St. Mary's Love and Care Home

Allegation investigated: Staff left resident unattended on the floor Staff refused to help the resident Staff did not provide a comfortable environment for resident

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Assistant Administrator Phillip (Chris) Abaya who assisted with today’s visit. The investigation consisted of the following: During the initial visit conducted on 12/26/2023, LPA Janette Romero conducted an unannounced visit, toured the facility and obtained copies of pertinent documentation. The facility was advised that the investigation requires further inquiry and possible additional visits and/or phone calls may be necessary to determine findings. During today’s visit, LPA Gutierrez toured resident bedrooms, obtained staff roster, resident roster, reviewed R1’s file and obtained copies of preplacement appraisal information, face sheet, physician report, facility notes, and texts messages with staff and C1’s family. LPA requested any SIR’s that were submitted to CCLD for falls with residents within the last six months, LPA interviewed Assistant Administrator, staff #1-staff#3 (S1-S3), residents 2--6 (R2-R6), and delivered findings. Unsubstantiated In regard to the allegation” Staff left resident unattended on the floor “, It is alleged that C1 slept out of his/her bed and was left unattended. During interview with Assistant Administrator, and staff four (4) out of four (4) stated that they have never left a resident on the floor. Administrator stated that C1 would become very agitated and try to transfer him/herself even though there were two people assist. S1 stated that C1 would fall trying to get up and did not wait for staff to assist. During interviews with residents three (3) out of four (4) state that they have never been left unattended by staff. One (1) resident was confused by LPA’s question. LPA reviewed staff notes and all indicated that C1 fell while trying to get out of bed without notifying staff. LPA also reviewed text messages between staff and C1’s family after each incident. LPA also reviewed SIR reports and files for the last six months and did not see any incidents of residents being left unattended. In regard to the allegation” Staff refused to help the resident”, It is alleged that facility refused C1 help after C1 called facility helpline and staff said no one is going to help you. During interview with Assistant Administrator, and staff four (4) out of four (4) stated that they have never refused to assist a resident. Staff all stated that residents push the call button or yell for help and they come right away. All staff indicated that there is no facility helpline, only a bush button. During interviews with residents three (3) out of four (4) state that they have never been refused by staff for help. One (1) resident was confused by LPA’s question. R1 stated that staff was very attentive and that even if he/she doesn’t push the button all they have to do is yell and staff comes. LPA asked Administrator if any staff had any write-ups in file and was told no one had ever been given. In regard to the allegation” Staff did not provide a comfortable environment for resident”, It is alleged that C1’s mattress was sagging causing him/her to slide out of bed. During interview with Assistant Administrator, and staff four (4) out of four (4) all stated that they have had no issues with mattress. Administrator stated that if a mattress needs to be replaced facility does not have a problem with that. LPA reviewed text messages between staff and family of C1 asking family to authorize with primary doctor or home health for a fully motorized bed. LPA interviewed four (4) residents and three (3) residents stated there mattress were fine. R3 was very confused and didn’t remember if he/she had any problems with mattress. R1 stated that mattress was fine and that staff even ordered them a bubble mattress for extra comfort. LPA did a tour of all five (5) residents’ beds and found all mattress in good condition. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Licensee, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 2, 2026 · control 18-AS-20231218152726

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Toni Nwala and LPA Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPAs was greeted by assistant administrator Phillip Abaya, notified him of the purpose for the visit and was allowed to enter the facility to conduct the inspection. Facility Overview: The facility is a one story building with five(5) residents bedrooms, One (1) staff room, two and half(2.5) bathrooms, a sun room, an office and a kitchen area. There is a gated pool with a secured lock and there are no firearms on the premises Backyard was clean and free of debris . Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the garage and inaccessible to residents. The smoke detector and carbon monoxide detector were in good working condition. LPA observed fire extinguishers to be in compliance with the department requirements and with an expiration date of November 11, 2026 The water temperature was tested within regulations measuring at 113.9 F Care & Supervision/Administration: Adequate staff were present to supervise residents during the visit. The administrator holds a current administrator’s certificate with expiration date of April 22, 2026 and a CPR certification with the expiration date of February 11, 2027 Record Review and Resident/Staff Files: LPA reviewed files for three(3) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. LPA observed first aide kit to be locked and inaccessible to the residents in care. The residents and staff files were kept in a locked cabinet in the kitchen area and inaccessible to unauthorized individuals Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the kitchen area. LPA reviewed medications for three(3) residents, confirming that all medications were listed and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last emergency drill conducted on 03-1-2026, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Administratorthe state’s words, verbatim · CDSS document, Mar 18, 2026

