Solaris 36

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Correia conducted a case management to introduce herself, conduct brief facility tours and secure records. During the visit, LPA met with Administrator Justin Mendoza, took tours of Melrose, 48, 34, 36, 28, and 30, briefly spoke with residents in care, and obtained facility records. An exit interview was conducted with Administrator Mendoza to whom a copy of this report and the Licensee Rights (LIC9058) will be provided to at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 16, 2025

Allegation investigated: Licensee has abandoned the facility. Licensee has lost control of property. Licensee did not report sale of facility.

Licensing Program Analyst (LPA) Liliana Silveira conducted a virtual meeting on Microsoft Teams with Licensee Xiaoqing “Leslie” Wang to deliver complaint findings. LPA stated the purpose of the meeting with Leslie. The investigation consisted of observations, interviews and a records review. On January 30, 2025, it was alleged that the Licensee had abandoned the facility. A Licensing Program Analyst (LPA) from the Department conducted an unannounced Health & Safety check on January 31, 2025. The LPA observed that there were caregivers present, changing residents and preparing dinner for the residents. The LPA also observed that the facility was clean. Interviews with the current acting Administrator revealed that in June 2024, two Administrators had quite and left the residents with care staff. Interviews with three (3) care staff who worked at the facility during June 2024, revealed that even though the Administrators quit, care staff remained working at the facility until the Licensee came soon after to manage the facility. (CONTINUED ON NEXT PAGE, LIC 9099-C) Unsubstantiated (CONTINUED FROM PAGE LIC 9099) An interview with the Licensee revealed that in June 2024, as soon as they were informed that the Administrators quit, the Licensee returned to the facility to check on the residents and manage the facility. There was not enough evidence to support this allegation. It was also alleged that the Licensee had lost control of the property and did not report the sale of the property. A records review revealed that a Property Management Agreement provided by the Licensee, dated September 20, 2019, and with expiration date of September 20, 2029, demonstrated that the property is leased to Solaris Capital Group Inc. An interview with the Licensee revealed that they still act as property manager for the property via Solaris Capital Group Inc. The interview also revealed that the property owner has no intention of selling the property at this moment. An interview with the current Administrator, who represents a new management group, revealed that they are in current negotiations with the Licensee/Property Manager to take over the lease and have applied for a license with Community Care Licensing Division. There was not enough evidence to support these allegations. The allegations that the Licensee had abandoned the property, had lost control of the property and did not report the sale of the property are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred, therefore the allegations are unsubstantiated. LPA Silveira conducted an exit interview with Leslie. A copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 03/22) were provided via email. Confirmation via email by Linda confirms receipt of this report.the state’s words, verbatim · CDSS document, Jun 9, 2025 · control 08-AS-20250130155352

Allegation investigated: Staff is not following universal precautions when assisting sick residents

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegations. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Justin Mendoza. On January 7, 2025 the Department received this complaint which alleged staff were not following universal precautions when assisting sick residents. Specifically, this complaint alleged a staff member did not wear a mask while caring for a resdient with COVID. The Department’s investigation included a facility tour, record reviews, as well as interviews with residents, staff and outside sources. LPA interviews and records reviewed corroborated that there is not, nor has there been any staff that goes by the name of the alleged staff that was alleged to have not worn a mask when caring for a resident with COVID. (Continue on LIC9099-C) Unsubstantiated (Continued from LIC9099) Residents, staff, and outside sources alike report not witnessing any staff not wearing masks while caring for sick residents. Staff reported that when a resident did have COVID, protocol derived from the COVID Mitigation Plan was implemented. Staff were able to explain that this included staff donning proper Personal Protective Equipment (PPE) and isolating infected resident away from other residents until tested negative. The Department has investigated the allegation that staff were not following universal precautions when assisting sick residents. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate this allegation and therefore deemed unsubstantiated. An exit interview was conducted with Administrator Justin Mendoza, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, May 7, 2025 · control 08-AS-20250107102819

