St. Francis Home for the Elderly

Allegation investigated: Resident has multiple pressure injuries, including at least one unstageable pressure injury.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above for the purpose of delivering findings. LPA met with Staff Anita De Ala and explained the purpose of the inspection. Adminstrator (AD) Runette Catibog was contacted by phone at 8:55 a.m. During the course of the investigation, interviews were conducted with Licensee Osvaldo “Oz” Santa Ana, AD, staff, and witnesses. By all accounts, Resident 1 (R1) had a prior working relationship with Licensee and AD, as R1’s sister had been a previous resident at the facility before passing away. Prior to October 11, 2021, R1 was still living at home and on October 11, 2021, R1 was admitted into the facility. At the time of R1’s arrival to the facility, they did not have any ulcers or redness on their Coccyx area and only had a small sore to their left toe. After about a month, R1 began to exhibit fits of anger toward staff and would not cooperate with being moved for regular rotation and cleaning. (Cont.LIC9009-C) Substantiated Staff would contact R1’s Responsible Party (RP) often, who would then come to the facility to try and calm R1 to get them to comply with staff. At one point during an outburst of anger, R1 punched a staff member in the abdomen. During their interview, AD stated that is when R1 developed some redness on their buttocks area. AD stated R1’s RP was notified about the change in demeanor and the redness, and R1’s RP informed AD they would talk with R1’s doctor. Per Green Meadows Home Health Care Medical Records dated November 3, 2021, Home Health did an initial interview and check of R1 and found no skin injuries or problems on November 3, 2021. On November 22, 2021, the Home Health nurse noticed redness around the Coccyx region and instructed facility staff to rotate R1 more often in order to avoid a skin ulcer. On December 6, 2021, Home Health came to the facility again to check R1’s wound. R1 became combative and would not allow Home Health nurse to inspect their Coccyx area. On December 9, 2021, R1’s RP contacted R1’s doctor who instructed R1 be transported via 911 to the hospital. Upon arrival at the hospital R1’s injury of an unstageable ulcer was discovered. During their interview, R1’s RP stated they were very involved with the care R1 was receiving while at the facility. R1’s RP stated they would be informed of R1’s verbal and physical outburst, and their resistance in allowing staff to provide care. Per R1’s RP, they asked R1 not be transported to the Veterans Affairs (VA) hospital or by emergency ambulance if avoidable. R1’s RP stated they did not want R1 to go to the VA hospital for care for personal reasons and did not want R1 to be transported by ambulance to limit expenses that are associated with emergency care. Per R1’s RP, both they and the facility could have made better decisions for R1’s care. R1’s RP stated staff at the facility did their best to assist R1 and to comply with their requests but subsequently caused delay in care that would have helped prevent R1 from developing an unstageable pressure injury. During their interview, AD stated they attempted to have R1 transported to the hospital when their mental status changed, and R1 showed redness to his Coccyx area, however, R1’s RP convinced AD to delay in transporting R1 for personal and financial reasons. Per AD, although they felt otherwise, they conceded with RP’s requests. (Cont. LIC9099-C) Based upon staff interviews, and record review of associated medical records there is evidence to corroborate the allegation that R1 developed an unstageable pressure injury due to Neglect/Lack of care and supervision. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations. (see LIC9099-D) and an Immediate $500 Civil Penalty is being assessed (see LIC421IM). Additional Civil Penalty is pending determination as per Health & Safety Code 1569.49(f). An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, May 21, 2025 · control 22-AS-20211213162011

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(6) · Plan of correction due date: May 22, 2025

Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services Based on staff interviews, the licensee did not comply with the section cited above as medical treatment for R1 was delayed, resulting in R1 developing an unstageable pressure injury, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: AD stated staff training regarding basic services and arrangements to meet residents' health needs including arranging transportation will be conducted and proof will be provided to LPA via email by POC date.

Type of visit: Required - 1 Year

On May 7, 2025, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Administrator (AD) Runette Catibog was present to assist with the facility inspection on today's date. The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for six (6) residents. Currently, there are zero (0) Hospice residents present during today’s visit. This is a single story home with attached garage facility. The facility has five bedrooms (two shared resident rooms, two private resident rooms and one staff room), and two full bathrooms. At around 12:50PM, LPA conducted a tour of the physical plant accompanied by Administrator Catibog, and the following was observed: Facility has an a pool with secured gate on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 109.0 degrees F. A comfortable temperature of 76 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has emergency food and water supply. Facility has one fire extinguisher which was mounted and fully charged. CONTINUED ON 809C During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 3/11/2025. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 11/24/2024 – 11/24/2025. A review of six residents (R1-R6) service files and two staff (S1-S2) personnel files revealed to be complete. The facility has the current administrator's certification on file for Runette Catibog Expiration 10/26/2025. No deficiencies during this inspection visit. An exit interview was conducted with Administrator Catibog,, and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 7, 2025

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting a Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the reason of the visit. Administrator Runette Catibog was notified of the visit and arrived later to assist. During the inspection, LPA and administrator conducted a tour of the physical plant and observed the following: The facility is a one-story home with four resident bedrooms, one staff room and two bathrooms. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets and an adequate additional supply is present. The backyard has a shaded area and the route of egress is free of clutter and obstructions. There are currently six residents in care at the facility, two of which are receiving hospice care. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Combined smoke and carbon monoxide detectors tested operational. There is a fire extinguisher present which was observed to be fully charged with up-to-date maintenance. Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The staff room and laundry area were observed to be locked by facility staff. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPA reviewed six resident files and five staff files. LPA conducted or attempted six resident and two staff interviews. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 17, 2024