Sutro Heights

Allegation investigated: -Staff inappropriately gave resident alcohol

On 05/20/2026 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced complaint inspection to deliver findings regarding the complaint allegations received. LPA met with staff, Shirley Aguado, LPA explained the purpose of the visit. Administrator, Laymer Pamintuan, was contacted over the phone and grant permission to staff, Lea Pantangco, to sign all required documents. Regarding the allegation that staff inappropriately gave resident alcohol, the Department conducted interviews and reviewed records. There was insufficient corroborating documentation and witness statements to determine whether the alleged incident occurred. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove whether the allegations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed and a copy of this report is left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 20, 2026 · control 14-AS-20260227114134

Type of visit: Case Management - Incident

On 4/1/2026 LPA Grace Donato made an unannounced Case Management-Incident visit. LPA met with Staff Lea Pantangco. LPA explained the purpose of the visit. CCLD received an incident report regarding a resident (R1) who eloped from the facility on 3/27/2026. R1 asked another resident (R2), to open the door out of the house. While caregiver S1, was getting groceries on the lower level, R2 was trying to be helpful and let R1 outside. Based on records review R1 has neuro cognitive issues and may not able to leave the facility unassisted. LPA interviewed ADM through the phone and it was mentioned that a staff left the residents on the 2nd floor to get some groceries downstairs. R2 opened the door for R1 and R1 was able to go out. LPA observed all doors have alarms that has keys to be able to turn it off. The main door on the 2nd floor where R1 went out has the keys kept in the drawer by the door, easily accessible by other residents. R1 has returned back to the facility after a few hours. Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. Report is reviewed with the assistant administrator and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Apr 1, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 2, 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 and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews, records review and observation, R1 was able to leave the facility unassisted which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: Licensee/administrator shall submit a plan in writing on how to ensure residents who are unable to leave the facility unassisted are being monitored and are being provided adequate supervision to ensure safety. Licensee to submit by POC due date.

Type of visit: Required - 1 Year

On 3/17/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA toured the physical plant. This is a 3-story building with 9 bedrooms, 2 bathrooms, a kitchen, living room, dining room, office and backyard. All bedrooms had the required furniture and sufficient lighting. No accessible bodies of water or hazards were observed. The facility was maintained at a comfortable temperature. The facility's fire alarms and carbon monoxide detectors were observed to be in working order. The facility's fire extinguishers were last checked on April 9th, 2025 and were observed to be fully charged. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility's first aid kit was observed to have all the required items. All sharp objects, soap, detergents, and poisons were observed to be locked and in-accessible to persons in care. LPA reviewed 6 staff records and 5 resident records. All were observed to be complete. A review of Centrally Stored Medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility. During the tour of the physical plant, LPA Calandra observed that R1 and R2 had full bed rails. A type A citation was provided for this deficiency. Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct said deficiencies by the POC due date may result in civil penalties. An exit interview was conducted. A copy of the report along with Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 17, 2026

Type of visit: Required - 1 Year

On 3/6/2025, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Lea Pantango and Caregiver Julio Yap. The facility currently provides care for 9 residents some of which with a diagnosis of dementia. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located throughout the facility were found to be charged. Smoke detectors were present in each common room and resident bedroom. Carbon monoxide detector located in hallways were tested an in working order. Emergency disaster plan is reviewed and completed. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for residents in care. There was a supply of hygiene products and paper products available for residents. Resident's bedroom have lighting & appropriate furnishings and bedding items. Restrooms for resident use were equipped with non-slip mats, grab bars and kept in good condition. During inspection, LPA observed container of powder bleach in resident restroom not kept in secured storage. Staff immediately removed the cleaning supply and stored properly. There is a large outdoor patio equipped with appropriate shading for resident use. Medications are stored in the kitchen and found to be secured. Upon spot review of medications, LPA found that the facility has centrally store medication records updated and in order. LPA conducted a sample file review for residents and found 3 resident appraisals not signed or completed. Upon a sample review of staff files LPA found that all caregiver staff have current 1st aid and CPR certification, annual training, health screening reports on file. LPA requested the following documents be sent to CCL by COB 3/20/2024: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.the state’s words, verbatim · CDSS document, Mar 6, 2025

