South Pacific Villa

Allegation investigated: Neglect resulted in stage 4 pressure injury Lack of incontinence care resulted in skin condition Medication was not issued as prescribed

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with facility staff Angelina Escobar and explained the purpose of today's visit. Regarding the allegation neglect resulted in stage 4 pressure injury. The investigation revealed sufficient evidence to support the allegation. During the investigation, hospice documentation and photos dated 01/21/25 through 02/25/25 showed that Resident #1’s coccyx wound deteriorated from minor skin breakdown to a tunneling stage 4 pressure injury. The resident was identified as high risk for skin breakdown and required repositioning every two hours per hospice and physician orders. Hospice staff consistently documented that Resident #1 was found heavily soiled with urine and feces on multiple visits, with bedding saturated up to the resident’s shoulders. Staff interviews were inconsistent; one caregiver stated the resident was not repositioned during the night “because he was asleep,” while hospice nurses indicated they repeatedly educated staff on proper repositioning and moisture management. Based on the information obtained through interviews, record review, and hospice documentation, the preponderance of evidence revealed the facility failed to provide adequate care and supervision, resulting in a preventable decline in the resident’s skin integrity. Therefore, the allegation is SUBSTANTIATED. Continued.... Substantiated Regarding the allegation that lack of incontinence care resulted in a skin condition for Resident #1, the investigation revealed sufficient evidence to support the allegation. According to hospice progress notes and interviews, Resident #1 was frequently observed saturated with urine and feces, including bedding and clothing, upon hospice arrival. Staff reported providing incontinence care every three hours and as needed; however, hospice documentation indicated that such care was not consistently provided per the care plan. Hospice staff documented repeated education to facility caregivers on the importance of incontinence checks and timely care. Despite this, there was no record of compliance monitoring or corrective documentation by the facility to ensure staff followed the plan of care. Based on hospice records, interviews, and facility documentation, the preponderance of evidence demonstrates that the facility failed to provide consistent incontinence care, which contributed to further skin deterioration and discomfort. Therefore, the allegation is SUBSTANTIATED. Regarding the allegation that medication was not issued as prescribed, the investigation revealed sufficient evidence to support the allegation. During the 10-day visit conducted on 02/26/2025, two medication pills were observed on the floor next to Resident #1’s bed. Hospice nursing staff also reported missing Morphine tablets that were not documented on the MAR, and confirmed that staff had been educated multiple times on controlled-substance tracking. A caregiver stated that medications were occasionally crushed in ice cream to assist the resident with swallowing. Review of the physician’s report and medication orders revealed no authorization for crushing any medication. Based on observations, interviews, and record review, the preponderance of evidence demonstrated that the facility failed to ensure medications were administered and documented according to physician directions and hospice protocol. Therefore, the allegation is SUBSTANTIATED. The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22, and the California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on H&S Code section 1569.49(f). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted with Facility staff, Angelina Escobar , and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 21, 2026 · control 08-AS-20250224152208

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 22, 2026

87464 Basic Services (f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health andSafety Code section 1569.2(c).The following requirement has not been met as evidenced by: The facility neglected to provide proper care and supervision of Resident 1 leading to stage 1 pressure injury, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 21, 2026

Plan of correction: The licensee retrain all direct-care staff on: prroper turning and repositioning techniques, pressure injury prevention, Monitoring and reporting changes in skin condition, and submit proof to LPA by POC date of 02/22/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(a)(1)(2) · Plan of correction due date: Feb 22, 2026

87625 Managed Incontinence (a) The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances:(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered.(2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. The following requirement has not been met as evidenced by: Resident 1 was left soiled in urine and feces for extended periods of time contributing to a stage 1 pressure injury, which poses an immediate, heakth, safety, orpersonal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 21, 2026

Plan of correction: The licensee will retrain all direct-care staff on timely response to incontinent care needs, proper hygiene practices, monitoring and reporting skin breakdown, rashes, or discomfort, and submit proof to LPA by POC date of 02/22/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a) · Plan of correction due date: Feb 22, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.The following requirement has not been met as evidenced by: Resident 1 was not given all prescribed medications, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 21, 2026

