St Andrews Suites

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified herself to, and discussed the purpose of the visit to Administrator Sherwin Marcos. Community Care Licensing received an Incident Report on 8/17/26 in which it was reported that on 8/14/26, Resident #1 (R1) had a fall while left alone on the toilet when receiving toileting assistance from two staff. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] Per the report, R1 sustained a broken femur that required surgery. As of today, R1 has not returned to the facility from the hospital. During today's visit, LPA reviewed facility records and interviewed staff. Per records reviewed, R1 requires assistance with toileting, including equipment or assistance of another person. Interviews with staff admitted leaving R1 on the toilet alone and reported it was "the routine everyday" for R1. LPA consulted with Administrator regarding R1's care and supervision needs and the facility's plan moving forward. A deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). The citation is issued for facility neglect in not following R1's assessment outlining a need for toileting assistance. Civil Penalties are under review by the Department and may be assessed at a later date. An exit interview was conducted with Administrator Sherwin Marcos to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided at the conclusion of the visit. Signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 18, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Aug 28, 2026

87468.2: In addition to the rights listed in Section 87468.1 [...] residents...shall have all of the following personal rights: (8)To be free from neglect [...] This requirement is not met as evidenced by: Based on record review and interviews, the Licensee did not ensure R1 was receiving toileting assistance as indicated, resulting in injury. This posed an immediate health and safety risk to 1 out of 6 residents in care.the state’s words, verbatim · CDSS document, Aug 18, 2026

Plan of correction: R1 has not yet returned to the facility. Licensee will conduct an in-service training with staff on care plans and toileting assistance. Licensee will submit this to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angelica Boyles 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 Administrator Sherwin Marcos. According to the facility’s license, the facility has a maximum capacity of 6 residents of whom all may be non-ambulatory, of which one 1 resident may be bedridden. There is an approved hospice waiver for three 3 residents. LPA, accompanied by Administrator toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The internal ambient temperature was comfortable and compliant. Hot water temperature at taps accessible to clients were all compliant. There were at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking and dining equipment and utensils were present. There were no sharp objects, open-faced fireplaces or heaters observed accessible to residents. 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 Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records and files. The reviewed files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Administrator Sherwin Marcos 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, May 26, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Roman conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator, Sherwin Marcos. According to the facility’s license, the facility has a maximum capacity of six clients, of whom all may be non-ambulatory and one of which may be bedridden. LPA toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order, water temperature was measured at 105 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to client. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on the premises. Per Sherwin Marcos, no firearms or ammunition are kept at the facility. Carbon monoxide detectors and smoke alarms were tested at 1:15PM, emergency lighting, and facility telephone were all working. Fire extinguishers were present and serviced on 02/06/2025. First aid kit was complete and readily accessible. Resident records reviewed had required documentation. Staff records reviewed contained required documentation. However, the facility is missing the Plan of Operations manual. Licensee, Michelle Retzer reported to email the documents to LPA within the next two weeks. An exit interview was conducted with Administrator, Sherwin Marcos and Licensee, Michelle Retzer, to whom a copy of this report and the Licensee/Appeal Rights were provided during the visit. Their signature acknowledges the receipt of their rights.the state’s words, verbatim · CDSS document, Jun 17, 2025

The state marks this report as 3 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) 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 Administrator Sherwin Marcos. According to the facility’s license, the facility has a maximum capacity of six (6) residents of whom all may be non-ambulatory, of which one (1) resident may be bedridden. There is an approved hospice waiver for three (3) residents. During today’s inspection, there were a total of six (6) residents and per medical records, all were either ambulatory or non-ambulatory. LPA, accompanied by Sherwin Marcos 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 resident activities. Hot water temperature at taps accessible to clients were all compliant. There were at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no sharp objects, open-faced fireplaces or heaters observed accessible to clients. Medications were labeled, as required, and stored in locked areas. 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 and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete. Required licensing postings were observed in visible areas of the facility. Disinfectants/chemicals were observed in an unlocked interior facility room and exterior shed accessible to residents in care. During LPA’s visit, facility staff locked and secured all disinfectants and cleaning solutions, resolving the immediate risk. A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with Administrator Sherwin Marcos. An exit interview was conducted with Sherwin Marcos to whom a copy of this report, the LIC 809-D and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jun 12, 2024