

Type of visit: Case Management - Incident

Licensing Program Analyst’s (LPAs) Carmen Lopez and Ryan Fulton conducted an unannounced Case Management visit to cite deficiencies from a previous visit on May 6, 2020. LPA was greeted at the front door by Edgar Baltazar, Lead Concierge and granted entry after identifying themselves and disclosing the purpose of their visit. LPA discussed the purpose of the visit with Ada Navarrete, Director of Resident Care, Kristiana Lopez, Business Services Office Manager/Human Resource Manager, Joan Rink-Carroll, Director. The facility submitted an Unusual Incident Report on April 27, 2020, advising that on or about April 20, 2020, at approximately 9:50am, Resident #1 (R1) had an unwitnessed fall and was found face down on the floor. According to the report, R1 sustained a skin tear above the right eyebrow and had a complaint of pain to the right shoulder. R1 was admitted to Silvergate San Marcos Retirement Residence in October of 2017, to the Independent Living side of the facility and lived alone. Facility records revealed a fall risk assessment was completed, and that a score of 4 or more is at risk for falling. R1 was at a total of 2. R1’s Preplacement Appraisal dated October 17, 2017, listed no health or physical disabilities. R1 was able to ambulate, follow instructions, communicate their needs, complete all activities of daily living independently and leave the facility unassisted. Facility Physician’s Report dated February 6, 2020 stated that R1 had a diagnosis of congestive heart failure (CHF), hypertension (HTN), hyperlipidemia, aortic valve disorder, orthostatic hypotension, iron deficiency and anxiety. Interviews with staff revealed that R1 began having falls without injury. The facility staff spoke with family and agreed to move R1 to the Assisted Living side of the facility so that staff could keep a closer eye on the resident. R1 continued to have falls, one of which resulted in hospitalization. According to facility records and their updated fall risk assessment dated February 5, 2020, a score of 4 or more was considered at risk for falling. R1’s total score was 12, indicating they were a high risk for falls. Although the facility deemed R1 a high risk, facility records revealed that they did not implement all of their own plan to help minimize the risk of falls. According to facility records, R1’s Safety Awareness Tips to Minimize the Risk of Falls, R1 did not have a bed in a low position, a bed alarm or a floor pad. On April 22, 2019, R1 had been taken to the emergency room after a fall and received a new diagnosis of traumatic injury of head and a contusion to their right elbow. R1 was now ambulating with a walker. Interviews with staff revealed that a new care plan was developed and R1 was encouraged to call for assistance with bathing, dressing, toileting and getting up to prevent future falls. Staff stated they checked on the resident every one to two hours because R1 had dementia and would forget to call for assistance. However, the facility was unable to provide documentation of these checks, including dates and times. According to facility records, on February 3, 2020, R1 was transferred to the Memory Care Unit, despite their most recent Physician’s Report dated February 6, 2020, had no mention of a diagnosis dementia or mild cognitive impairment. Interviews with staff revealed that on February 18, 2020, R1 stood up to walk and fell. R1 was sent to the hospital but did not sustain injury and was discharged back to the facility the same day. On the same day, February 18, 2020, based on interviews and the facility’s Unusual Incident Report, at approximately 1:30pm, care staff heard a loud thump in R1’s room and found R1 lying on the floor. R1 stood up to walk and fell. R1 verbalized that they hit their head and complained of back pain. R1 was transported to the hospital via ambulance and the report stated that staff would continue to monitor the resident upon their return. Interviews conducted with staff revealed that staff state they checked on the resident every 10 minutes, however there was no log of dates and times to verify when those checks were being made. On February 27, 2020, the facility updated R1’s Physician’s Report. The report indicates a diagnosis of ES diastolic heart failure, FTN, hyperlipidemia and anemia. The Physician’s Report makes no indication that R1 is a fall risk, or that they have suffered a traumatic injury to the head, have any cognitive impairment or dementia. R1 is still able to follow instructions and communicate needs, however they are no longer able to leave the facility unassisted. Interviews with staff revealed that on March 22, 2020, R1 had another fall with no injury. On April 5, 2020, R1 had an additional fall with no injury. Facility records did not indicate a change in condition and the facility staff did not conduct a reappraisal. No records were kept of dates and times of when the frequent checks were being made or any update to the resident’s fall plan. On April 20, 2020, at 9:50am, the care staff was assisting another resident when they heard R1 in their room. Staff was not able to provide the time when they last checked on R1, but when they walked into R1’s room, they found R1 laying on the floor, face down, bleeding from the head with a skin tear on the right eyebrow and a complaint of pain to their right shoulder. R1 was bleeding so severely from their head, S1 had to change R1’s shirt. S1 treated the wound with a cold compress and bandage. After tending to R1’s wounds from the fall, S1 put R1 into a wheelchair, and rolled them into the dining room, and provided R1 breakfast. Although the resident had a history of frequent, reoccurring falls and a previous diagnosis of traumatic injury of the head, (also noted on the Unusual Incident Report dated April 27, 2020), interviews revealed that staff did not call 911, but instead left R1 in the dining room from 9:30am to 11:40am. Interviews with staff confirmed that the facility has a 911 policy for unwitnessed falls involving injury, yet staff waited over two (2) hours to make that 911 call. R1 was not sent out to the hospital until an outside source medical professional arrived for an unrelated visit and evaluated the resident. Lastly, outside source records revealed that R1 sustained a large hematoma on the side of their head, requiring stitches. Outside source records revealed that R1 succumbed to their injuries on April 21, 2020. The County of San Diego’s Death Certificate lists the cause of death as acute subdural hematoma and blunt head trauma caused by R1’s fall from April 20, 2020. Based on interviews and documentation collected from facility and outside source records, deficiencies are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8, on the attached LIC9099D. A civil penalty in the amount of $500 was assessed per Health & Safety code 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1. Determination of Civil Penalties under Health & Safety code Section 1569.49 are pending and under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Ada Navarrete, Director of Resident Care, Kristiana Lopez, Business Services Office Manager/Human Resource Manager, and Joan Rink-Carroll, Director . A copy of this report, LIC 421IM – Civil Penalty Assessment Form, LIC 811 Confidential Names, along with the Licensee/Appeal Rights (LIC9058 03/22) were provided to the licensee during the visit. Signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 26, 2024