Plan of correction: The licensee will ensure all staff responsible for medication assistance will receive retraining on medication administration procedures, including: Administering medications strictly according to physician orders Accurate documentation on the MAR Identifying and reporting missed or refused doses immediately, and submi proof to LPA by POC date of 02/22/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Caregivers Angelina Escobar and Alfredo Riosa. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, ages 60 and over with a hospice waiver for six (6) and bedridden approval for rooms #3 and #6. During today’s inspection there were four (4) residents in care. LPA and caregivers toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. A closet with chemicals was found locked, however the key was present in the door. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Caregivers Angelina Escobar and Alfredo Riosa, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. A Technical Violations and Technical Advisory note was issued regarding the facility's medication system and locked areas. An exit interview was conducted with Shanel Pronovost, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 11, 2025

The state marks this report as 6 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA identified herself and met with House Manager Angelina Escobar and caregiver Rosalinda Popoy, to discuss the purpose of the visit and elements of the complaint. During the visit Administrator Natalie Spence arrived to the facility; LPA also spoke with Licensee Shanel Pronovost via phone. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, of which two (2) may be bedridden in bedrooms #3 and #6. During today’s inspection there were five residents in care. LPA, House Manager Angelina Escobar and caregiver Rosalinda Popoy toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per House Manager Angelina Escobar, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Natalie Spence to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 3, 2024

Allegation investigated: Staff pushed resident. Staff yelled at resident. Staff administered medication to resident that was not prescribed. Staff forced resident to stand up. Staff did not follow food service requirements Staff broke resident’s hearing aid. Staff slept while on duty. Staff are unable to communicate with residents due to language barrier.

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced subsequent visit to deliver findings regarding the above complaint allegations. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Angelina Escobar, Staff. LPA conducted the initial investigation visit on August 24, 2023, and was able to interview clients, facility staff, and outside sources. LPA also reviewed records and conducted a physical inspection of the facility. It was alleged that staff pushed resident. Interviews revealed the staff are gentle with the residents. Interviews revealed that the staff assist the residents with showering and toileting. Interviews with staff revealed they are not rough with the residents and they have not pushed any of the residents. Staff denied the allegation. [CONTINUED ON LIC 9099-C] Unsubstantiated [CONTINUED FROM LIC 9099] It was alleged that staff yelled at resident. Interviews revealed they talk nicely to the residents and don't yell at them. Interviews revealed that sometimes staff speak louder to the residents because they have a hard time hearing at a regular tone so they speak up. Interviews revealed that someone could possibly misconstrue them yelling instead of just talking loudly so they can hear. Staff denied the allegation of yelling at the residents. It was alleged that staff administered medication to resident that was not prescribed. Interviews revealed staff denied the allegation of giving the resident medications that are not prescribed to them. Interviews revealed that they only give the medication prescribed to the residents. According to a record review, the residents medications were accounted for and the staff denied giving the residents other residents medications. Interviews revealed that if they were to give another resident someone else's medications they would be short and they have not been short on the medications. It was alleged that staff forced resident to stand up. Interviews revealed the staff assist the residents with standing up they don't force them to get up. Interviews revealed they have the residents stand when trying to assist them with changing or toileting. Any time a resident refuses they do not force the residents to do any thing they do not want to do. It was alleged that staff did not follow food service requirements. Interviews revealed the residents are fed good meals. Interviews revealed the staff cut up the food for the residents to eat and make sure the bites are small enough so they don't choke. Interviews revealed the staff give the residents choices when eating and what they will eat. It was alleged that staff broke resident’s hearing aid. Interviews revealed staff denied breaking the resident's hearing aid. When they observed the hearing aid was broken they reported it to the licensee and to the family that was around the same day the spouse observed the case to have a crack in it as well. [CONTINUED FROM LIC 9099] It was alleged that staff slept while on duty. Interviews revealed the staff do not sleep while on duty, the staff denied this allegation. There are enough staff working at the facility and the staff will take a nap on the break times only. Interviews revealed that the licensee has explained to the staff not to sleep out in the open they can go into the staff room if they want to take a nap. Interviews revealed the staff are live in and if they are on their breaks they may take a quick nap but not in any of the open areas around the facility. It was alleged that staff are unable to communicate with residents due to language barrier. Interviews revealed the staff speak english and can communicate with the residents. Interviews revealed the staff are all Bi lingual and speak Tagalog as well. Interviews revealed the staff do sometimes speak Tagalog while trying to help each other when assisting the residents. Interviews revealed the residents do not have an issue with that. The Department determined that the allegations of staff pushed resident, staff yelled at resident, staff administered medication to resident that was not prescribed, staff forced resident to stand up, staff did not follow food service requirements, staff broke resident’s hearing aid, staff slept while on duty and staff are unable to communicate with residents due to language barrier are unsubstantiated. An exit interview was conducted with Angelina Escobar, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit..the state’s words, verbatim · CDSS document, Sep 25, 2024 · control 08-AS-20230818110847