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite additional deficiencies which were identified during a separate complaint investigation. LPA was welcomed by and identified himself to Caregiver Jovina Franco. LPA then met with and discussed the purpose of the visit with Administrator Jushua "Justin" Mendoza, who arrived shortly after. According to facility care and hospice records, and corroborated by staff and outside source interviews, Resident #1 (R1) had no pressure injuries or areas of open skin when they first moved into Solaris 36 in January 2020. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] R1 was initially under hospice care for lymphoma but they discharged from hospice services on 04/02/2020. Starting 04/03/2020, R1 was under the concurrent care of an outside home health (HH) agency. In their individual interviews: Staff #1 (S1) said sometime in April 2020, a closed mass on R1’s sacrum had opened-up, become “darker and softer to the touch,” “bluish” or “purplish,” had foul odor, and wept “yellowish” discharge. Staff #2 (S2) said a “fist”-sized area on R1’s sacrum opened-up, went from “normal color” to “red,” wept blood and puss, and smelled badly. S2 could not remember approximately when this started. Manager Staff #3 (S3) said their direct reports summoned them to personally look at R1’s sacrum on 04/01/2020, which had opened-up with foul odor and discharge. S1 said that R1’s responsible person (RP) and their HH agency [where R1’s assigned physician (PCP) was based] were timely informed by S3 of the skin breakdown on R1’s sacrum. However, interview of S3 showed they did not personally notify those parties of the problem. Rather, S3 was under the impression that S1 had completed such communication to RP and HH/PCP. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] According to HH records: 04/24/2020 was HH’s earliest documentation of a pressure injury on R1; a HH nurse wrote they observed a Stage 2 pressure injury to R1’s coccyx. By 04/26/2020, R1’s HH physician upgraded the coccyx to a Stage 3 pressure injury. On 04/27/2020, the HH nurse wrote R1 had “wounds [to] entire buttock and lower back” with “wound infection” and “very foul-smelling drainage,” “covered with necrotic tissue,” concluding, “[R1] has met all criteria for severe sepsis and requires immediate intervention.” R1 had “shallow breathing,” “rectal bleeding,” and was “very lethargic,” “difficult to arouse,” and only able to “moan when turned.” R1 had “petit seizures with involuntary twitching of all extremities,” “pale skin,” and “tachy heart rate.” HH records and interview of RP further showed: a HH nurse called RP on 04/27/2020, which was the RP’s first notification of pressure ulcers on R1’s body. It was the RP (who came to the facility), and not facility staff, who then called 911 to have R1 transported to a hospital Emergency Department (ED). S1, S2, and S3 confirmed that facility staff themselves did not call 911 or arrange emergency medical care for R1 [even after R1 exhibited signs of infection (e.g., change in color, foul odor, and discharge) and a life-threatening medical crisis]. Hospital records showed R1 arrived at the ED “very weak” and “awake but not oriented.” R1 was treated at the hospital for “toxic encephalopathy” (defined by the National Institutes of Health as “brain dysfunction caused by toxic exposure”). R1 had a Stage 4 pressure injury to their sacrum (requiring surgery) with the “abscess cavity covered by necrotic tissue,” a Stage 3 pressure injury to their right buttock with “necrotic tan-like skin,” a Stage 2 pressure injury on their left buttock, and unstageable pressure injuries to both heels. Records of the skilled nursing facility (SNF), where R1 went to recover after surgery, corroborated the severity of R1’s earlier-described skin injuries to their bottom. SNF records also showed R1 had a Stage 2 injury on their left heel and an undetermined stage pressure injury on their right heel. Per their LIC602 Physician’s Report, their LIC603 Resident Appraisal, their Functional Capability Assessment, and their plan of care, R1 had required assistance from Solaris 36 staff with dressing. R1’s HH agency had also instructed facility staff to “float” R1’s heels above their mattress to prevent skin breakdown. When CCLD individually asked S1, S2, and S3 if they observed or were aware of skin breaking down on R1’s heels leading up to their 04/27/2020 hospitalization, each staff said no. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809, 2 of 2] Regulation CCR 87466 required Licensee to “regularly observe [R1] for changes in physical [and] mental functioning,” to document such changes in condition, and to ensure they were timely “brought to the attention of the resident’s physician and the resident’s responsible person.” The preponderance of evidence showed Licensee did not meet this requirement. Regulation CCR 87465 required Licensee to arrange timely medical care congruent to the needs of R1, including telephoning 9-1-1 if a “circumstance has resulted in an imminent threat to [R1’s] health including but not limited to, an apparent life-threatening medical crisis.” The preponderance of evidence showed Licensee did not meet this requirement. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Administrator Jushua "Justin" Mendoza, to whom a copy of this report, the LIC 809-D page, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Mar 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 18, 2025

