St. Mary's Residential Care Home II

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds, including detached storage building, which is locked and inaccessible. There are 5 client bedrooms, two full bathrooms, one staff bedroom--with 2 beds--living/dining room, and kitchen. Clothes washer and dryer are located in two car garage. The backyard is level, fenced and mostly paved. Medications are secured in locked cabinet in kitchen. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Hot water temperature is tested in bathroom. A comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is maintained and complete. Perishable and non-perishable fruits, vegetables and protein are maintained, as well as supplies of bed and bath linens and hygiene products. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Client files are reviewed, including Centrally Stored Medications Records. Mariluz Arimas (x 11/26), Merlito Arimas (x 9/26) and Mialynn Arimas (x 12/27) are certified RCFE administrators that oversee facility operations. The following licensing forms are requested to be completed and submitted to CCLD BY 6/3/26: - Emergency Disaster Plan (LIC610) - Personnel Report (LIC500) Proof of current liability insurance is given to LPA today. Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Also, see Technical Advisory Note--8 pages.the state’s words, verbatim · CDSS document, May 20, 2026

Allegation investigated: Facility staff did not provide resident with care, supervision, and services Facility did not allow home health nurse visit to a resident while in care

On August 18, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to deliver and discuss the findings of a complaint allegation and investigation. Upon arrival, LPA met with caregiver (S1), Karen Marcela and disclosed the purpose of the visit. On 05/23/2025, the Department received a complaint with allegations that “Facility staff did not provide resident with care, supervision, and services” and “Facility did not allow home health nurse visit to a resident while in care”. On 08/05/2025, during the facility visit, LPA observed R1 sitting in a wheelchair in the living room watching TV, with S1 seated next to R1 and attending to R1. Continued on LIC9099-C Unsubstantiated On 05/28/2025 and 08/05/2025, LPA interviewed three (3) staff members (ADM, S1, and S2) and R1’s POA. R1’s POA stated that facility staff attended to R1’s needs very well, consistently monitored R1, and provided daily updates on R1’s condition. Medications were always administered on time. POA stated that they visit R1 at the facility 6 to 7 days a week. The ADM and staff provided the best possible care, and there was no neglect. R1 ate well, and a food assistant was available. R1’s POA expressed being very satisfied with the care provided, stating that R1 was receiving the best care possible for R1’s condition. R1 was not on total care and did not have ulcers, falls, or bruises. R1’s POA stated that the RP was not helpful, refused to come on 05/20/2025 to evaluate R1, did not want to know R1’s symptoms, and offered the ER as the only option, and instructed staff to take R1 to the hospital. R1’s POA further stated that they decided not to allow RP to visit the facility on 05/21/2025 to see R1, as they have already changed the home health agency and expressed being very satisfied with the new agency, noting improved communication. ADM stated that on 05/20/2025, staff showered R1, and R1 ate all meals, did not vomit, and did not have a fever. R1 appeared tired, confused, and was not walking around. Staff updated R1’s POA when the POA visited the facility that evening. The POA called RP and asked RP to visit the facility to evaluate R1; however, RP refused to come and instructed the POA to take R1 to the hospital. The POA and ADM decided not to call 911 since R1 was sleeping and instructed staff to observe R1 throughout the night and call 911 if there was an emergency. The next day, the POA and ADM decided to have R1 transported to the hospital via ambulance for evaluation. While at the hospital, the POA requested a change of home health agency. When RP called ADM on 05/21/2025, ADM informed RP not to come to the facility as R1 was in the hospital and the POA had already requested a new home health agency. ADM further stated that R1 was not on total care. R1 walked with a walker, received PT at the facility for exercises, could feed themself, and could get up from bed. R1 had not experienced any falls and never had bruises or injuries. Occasionally, R1 experienced episodes of hallucinations, and some medications caused R1 to feel tired. Continued on LIC9099-C S1 stated that they were not working on 05/20/2025; however, the next day, they observed R1 to be weak, remaining in bed and unable to get up. ADM and R1’s POA came to check on R1 and decided to have R1 taken to the hospital for evaluation. S1 stated that they observed changes in all residents and communicated with ADM or called 911 if needed. S1 further stated that it was R1’s POA who wanted to change the home health agency, as RP had refused to come to evaluate R1. S2 stated that on 05/20/2025, R1 was very sleepy, and RP called ADM requesting that 911 be called to take R1 to the hospital. ADM asked S2 to check on R1, and S2 informed ADM that R1 was sleeping. The next day, R1’s POA came to the facility and decided to have R1 taken to the hospital, as R1 was unable to stand. S2 stated that they had no idea why ADM did not allow RP to come to the facility. On 05/28/2025, LPA received and reviewed R1’s LIC602 Physician’s Report, dated 03/24/2025, which stated that R1’s diagnosis was Parkinson’s Dementia, with mental condition noted as confused, and that R1 was able to communicate needs and feed themself. On 05/28/2025, LPA received and reviewed R1’s LIC625 Appraisal/Needs and Services Plan, dated 03/01/2024 and signed by R1’s POA on 08/11/2024, which stated that R1 required assistance with transferring in and out of bed and was able to walk using a walker. On 05/28/2025, LPA received and reviewed R1’s LIC9172 Functional Capability Assessment, dated 11/17/2022, which stated that R1 was confused at times, required assistance with transferring, could feed themself completely or with help from another person, walked with support, and used a walker and/or wheelchair. On 05/28/2025, LPA received and reviewed R1’s progress notes for 05/20/2025, which stated that R1 was more confused than usual, was weak, unable to get up from bed, and that R1’s POA was called regarding R1’s condition. On 05/28/2025, LPA received and reviewed R1’s hospital discharge report, dated 05/25/2025, which stated that R1 had a urinary tract infection (UTI). Continued on LIC9099-C Based on observations, interviews conducted, and records reviewed, the facility staff provided R1 with care, supervision, and services. R1’s POA visited the facility frequently, received regular updates, and expressed high satisfaction with the care provided. There was no evidence of neglect or failure to meet R1’s care needs. The refusal for RP to come on 05/21/2025 occurred when R1 was already in the hospital, and the decision to change home health agency originated from R1’s POA, not from a facility policy to deny access while R1 was in care. The timing and circumstances did not demonstrate that the facility wrongfully denied necessary medical services. The Department has determined that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation(s) are UNSUBSTANTIATED. No deficiencies were cited under the California Code of Regulations, Title 22. An exit interview was conducted with the Caregiver. A copy of this report was discussed and provided to the Caregiver, Karen Marcela, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 26-AS-20250523163931