Allegation investigated: -Licensee did not follow hospice care plan for resident(s). -Licensee did not give resident a medication as prescribed. -Licensee did not serve resident(s) food that was presentable.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Alfred Riosa. The Complainant alleged that Licensee did not follow the hospice care plans for Resident #1 (R1) and Resident #2 (R2), because facility staff did not comply with hospice instructions to transfer R1 and R2 from wheelchair to recliner during portions of the day (to alleviate pressure on skin and prevent breakdown) and to elevate R2’s legs (to prevent edema/swelling). It was also alleged that Licensee did not give R1 their eye drop medication as it was prescribed, and that Licensee did not serve resident(s) food which was presentable. CCLD’s investigation involved unannounced facility tours / welfare checks. LPA also reviewed pertinent facility and hospice care records, and interviewed relevant staff, residents, and outside sources. [CONTINUED ON LIC 9099-C, 1 of 4] Unsubstantiated [CONTINUED FROM LIC 9099] Care records and interviews of facility staff and outside sources showed that R1 had had Alzheimer’s Disease, was incontinent, wheelchair-bound, and required a hoyer-lift machine with caregiver assistance to transfer both in and out of bed, and in and out of wheelchair. According to R1’s hospice agency written care plan, there was an instruction for R1 to be “up to recliner 2 times a day [effective] 05/18/2022.” However, the electronic time and date-stamped nature of the hospice care plan showed that said instruction was not transcribed/written into R1’s hospice agency care plan until 07/01/2022 (the date the complaint was filed). Per the hospice agency’s electronic time and date-stamped progress notes: During April 2022, R1’s hospice care plan described “turning [them] every few hours in bed” to prevent skin breakdown. The recliner topic came to relevance after R1's responsible person expressed concern that R1 might be socially isolated if they were put back to bed (inside their bedroom away from their housemates) during portions of the day. Interviews of facility staff and hospice staff, corroborated by hospice progress notes, showed: During May 2022 through end of June 2022, R1’s hospice nurse gave repeated verbal instruction to facility staff to help R1 transfer from their wheelchair to the recliner during the day so that R1’s skin could get some relief from pressure. During this same period, facility caregivers and a manager repeatedly conveyed to the hospice agency their concern that R1’s body had become increasingly "stiff," and that transferring R1 to the recliner would negatively impact their skin instead of helping it. Facility staff expressed that they preferred to transfer R1 to bed, where R1 could be more comfortably transferred and more effectively rotated in bed. [According to the Mayo Clinic’s encyclopedic chapter on “Bedsores (pressure ulcers)”: “Friction occurs when skin rubs against clothing or bedding…and can make fragile skin more vulnerable to injury…and shear occurs when two surfaces move in the opposite direction.”] Due to R1's baseline cognitive impairment, they were unable to be interviewed by CCLD about their own care preferences. Over multiple unannounced site visits to the facility during July 2022: LPA observed facility staff use the reclining feature of R1’s wheelchair to help redistribute pressure on their body. LPA also observed facility staff use a hoyer-lift machine to transfer R1 from wheelchair to bed after lunchtime, so that their skin could get rest from pressure. Regulation requires RCFE licensees to “ensure that the hospice care plan is current, and accurately matches the services being provided, and that the [resident’s] care needs are being met at all times.” Although Licensee’s staff did not follow hospice’s specific instruction for recliner-use for R1, Licensee also timely and repeatedly communicated their reasonable basis for not doing so to both R1’s hospice team and responsible person. [CONTINUED ON LIC 9099-C, 2 of 4] [CONTINUED FROM LIC 9099-C, 1 of 4] Licensee advocated in the spirit of R1's interests and offered an alternative method for protecting R1's skin while minimizing their discomfort. Such communication also occurred via in-person care conference/meeting. Licensee continued to ensure that R1’s weight was redistributed throughout the day and indeed met R1’s skin integrity needs. Hospice care records and interviews of hospice agency staff, R1’s responsible person, and facility staff, unanimously showed: R1 had no areas of skin redness or breakdown anywhere on their body during the complaint allegation time frame, and even as of the start of CCLD’s complaint investigation on 07/07/2022. Care records and interviews of facility staff and outside sources showed that R2 had Alzheimer’s Disease, was incontinent, wheelchair-bound, and required a sit-to-stand machine and caregiver assistance to both transfer in and out of bed, and in and out of wheelchair. According to R2’s hospice agency written care plan: From 05/27/2022 through 07/11/2022, there was an instruction from hospice to facility staff to turn R2 every “2 hours with pillow support,” to include during the day. There was no specific