87465 Incidental Medical and Dental Care: “(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis…” This requirement was not met, as evidenced by: Based on interviews and records reviewed, Licensee did not immediately telephone 9-1-1 in response to an apparent life-threatening medical crisis affecting 1 of 5 residents (R1), which posed an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: As of the date of deficiency issuance, R1 no longer lives at the facility, resolving the immediate risk. Licensee agreed to use a third-party source to retrain all current direct care staff on the topics of: a) Recognizing and Responding to Medical Emergencies, and b) Regulations 87465 Incidental Medical and Dental Care and 87469 Advance Directives and Requests Regarding Resuscitative Measures. Licensee agreed to E-mail a copy of the training certificates and/or sign-in sheet to LPA, by 04/18/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87466 · Plan of correction due date: Mar 18, 2025

87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed for changes in physical, mental…functioning… When changes such as…deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.” This requirement was not met, as evidenced by: Based on interviews and records reviewed, Licensee did not ensure that 1 of 5 residents (R1) was regularly observed for changes in physical and mental functioning, and that their deterioration was timely brought to the attention of their physician and responsible person. This posed an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: As of the date of deficiency issuance, R1 no longer lives at the facility, resolving the immediate risk. Licensee agreed to use a third-party source to retain all current direct care staff on the topics of: a) performing head-to-toe observation of residents during personal care and b) timely documenting and reporting changes in condition to facility leadership, physician, and responsible party. Licensee agreed to E-mail a copy of the training certificates and/or sign-in sheet to LPA, by 04/18/2025.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management Visit to cite deficiencies which were identified during a separate visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Justin Mendoza, Administrator. On 02/07/2025 and on today's date, LPA Holmes reviewed records and conducted a tour of the facility and observed residents in care. According to records reviewed: ~There weren't any prescriptions for a bed rail on one of the residents beds. ~There weren't any prescriptions for over the counter medications. LPA observations also revealed: ~The physical plant was unclean by having several large spider webs in the bathroom ~ Facility also had a broken toilet seat that was not able to be used. ~Several rooms were missing chairs ~The hot water was over 120 degrees at the time of the visit. Based on records reviewed, inspection, interviews and LPA observations deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages) An exit interview was conducted with Justin Mendoza, Administrator. A copy of this report, the LIC 809-D page and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Feb 26, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(2) · Plan of correction due date: Feb 27, 2025

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above for hot water over 120 for 5 out of 5 residents (5residents), which poses an immediate health risk to residents in carethe state’s words, verbatim · CDSS document, Feb 26, 2025

Plan of correction: Licensee turned down water temperature while LPA was at the facility. Licensee will check and montior daily to make sure the water is not too hot. Licensee will send a photo of water in normal range by POC due date of 02/27/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Mar 12, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above, there were several large spider webs at the ceiling in the bathroom and the bathroom is under construction that is used by 5 out of 5 residents (5 residents), which poses a potential health risk to residents in carethe state’s words, verbatim · CDSS document, Feb 26, 2025

Plan of correction: Licensee will keep all bathrooms clean and monitor for spider webs. Bathroom is under construction due to a leak at this time and will be completed by 03/12/2025. POC is due by 03/12/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(6) · Plan of correction due date: Feb 27, 2025

Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above, there was a broken toilet seat that could not be used by 5 out of 5 residents (5 residents), which poses a potential health risk to residents in carethe state’s words, verbatim · CDSS document, Feb 26, 2025

Plan of correction: Licensee fixed the toilet seat by putting a new toilet seat on. Corrected during the visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(2)(B) · Plan of correction due date: Feb 27, 2025