INCIDENTAL MEDICAL & DENTAL CARE - “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…” This requirement is not met as evidenced by: Based on outside source records and interviews, on 04/20/20, the licensee, did not call 911 for 1:79 residents in care until two (2) hours after R1 sustained an unwitnessed fall. R1, who has a history of traumatic injury to the head, sustained an acute subdural hematoma caused by blunt head trauma from a fall which later resulted in death. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: The Facility will corrdinate a date of training with their local Fire Department within the next 24 hours and submit a letter to LPA with the date of all staff training to be conducted by 3/26/2024. Facility will submit all staff training documents regarding emergency assessments by 4/16/2024. This is an amended version of the original report created on 03/26/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Apr 9, 2024

REAPPRAISALS – “…The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident’s physical, medical, mental and social condition…”. This requirement is not met as evidenced by: Based on facility records and interviews, the licensee did not reappraise 1:79 residents in care when a change in condition occurred. This poses a possible health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: The facility will conduct in-service training with the LVNs and Assistant's Director of Resident Care regarding updates to the residents reappraisal on a yearly or on an as needed basis by POC due date, 04/09/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Apr 9, 2024

PERSONAL RIGHTS – “…to not be locked into any room, building or on facility premises day or night…” This requirement is not met as evidenced by: Based on interviews, facility records and outside source records, 1:79 (R1) residents were placed into the locked dementia unit with out a physician’s diagnosis of dementia or cognitive impairment. This poses a possible health & safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: The facility will be submitting the Physician's Report (LIC602) for their Memory Care Unit residents along with a Roster of Residents to review the assessments of resident's diagnosis to LPA by POC due date, 04/09/2024.