mention in this document about R2 needing to be transferred from their wheelchair to a recliner. There was a subsequent added instruction for facility staff to “elevate [R2’s] legs 2 times per day,” which took effect on 05/18/2022. However, the time and date-stamped nature of the hospice care plan showed that said instruction was not transcribed/written into R1’s hospice agency care plan until 07/01/2022 (the date the complaint was filed). According to hospice agency progress notes: On 05/11/2022, R2’s hospice nurse wrote that they educated facility staff to “elevate patient’s legs throughout the day to decrease dependent edema.” During most of May 2022, facility staff did transfer R2 from wheelchair to recliner after lunchtime, while also encouraging R2 to elevate their feet. However, on 05/27/2022, facility staff told a hospice nurse they believed that doing both steps simultaneously (i.e., putting R2 in the recliner while also elevating their legs) contributed to R2 developing new redness on their buttocks. On 06/28/2022, facility staff reiterated their concern to the hospice agency, and by 07/01/2022, progress notes show that hospice staff and facility management reached a new consensus: after lunchtime, facility staff would help R2 lay on their side, in either their bed or on the facility’s couch, to give R2’s skin about a two-hour rest from the wheelchair. Interviews of R1’s hospice nurse and R1’s responsible person corroborated that by 07/01/2022, the affected skin on R2’s “upper left buttock” became Stage 2, meaning the top layer of skin was broken. [CONTINUED ON LIC 9099-C, 3 of 4] [CONTINUED FROM LIC 9099-C, 2 of 4] Over multiple unannounced site visits to the facility during July 2022: LPA observed facility staff help R2 to lay on their side (and not their bottom) on the living room couch after lunchtime. Staff simultaneously used pillows to elevate R2’s feet and separate their knees. In their interview, a credible outside source corroborated that facility staff also followed these steps on days when LPA was not present. Per interviews and hospice records, facility staff had requested and received from the hospice agency a Low-Air-Loss (LAL) mattress for R2 in late June 2022. Hospice progress notes showed that LAL mattress was added to R2’s hospice care plan on 06/29/2022. [According to Encylopedia.com, LAL mattresses have “interconnected air cells with a minimum depth of five inches…[allowing] air to escape from the surface of the bed.” They are proactive tools used to prevent skin pressure injuries.] Regarding the second allegation about R1’s medication: Hospice records showed R1 was prescribed a routine eye drop (for treatment of glaucoma) to be administered at bedtime every day, in each eye. However, this order was discontinued by R1's hospice physician on 07/01/2022. LPA interviewed facility caregivers and manager, who unanimously reported that while R1 took other medications willingly, they actively resisted the eye drops by doing such things as yelling out or swatting their hands. They said that staff communicated this resistance to R1’s hospice agency a few months prior to 07/01/2022, and that they continued to attempt/offer (unsuccessfully) eye drops to R1 until the discontinue order was received. R1’s hospice nurse corroborated that if R1 did not receive said eye drops, it was “probably” because R1 resisted them. The same nurse confirmed R1 had spatial vision issues, did not like being touched, and generally expressed protest by either yelling out or pushing the hands of staff away from them. R1’s responsible person confirmed that R1 was known to “wince with movement” and resisted teeth brushing as much as the eye drops. According to regulation, “Assistance with self-administration does not include forcing a resident to take medication…or otherwise infringing upon a resident’s right to refuse to take a medication.” [CONTINUED ON LIC 9099-C, 4 of 4] [CONTINUED FROM LIC 9099-C, 3 of 4] Regarding the third allegation about food presentation: Over three unannounced visits (on 07/07/2022, on 07/22/2022, and on 04/25/2024), LPA observed a four separate meal preparations and meal services at the facility. Each meal served to the residents was balanced, nutritious, and visually appealing/presentable. In their interviews, staff consistently confirmed that they were mindful to plate food portions in a presentable way. Only two of the six residents in care (who lived at the facility during the allegation time frame) were cognitively capable of being interviewed; both residents told LPA that the food served was of good quality and presentable. Multiple outside visitors were also interviewed; they said that the food served to residents was of good quality and presentable. Licenses had a sample food menu available at the facility, and it showed balanced meal offerings. Based on interviews and records, a preponderance of evidence does not exist to show that Licensee neglected the hospice care plans for R1 or R2, or that Licensee did not offer R1 their eye drops as prescribed, or that Licensee did not serve residents food that was presentable. These allegations are therefore Unsubstantiated. An exit interview was conducted with Riosa, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 08-AS-20220701160009