Type of visit: Required - 1 Year

On May 15, 2025, at 09:50 AM, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the caregiver, Karen Marcela, and disclosed the purpose of the inspection. The caregiver informed the LPA that the facility had (6) residents in care and (2) staff members present at the time. At 10:06 AM, the LPA initiated a walk-through of the facility, accompanied by the caregiver. LPA inspected the kitchen and found it clean, with no food preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet containing knives and sharp objects, and a locked cabinet under the sink with detergents and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted. LPA inspected the dining area adjacent to the kitchen and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. The indoor temperature reading of 72°F on a thermostat was observed in the hallway at the time of the visit. LPA inspected the living room and observed it clean, with all furniture in good repair. There were sofa sets, chairs, tables, and a television in the living room. (2) residents were observed sitting in the living room watching TV. LPA inspected the fire extinguisher mounted on the wall in the living room and found it fully charged, with the Continued on LIC809-C last service tag dated 07/29/2024. The caregiver tested the smoke and carbon monoxide detector located in living room in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit. LPA inspected the garage and found it clean. A washer, a dryer, a refrigerator and a freezer containing additional food supplies, storage racks shelves with non-perishable food items, incontinence supplies, file cabinets, suitcases and cabinets containing pillowcases, mattress pads, bedsheets, and towels were observed inside the garage. LPA toured the backyard and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. No bodies of water were noted. LPA inspected (1) storage shed in the backyard and noted a Hoyer lift, wheelchairs, and mattresses stored. LPA reviewed five (5) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had an Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members were associated with the facility. LPA observed locked centrally stored medication cabinet in the kitchen. Medications were organized separately for each resident. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete. LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster (Fire and Earthquake) Drills were conducted every two months, with the most recent drill completed on 05/07/2025. The following updated forms are requested to be submitted to CCLD by 05/22/2025: 1) LIC 500: Personnel Report 2) LIC 308: Designation of Facility Responsibility 3) Certificate of Liability Insurance 4) Administrator Certificate(s) No deficiencies were cited during today's visit. An exit interview was conducted with the caregiver. A copy of this report was left with the caregiver, Karen Marcela, whose signature on this form confirms receipt of the report.the state’s words, verbatim · CDSS document, May 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Mariluz Arimas. During the visit, LPA observed 6 residents and 3 staff. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 5 resident bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 74 degrees F, and hot water temperature was measured at 118 degrees F in both resident bathrooms. Fire extinguisher was serviced in July 20, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA requested to see the facility first aid kit and facility fire/earthquake drill log. LPA reviewed the facility fire/earthquake drill log, which only had the last documented drill at January 8, 2021. ADM stated the facility's last drill was on January 13, 2024. ADM stated she could not find the documentation for fire/earthquake drills for the year 2023-2024. LPA reviewed facility records for 3 staff and 3 residents. While reviewing resident R3's records, LPA observed resident R3 has dementia. R3's last physicians report is dated November 15, 2022. ADM stated she did not have an updated physicians report for resident R3. LPA requested to review residents R1-R3's weight record log. ADM stated she does not have a weight record log. Page 1 Out of 2 LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 2 residents. Deficiencies are being cited during today's visit, see LIC809-D. This report was reviewed with Administrator Mariluz Arimas and a copy of the signed report was provided. Appeal Rights were provided. Page 2 Out of 2. END OF REPORTthe state’s words, verbatim · CDSS document, May 8, 2024