Resident bedrooms shall be provided which meet, at a minimum, the following requirements:Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in 4 out of 4 resident rooms were missing chairs (4 residents), which poses a potential health risk to residents in carethe state’s words, verbatim · CDSS document, Feb 26, 2025

Plan of correction: Licensee put chairs in all of the rooms during the visit. Corrected the during the visit

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(3) · Plan of correction due date: Feb 28, 2025

A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in 1 out of 5 residents (1 residents) did not have a prescription for a bedrail, which poses a potential health risk to residents in carethe state’s words, verbatim · CDSS document, Feb 26, 2025

Plan of correction: Licensee immedaitely removed the bed rail. Corrected during the visit

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465c()(1) · Plan of correction due date: Mar 6, 2025

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation. Based on LPA observation, the licensee did not comply with the section cited above in 1 out of 5 residents (1 residents) by having a prescription for over the counter medications , which poses a potential health risk to residents in carethe state’s words, verbatim · CDSS document, Feb 26, 2025

Plan of correction: Licensee contacted Residents son to contact the doctor to attain a prescription for the over the counter mediations. POC due by 03/06/2025. Licensee will subnit to LPA by email a copy of the prescription

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Justin Mendoza, Administrator. LPA briefly toured the facility, performed a health and safety welfare check. There are five residents at this facility at this time. LPA Holmes spoke with staff and residents. No deficiencies were observed or cited on this date. No heath and safety concerns at this time. An exit interview was conducted with Justin Mendoza, Administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 26, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Justin Mendoza, Administrator. LPA briefly toured the facility, performed a health and safety welfare check. There are four residents at this facility at this time. LPA Rodgers spoke with staff and residence. No deficiencies were observed or cited on this date. No heath and safety concerns at this time. An exit interview was conducted with Justin Mendoza, Administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 7, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with On-Site Manager Anafe Rivera. According to the facility’s license, the facility has a maximum capacity of six (6) clients, all of whom may be non-ambulatory. During today’s inspection, there were a total of six (6) clients in care. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by Anafe Rivera, toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas. (CONTINUED ON LIC809-C) (CONTINUED FROM LIC809) No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Confidential records were stored in locked areas. Anafe Rivera also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. LPA issued two (2) technical violations. An exit interview was conducted with Ms. Rivera, a copy of this report and LIC 811 (Confidential Names List) along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to them.the state’s words, verbatim · CDSS document, May 21, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Onsite Manager Anafe Rivera. During today’s visit, LPA toured the facility, reviewed staff and client records, and interviewed clients. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. An exit interview was conducted with the Anafe Rivera, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, May 20, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with House Manager Joseph Bisco. LPA then met with Site Manager Anafe Rivera, who arrived later during the visit. Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 02/02/2024). According to the LIC624, Licensee on 01/30/2024 first became aware of an allegation of physical abuse of a sexual nature by Staff #1 (S1) against Resident #1 (R1), via a third-party source. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a facility tour / welfare check, collected and reviewed pertinent records, and interviewed S1 and other relevant staff. As of the date of LPA’s visit, R1, who was a hospice patient, had since passed away and thus could not be interviewed. According to R1’s latest LIC602 Physician’s Report (dated 01/10/2024): R1’s primary diagnosis was “high grade glioblastoma multiforme” (i.e., a malignant cancerous brain tumor) which was Stage 4 (i.e., advanced). R1’s doctor wrote that R1 was occasionally confused and while R1 was ambulatory, R1 was not able to safely leave the facility unassisted. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] Records and staff interviews consistently showed: R1 alleged that during one morning in late January 2024, S1 on one (1) occasion touched R1 inappropriately as S1 was assisting them in their bedroom. During the few days leading up to the incident, as well as the date of the incident, R1 was battling a cold with fever. R1 was so weak that they were on continuous bedrest. While staff brought food and drink to R1 and offered to feed them, S1 drank little and ate nothing for at least three straight (3) days. While R1 was normally accustomed to using the restroom by themselves, during their cold, they required staff help with incontinence care. Per interview of S1: During the incident, R1 was in bed and S1 wanted to check and see if R1 had soiled themselves. S1 asked R1 to turn their body away from them; R1 understood and complied with turning themselves. S1 then briefly felt R1’s bottom with their hand from the outside (without ever removing or lowering R1’s pants), finding that R1 had not yet soiled themselves. S1 then prompted R1 to turn back to center. During the days R1 was sick, there was evidence of increased confusion. For example, on one occasion, S1 observed that R1 had disrobed, then tried to put their pants on their upper body, and their shirt on their lower body. Upon learning of the incident, Licensee timely conducted an internal investigation, the findings of which did not support the allegation. R1 did not allege, nor did Licensee discover, any indication of physical injury to R1. Per record review and manager interview: Licensee submitted a written report regarding the alleged physical abuse to CCLD and the San Diego County Long Term Care Ombudsman Program (LTCOP), as required. However, Licensee did not report the allegation to the local law enforcement agency, as was required to be done within 24 hours. During the course of today’s site visit, LPA’s interviews with staff revealed a separate incident also involving R1: On 01/20/2024, R1 eloped from the facility (meaning they left without staff supervision). After 40 minutes of searching, staff located R1 over one mile from the facility. R1 was uninjured. Law enforcement was not notified or involved in the search. R1’s elopement incident was not reported to CCLD, as was required to be done within seven (7) days of incident occurrence. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] LPA observed, and staff interviews confirmed: Licensee did not possess a written Absentee Notification Plan (or an equivalent missing resident policy) as part of the written record of care for R1 or any of the five (5) current residents of the facility. Two (2) residents, Resident #2 (R2) and Resident #3 (R3), were formally diagnosed with dementia. However, Licensee’s staff had manually turned off / disabled staff alert devices on its exterior doors. Three (3) deficiencies were cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Rivera, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Mar 20, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Apr 19, 2024