Allegation investigated: Licensee centrally stored an expired resident medication.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Alfred Riosa. The Complainant alleged that Licensee maintained in its locked central storage (where it keeps medications which are intended to be given to residents) a medication which was beyond its expiration date. CCLD’s investigation involved unannounced facility tours / welfare checks. LPA also reviewed pertinent care records and interviewed relevant staff, residents, and outside sources. [CONTINUED ON LIC 9099-C] Substantiated [CONTINUED FROM LIC 9099] During a 07/22/2022 site visit, LPA, accompanied by staff, inspected the centrally stored medications and their packaging, which Licensee kept on hand and secured for residents. Of the six residents in care, LPA observed that two residents [Resident #1 (R1) and Resident #2 (R2) had at least one expired medication in Licensee’s central storage. Specifically: R1 had an unopened blister pack/card of as-needed (PRN) tablets which had expired in January 2022. R2 had an opened bottle of PRN tablets which had expired in February 2022. During LPA’s visit, staff confirmed that the medications in question were expired, and removed them from central storage (in preparation for discarding and ordering of replacements). Based interviews and LPA observation, a preponderance of evidence existed to show that Licensee centrally-stored an expired resident medication. The allegation was therefore Substantiated. One deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Riosa, to whom a copy of this report, the LIC 9099-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 08-AS-20220701160009