Type of visit: Required - 1 Year

On 03/17/25 Licensing Program Analyst (LPA) Debbie Palacios conducted an unannounced one (1) year required visit. LPA was granted entry by caregiver, Aquilina Latayan, who was informed of the purpose of visit; Administrator Philip Abaya arrived shortly after. At the time of the visit there were two (2) caregivers, Administrator and six (6) residents present. All staff present were observed to have obtained proper fingerprint clearance and were associated to the facility. LPA observed the following during today's visit: LPA conducted a tour of the facility with caregiver, Aquilina. The physical plant is a single story structure that contained four (4) resident bedrooms, one (1) staff bedroom, and three (3) bathrooms. The facility has a (1) formal dining rooms, kitchen, living room, an office area,garage, and a gated backyard. Indoor and outdoor passageways were free of obstruction. LPA observed an in-ground pool in the backyard, which was gated and locked. The facility has more than a two (2) day supply of perishable food and seven (7) day supply of non-perishable foods. Extra linen were observed in two (2) separate closets located in the hallway. There were two (2) freezers observed in the garage that were observed to be fully stocked. Dishes and utensils were in sufficient supply and in good repair. Knives and sharp items were observed in a locked kitchen cabinet. Resident bedrooms had the required bedding, furniture, and lighting. The smoke and carbon monoxide detectors were tested and were observed to be operable. Centrally stored medications were observed in a locked kitchen cabinet. The outdoor patio was observed to have shaded seating to encourage outdoors socialization. Two (2) fully charged fire extinguishers were observed in the facility. The facility was observed to be in a clean condition; free of dirt, insects, rodents, and pests. LPA observed that the laundry room was locked and had the cleaning supplies and detergents locked in a cabinet. Staff files reviewed include but not limited to have personnel records, health screenings, criminal record clearance, required training, and valid first aid/CPR certification. Administrator certificate is current until 04/22/26. Resident files included but are not limited to signed admission agreements, pre-placement, personal rights, needs and service plans, and updated physician reports. Facility sketch, CCL complaint poster, license and emergency disaster plan is posted on a wall located in the living room. During today's visit, LPA did not observe any immediate violations or concerns. An exit interview was conducted, and a copy of this report was reviewed and provided.the state’s words, verbatim · CDSS document, Mar 17, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator Janard Lansangan and informed her of the purpose of today's inspection. Below is a summary of what was observed: Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include soap and paper towels at hand washing stations, and hand washing guides posted above sinks. Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 113.9 degrees. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. LPA Colvin observed an in-ground pool in the backyard, which was gated and locked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. Knives and other sharp objects are kept locked away and out of resident reach. Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 non-ambulatory residents, one of which may be bedridden. Facility has a hospice waiver for 2 residents. Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator with a current Administrator Certificate. LPA Colvin reviewed staff records and confirmed current CPR/First Aid Certification as well as training relevant to the facility and residents' needs. All staff have criminal background clearance that has been transferred to the facility. Resident Records: LPA Colvin reviewed the files for all 6 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin observed that three residents (R1, R2, & R3) diagnosed with Dementia have Physician's Reports that are over one year old. Deficiency cited. Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file. LPA Colvin observed that the facility has not documented an Emergency Disaster Drill since 2020. Deficiency cited. Planned Activities: LPA Colvin confirmed with interviews of staff and residents that the facility provides activities for residents to engage in and are tailored to their interests. An exit interview was conducted with Administrator Janard Lansangan and a copy of this report, LIC809D, LIC9098 Proof of Corrections, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 17, 2024