87211 Reporting Requirements: “(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 6 residents (R1), licensee had knowledge of suspected physical abuse against them which did not result in serious bodily injury, and did not report it to the local law enforcement agency within twenty-four (24) hours. This posed a potential safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: CCLD subsequently cross-reported the incident to local law enforcement. Licensee agreed to utilize a third-party source to retrain its staff on Abuse definitions and How to Be a Mandated Reporter in California. Licensee agreed to E-mail LPA the training sign-in sheet by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Apr 19, 2024

87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident." This requirement was not met, as evidenced by: Based on records and interviews, 1 of 6 residents (R1) had an incident which threatened their welfare, safety, or health, and Licensee did not submit a written report of the incident to the licensing agency within seven days of incident occurrence. This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Licensee agreed to compose an LIC624 Incident Report describing R1’s January 2024 AWOL incident, and to send a copy of the LIC624 to the CCLD San Diego Regional Office (CCLASCPSanDiegoRO@dss.ca.gov). Licensee agreed to utilize a third-party source to retrain its facility managers on Regulation 87211 Reporting Requirements. Licensee agreed to E-mail LPA the training sign-in sheet by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.317 · Plan of correction due date: Apr 19, 2024

1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall…develop and comply with an absentee notification plan…The plan shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility…and the circumstances in which [they] shall notify local law enforcement.” This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff did not develop an absentee notification plan for 6 of 6 residents (R1 through Resident #6), which posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Licensee agreed to write an Absentee Notification Plan/policy meeting the requirements of CA H&S Code 1569.317, and to train all its staff on it. Licensee also agreed to place a copy of said Absentee Notification Plan in the care file for every current and future client in care, right next to (i.e., as an addendum to) that client’s Needs and Services Plan. Licensee agreed to E-mail the Plan and the training sign-in sheet to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(j) · Plan of correction due date: Apr 19, 2024

87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by: Based on records and interviews, during today’s visit, Licensee did not have continuously active auditory devices or other staff alert features to monitor exits, which posed a potential safety risk to 2 of 5 residents (R2 and R3) in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: During today’s visit: Licensee activated (turned on) the auditory alarms at each exterior door (other than the lobby front door). Licensee agreed to retrain its staff to keep all such alarms activated 24/7. Licensee agreed to E-mail a copy of the staff training sign-in sheet to LPA, by the POC due date.