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(4) · Plan of correction due date: May 25, 2024

87465 Incidental Medical and Dental Care: “(h)(4) All centrally stored medications shall be…maintained in compliance with state and federal laws.” This requirement was not met, as evidenced by: Based on interview and LPA observation, Licensee did not ensure that all centrally stored medications were maintained in compliance with state and/or federal laws. This posed a potential health and safety risk to 2 of 6 residents (R1 and R2) in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: During LPA’s 07/22/2022 site visit, staff confirmed that the medications in question were expired, and removed them from central storage (in preparation for discarding and ordering of replacements). This resolved the immediate risk. Licensee agreed to retrain its staff to self-audit centrally stored medications, at least monthly, to remove and reorder medications which are about to expire. Licensee agreed to submit the training sign-in sheet to LPA, by the POC due date.

Allegation investigated: Licensee retaliated against a resident.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Alfred Riosa. The Complainant alleged that Licensee retaliated against a resident, after CCLD had commenced investigating a separate Complaint which preceded this one. CCLD’s investigation involved an unannounced facility tour / welfare check, review of relevant third-party records, and interviews of pertinent facility staff and outside sources. Under regulations, residents of privately-operated RCFE’s have the right to be free from “interference, coercion, discrimination, and retaliation in exercising their rights,” rights of which include “confidentially registering complaints” with the Department. [CONTINUED ON LIC 9099-C] Substantiated [CONTINUED FROM LIC 9099] On 07/07/2022, CCLD commenced a separate complaint investigation regarding this facility, not disclosing the identity of that case’s Complainant. During that site visit, Licensee was instructed verbally and in writing that the case status as of that date was “Needs Further Investigation,” that the investigation was active/ongoing, and that additional interviews would need to be conducted by CCLD. Interviews of outside sources and review of outside source records showed: After CCLD’s departure from the facility on 07/07/2022, Licensee approached and questioned responsible parties and hospice personnel belonging to two residents [R1 and Resident #2 (R2)] regarding the complaint allegations, allegations of which were still under active investigation by the Department. Persons reported that Licensee’s actions created discomfort. Based on interviews and records, a preponderance of evidence exists to show that Licensee’s actions did not uphold residents’ right to confidentially register complaints, free from interference and/or retaliation. The allegation is therefore Substantiated. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Riosa, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 08-AS-20220722110605

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(3) · Plan of correction due date: May 25, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents…shall have all of the following personal rights: (3)…Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.” This requirement was not met, as evidenced by: Based on records and interview, Licensee did not ensure that 2 of 6 residents (R1 and R2) were free from interference and retaliation in exercising their rights. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Licensee agreed to utilize a third-party source to retrain all facility managers and staff on Resident’s Personal Rights, as articulated in CCLD’s form LIC613C-2. Licensee agreed to submit the training sign-in sheet to LPA, by the POC due date.

Allegation investigated: Licensee pursued resident eviction for invalid reason.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Alfred Riosa. The Complainant alleged that Licensee served an eviction letter regarding Resident #1 (R1), and that the reason for the eviction was invalid. CCLD’s investigation involved an unannounced facility tour / welfare check, review of relevant facility and third-party records, and interviews of pertinent facility staff and outside sources. Interview of facility manager and outside sources, and records reviewed, aligned to show: Licensee met with R1’s responsible person (RP) on 07/19/2022 for a care conference meeting, during which Licensee personally served RP with an eviction letter titled, “30 Days Notice.” [CONTINUED ON LIC 9099-C] Unsubstantiated [CONTINUED FROM LIC 9099] CCLD reviewed a copy of this letter, which cited the reason for eviction was that R1 now required a “higher level of care” beyond what the facility could provide. According to the 07/19/2022 care conference meeting agenda, and corroborated by interviews of both parties, one of the cited changes in condition for R1 since move-in was that they had increased “stiffness” in their body and that they had lost the ability to help staff during transfers and repositioning in, and to/from, bed. R1 had also become increasingly frightened during said transfers. According to R1’s LIC602A Physician’s Report (dated 07/30/2021), their doctor determined that R1’s was of “non-ambulatory” status, as of that date. (According to the LIC602A’s printed instructions for the doctor, which conform to regulatory definitions, residents who cannot turn or reposition themselves in bed must be deemed “Bedridden” instead of “Non-Ambulatory.”) The LIC603 Pre-Placement Appraisal, which Licensee authored on 08/04/2021, corroborated that R1 was “Non-Ambulatory” status, as of that date. Interviews of facility caregivers aligned to show: When R1 first moved-in to the facility, R1 was wheelchair-dependent and on hospice are, but their body was still strong enough that they could bear some of their own body weight during transfers. R1 at time of move-in required assistance of one caregiver for transfers, without needing a mechanical lift. They were also able to turn and reposition themselves in bed. Over time, R1 graduated to requiring a Hoyer-lift machine with a sling, plus assistance of two caregivers, for transfers. By the time of the 07/01/2022 care conference, R1 was no longer able to turn and reposition themselves in bed. Hospice agency electronic date and time-stamped progress notes showed: During the three months leading up to 07/19/2022, multiple hospice staff documented that R1 was becoming harder to transfer due to increasing stiffness in their body. Per R1’s hospice care plan, the Hoyer lift machine was added to the plan on an as-needed basis starting 01/12/2022. The Department determined that the basis for R1’s eviction was valid. [CCLD found that the contents of Licensee’s eviction letter did not meet all regulatory requirements – these deficiencies were addressed on a separate Case Management visit report.] Based on interviews and records, a preponderance of evidence does not exist to prove that Licensee pursued a resident eviction for an invalid reason. The allegation is therefore Unsubstantiated. An exit interview was conducted with Riosa, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 08-AS-20220722110605

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit to cite deficiencies which were identified during a separate Complaint Investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Alfred Riosa. Interview of facility manager and outside sources, and records reviewed, aligned to show: Licensee met with the responsible person (RP) for Resident #1 (R1) on 07/18/2022 for a care conference meeting. During this meeting, Licensee personally served RP with an eviction letter titled, “30 Days Notice.” CCLD reviewed a copy of this letter. Although the Department determined that the basis for R1’s eviction was valid, the contents of Licensee’s eviction letter did not meet all regulatory requirements. Licensee did not include in the letter “a statement informing residents of their right to file a complaint with the licensing agency” and the name, address, and telephone number of the local licensing office and the State Long Term Care Ombudsman office, as was required. Licensee did not include in the letter the required disclosure statement described in California Health and Safety Code Section 1569.683(a)(4), which reads: "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." Interviews showed that R1 voluntarily moved out of the facility prior to the expiration of 30-day notice period. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (see the LIC 809-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Riosa, to whom a copy of this report, the LIC 809-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 25, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d)(1)(C) · Plan of correction due date: May 25, 2024

87224 Eviction Procedures: “(d)(1) The notice to quit shall include the following information: (C) A statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office.” Based on records and interview, for 1 of 6 residents (R1), Licensee did not ensure that their notice to quit included a statement informing them of their right to file a complaint with the licensing agency, including the name address and telephone number of the local licensing office and the State Long Term Care Ombudsman office. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Licensee agreed to utilize a third-party source to retrain all facility managers on RCFE Eviction Procedures (as described in California Code of Regulations, Title 22, Section 87224 and California Health and Safety Code Section 1569.683). Licensee agreed to submit proof of training completion to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(d)(1)(D) · Plan of correction due date: May 25, 2024

87224 Eviction Procedures: “(d)(1) The notice to quit shall include the following information: (D) The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." Based on records and interview, for 1 of 6 residents (R1), Licensee did not ensure that their notice to quit included the exact statement that is specified in California Health and Safety Code Section 1569.683(a)(4). This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Licensee agreed to utilize a third-party source to retrain all facility managers on RCFE Eviction Procedures (as described in California Code of Regulations, Title 22, Section 87224 and California Health and Safety Code Section 1569.683). Licensee agreed to submit proof of training completion, by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to caregivers Rose Popoy and Angelina Escobar. LPA spoke with administrator Shanel Pronovost via phone, and Administrator Natalie Spence came to the facility during the visit. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, two (2) of whom may be bedridden in rooms #3 and #6 only. During today’s inspection there were 5 residents in care. LPA and caregivers toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Facility contained at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. No toxic chemicals/poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed staff and client records/files. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. LPA reviewed medication administration procedures with facility staff and management. No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Natalie Spence to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 8, 2023