Allegation investigated: Licensee did not provide resident's authorized representative with resident's records

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in a complaint investigation on the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Assistant Administrator Von Rivera. On February 27, 2024, Community Care Licensing (CCL) received a complaint alleging the responsible party did not receive a copy of admissions agreement with itemized items at signing on February 14, 2024. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Interview with outside source revealed that R1 was moved into the facility late on February 14, 2024. Interview with Administrator confirmed that R1 was moved into the facility after hours and Administrator was unable to provide responsible party with admissions agreement. Interview with responsible party confirmed that they did not receive a copy of agreement at time of signing. Substantiated Based on interviews, and records reviewed, a preponderance of evidence exists to support the allegation. A technical violation is being issued due to no direct health, safety or personal rights risk to R1. An exit interview was conducted with Assistant Administrator Von Rivera, to whom a copy of this report,LIC9102 TV, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. According to allegations R1’s responsible party was not issued a refund after only residing at the facility for five days. According to records collected, R1 moved into facility on February 14, 2024, and moved out on February 19, 2024. Interview with administrator revealed that a refund of $2,400 was issued. Interview with outside source revealed that resident’s responsible party verbally confirmed that the refund received was to be used for another facility. Interview with outside source confirmed that refund was forwarded to the facility R1 was moved into on February 21, 2024. Interview with responsible party established that responsible party agreed to have the funds forwarded to another facility. It was also alleged that on February 16, 2024, R1 had bleeding from the rectum and facility staff did not clean R1 accordingly. Interview with staff revealed that the incident did occur, but R1 has a condition that causes rectal bleeding often. Interview with outside source revealed that R1 was observed to be clean and kempt on the date of the incident. Interview with other residents revealed that staff provided timely hygiene assistance. Records collected revealed R1 has diverticulitis of the colon. It was also alleged that on February 17, 2024, R1 was not issued pain medication as prescribed. According to interview with outside source, staff were appropriately trained to provide R1 with sublingual medication for pain. Outside source also revealed that staff were continuously in contact with medical provider when requesting for guidance on medication administration. Interview with outside agency revealed that due to R1’s condition, some of R1’s medication would be spit up, but sublingual medication would provide effect even if spit out. Additionally, it was alleged that staff did not seek medical assistance after having multiple bed bug bites and rectal bleeding on February 19, 2024. Interviews revealed that an outside agency was providing daily medical visits to R1. Interviews also revealed that bites could not be confirmed to be bed bugs and facility had not been exposed to bed bugs. Photographs collected could not confirm bites were a result of facility care. Records collected also confirmed that the outside source agency was providing medical care. Lastly, it was alleged that facility did not treat for pest, resulting in R1 sustaining bug bites. According to staff, facility receives monthly pest treatment by a third-party contractor. During visit, LPA Strong did not observe any live pest in the facility. Based on records reviews, the facility has a continuous pest contract for monthly services. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation are unsubstantiated. An exit interview was conducted with Assistant Administrator Von Rivera, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 15, 2024 · control 08-AS-20240227155411

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Daniel Pena, conducted an unannounced Case Management-Other visit to the facility. LPA was greeted at the entrance by Caregiver, Joseph Bisco. After identifying himself and explaining the purpose of the visit, LPA was allowed inside. During the visit, LPA toured the facility, interacted and observed six residents and two staff. LPA conducted a health and safety check of all residents present. No health and safety concerns nor deficiencies were observed and no citations were given. An exit interview was conducted with Caregiver, Bisco and a copy of this report and the Licensee Appeal/Rights was given to Mr. Bisco. Mr. Bisco's signature serves as receipt for the documents provided.the state’s words, verbatim · CDSS document, Jan 25, 2024

Allegation investigated: Staff neglect contributed to resident developing pressure injury(ies).0

Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA was met by Vely Vidal, Caregiver and was granted entry into the facility. LPM met with Anafe Rivera, Site Manager to discuss the purpose of the visit. Investigation consisted of interviews with residents, staff, outside sources, record review, and a tour of the facility. It was alleged that neglect resulted in serious bodily injury of Resident #1 (R1). A Confidential Names form was provided to Ms. Rivera. Investigation revealed R1 was admitted to the facility in January 2020. Record review and interviews revealed R1 was receiving hospice services from admission until April 2, 2020, at which point hey discharged and were followed by a home health agency from April 3, 2020, through their move out date on April 27, 2020. Review of R1’s medical assessment, dated January 11, 2020, revealed R1 had a history of skin breakdown. R1 was incontinent of bowel and bladder and considered non-ambulatory. Review of R1’s resident appraisal and hospice documents upon admission did not note that R1 had skin problems. Hospice records from January 15, 2020, documented R1 had some dermatitis on their inner buttocks. Substantiated All areas of skin on R1 were closed. Interviews with facility caregivers and managers unanimously corroborated that while there was some rash R1’s bottom at time of move in, there were no actual open areas of skin. Staff and outside interviews, and R1’s LIC602 Physician’s Report, corroborate that R1 was incontinent and wheelchair dependent. According to R1’s Hospice Plan of Care, R1 needed to be turned and repositioned in bed every 2 hours, and hospice nurses educated facility staff on the importance of preventing skin breakdown as opposed to wound treatment. Records and interviews revealed R1 was discharged from Hospice on April 2, 2020, and began services with a Home Health Agency (HHA) on April 3, 2020. Record review from the HHA, noted that between April 4, 2020, and April 9, 2020, four different HH staff documented that they provided facility staff education on how to maintain R1’s skin integrity. On April 9, 2020, HHA staff instructed facility staff to implement a turning schedule which restricted R1’s time in one position for 2 hours or less as R1 was restricted to bed. They also instructed staff to float R1’s heels off their bed surface at all times. Interviews with direct care staff revealed staff knew R1 needed to be rotated/repositioned when in bed, but no staff provided that they knew R1’s heels needed to be floated above the bed surface. Although R1’s HHA instructed R1 needed to be repositioned/rotated in bed every 2 hours or less, interviews of R1’s actual caregivers showed while R1 was in bed staff stated they turned R1 every 2-3 hours, and twice during the night. None of the staff stated they floated R1’s heels above the bed surface. Review of facility records revealed the licensee was unable to produce a Needs and Services Plan / Care Plan for R1. Review of Hospice records revealed that from January 13, 2020, through April 2, 2020, the rash on R1’s bottom was effectively managed with creams. R1’s skin remained closed and there were no pressure injuries to R1’s bottom during this period. There was no documented problem with skin on R1’s heels or back during this time either. Review of HHA records corroborate that when hospice ended and HHA took over, R1 did not have pressure injuries and their feet were assessed and appeared normal. HHA noted a mass on R1’s sacrum, but it was intact and not red. Interviews with staff corroborated that R1 moved into the facility with a pre-existing raised bump on their sacrum, but it was closed and normal-skin tone at that time. Staff interviews revealed that on or about April 1, 2020, staff observed that R1 developed a 1-inch by 3-inch pressure injury to R1’s right buttock which involved the top layer of skin. Staff did not describe this wound as deep. The mass on R1’s sacrum had turned bluish or purplish, had opened up, was weeping yellowish discharge, and had foul odor. Facility care staff notified their supervisor who corroborated that the wound on R1’s sacrum had opened up by April 1, 2020, and that over time it got worse and developed foul odor and discharge. Staff stated the wound was reported to HHA staff, R1’s physician, and R1’s responsible party. Review of R1’s HHA records revealed that on April 24, 2020, R1’s feet were still intact, but there was now a stage 2 pressure injury to R1’s coccyx. By April 26, 2020, a HHA physician upgraded the pressure injury to a stage 3 pressure injury, and on April 27, 2020, medical professionals documented wounds to R1’s entire buttock and lower back with wound infection and very foul-smelling drainage. The wounds on R1’s buttock was covered with necrotic tissue. According to medical professionals, on April 27, 2020, R1 met all criteria for severe sepsis and required immediate intervention. R1 was observed with shallow breathing, rectal bleeding, and was very lethargic and difficult to arouse. R1 was transported to a hospital and was admitted for inpatient treatment. Review of hospital records revealed R1 was diagnosed with multiple stage 3 pressure injuries on their back, heels, and coccyx, and a stage 4 pressure injury of the sacrum that required surgery. Medical professionals noted that there was extremely foul-smelling pus coming from the pressure injuries on R1’s sacrum and buttocks, and that these latter ulcers had likely been there for some time. The stage 4 pressure injury over the sacrum was 5 x 8 cm with an abscess cavity covered by necrotic tissue; a stage 3 pressure injury of the right buttock measuring 3 X 5 cm with necrotic tan-like skin; a stage 2 pressure injury of the left buttock measuring 2 x 3 cm; and unstageable pressure injuries of the bilateral heels measuring 3 x 3 cm. Hospital records also noted that there was infected skin and subcutaneous tissue, fascia, and muscle all the way down to the sacral bone. During the surgery, medical professionals found R1’s sacral bone had “bony prominences” that contributed to the formation of pressure ulcers. Although R1 had bony prominences that contributed to the formation of the pressure injuries, interviews with staff revealed that staff did not comply with R1’s care plan and turning and repositioning schedule and did not float R1’s heels. R1 passed away on July 3, 2020. According to R1’s death certificate, R1 passed away due to Acute Respiratory Failure, and Primary Central Nervous System Lymphoma. There were no other significant conditions contributing to R1’s death. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is deemed substantiated. A civil penalty in the amount of $500 is being assessed per Health and 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 and Safety Code Section 1569.49 are pending and under review by the Program Administrator of the Community Care Licensing Division. On today’s date, the Department is issuing a $500.00 civil penalty under HSC 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1. This deficiency is being cited per California code of Regulations, Title 22, on the attached LIC 9099D. An exit interview was conducted with XXXXX and a copy of this report, LIC 421IM – Civil Penalty Assessment Form, and Licensee/Appeal Rights (LIC 9058 01/16), were provided to them at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 08-AS-20200428113435

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.39(d) · Plan of correction due date: Nov 13, 2023

ASSISTANCE WITH ACCESSING HOME HEALTH OR HOSPICE SERVICES; RECEIPT OF MEDICAL SERVICES - Failure to meet or arrange to meet the needs of those residents who require health-related services as specified in the resident’s written record of care...is a licensing violation and subject to civil penalty pursuant to Section 1569.49. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure the written record of care identified by the home health agency for one 1 of 6 residents was not being followed. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2023

Plan of correction: Facility will conduct an in-service training for all staff that provide care to residents on wound prevention including turning timing, documentaion and staff communication regarding care provision. Attendance and training content will be sent to licensing by POC date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced case management visit to cite violations that were identified during a complaint investigation. LPA was met by Veyl Vidal, Caregiver and was granted entry into the facility. LPM met with Anafe Rivera, Site Manager to discuss the purpose of the visit. Interviews revealed that from late February 2020 through part of May 2020, the facility’s administrator was out of the country, and thus not present to observe residents or supervise staff. S4 was left in charge of the facility. However, according to interviews, and corroborated by CCLD’s records, S4 did not have an RCFE Administrator Certificate, and was thus unqualified to provide full-time, ongoing leadership at the facility. This deficiency is being cited per California code of Regulations, Title 22, on the attached LIC 809D. An exit interview was conducted with Anafe Rivera, Site Manager and a copy of this report, LIC 421IM, Confidential Names form (LIC 811) and Licensee/Appeal Rights (LIC 9058 01/16), were provided to them at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 30, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Nov 13, 2023

All facilities shall have a qualified and currently certified administrator…. 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 the administrator being absent and leaving the facility without a qualified substitute posing a potential risk to six of six residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2023

Plan of correction: Facility will develop a policy for ensuring that a certified administrator will be presnet at the facility during periods of extended absence from the facility by the regular administrator. This policy will be sent to to licensing by the POC date.