Allegation investigated: - Staff are not providing medications as prescribed to resident(s) in care

Based on observations by medical professional and review of medication records, this allegation is substantiated. The preponderance of evidence standard has been met. Client #1 was prescribed Cephalexin on 8/8/23 but facility failed to obtain the antibiotic medication because the client did not pick it up. Staff did not make arrangements to pick up or have antibiotic delivered until 7 days later. In addition, Olodaterol/tiotropium inhaler was not refilled, as staff was observed giving client the inhalation device without the medication cartridge installed. Deficiency of the California Code of REgulations, Title 22 is cited on a following page. Substantiatedthe state’s words, verbatim · CDSS document, Jul 25, 2024 · control 14-AS-20230817153442

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 26, 2024

INCIDENTAL MEDICAL CARE The licensee shall assist residents with self-administered medications as needed. This requirement was not met, as staff failed to obtain antibiotic prescribed to client #1 on 8/8/23 in a timely manner. Licensee failed to ensure that client received Rx medication when prescribed, which posed an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Plan/proof of correction to address timely administration of prescribed medications will be submitted to CCLD BY DUE DATE

Allegation investigated: - Facility grounds are unkept and full of debris - Staff does not ensure that resident's room is ventilated

Based on observations made on 10/2/23 during initial complaint visit, this allegation is substantiated. The preponderance of evidence standard has been met. In backyard, a mattress covered with a ripped mattress cover was observed on top of a patio table and chairs, a plush blanket was draped over a hedge, two wheelchairs were stored under stairs, and numerous empty cardboard boxes were scattered. In addition, boxes, filled plastic bags, tables and overgrowth of plants obstructed the ground level passageway leading from street to backyard. See Facility Evaluation Report of 10/2/23 for Type B deficiency cited. Front room on ground floor was created by construction of wall in bedroom. Wall has since been removed after citation issued on 10/2/23; see Facility Evaluation Report. The small front room formed by the wall had no window. Deficiency of the California Code of Regulations, Title 22 is cited on a following page. Substantiated Based on staffing schedules observed when complaint investigation was initiated, it could not be determined that night staff was sufficient. However, LPA observed documentation of hoyer lift training for 4 staff. Pertaining to client's privacy, it was acknowledged by client during interview that bedroom door is often left open. He stated that this was not a concern. During previous complaint visit, bed linens were observed draped on foliage in backyard to be aired out. Staff were advised that this practice is not appropriate. According to staff, laundry is done daily and clothes washer and dryer are operable.the state’s words, verbatim · CDSS document, Jul 25, 2024 · control 14-AS-20230922090634

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 8, 2024

MAINTENANCE AND OPERATION The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met, as licensee failed to ensure that backyard and access to backyard are free of debris. This posed a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Administrator to submit plan of correction BY DUE DATE to ensure that grounds are at all times free of debris and accessible to residents, staff and visitors

Type of visit: Case Management - Deficiencies

During complaint investigation--which included review of medication administration procedures and staff training--deficiencies of the following California Code of Regulations, Title 22/Health and Safety Code are observed. Citations appear on a following page. Civil penalty of $100 is issued for violation of Criminal Record Clearance. Per Health and Safety Code 1569.69, in facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete 8 hours of in-service training on medication-related issues in each succeeding 12-month period. Citation appears on a following page.the state’s words, verbatim · CDSS document, Jul 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355 · Plan of correction due date: Jul 26, 2024

CRIMINAL RECORD CLEARANCE All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility obtain a CA clearance or a criminal record exemption as required by the Department. This requirement is not met, as staff RC is working with clientsfor over 30 days and does not yet have criminal record clearance. He was fingerprinted but not yet clieared. Licensee failed to ensure that staff working with clients have criminal record clearance, which poses an immediate health, safety or personal rights risk.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Staff RC must obtain Criminal Record Clearance to continue to have client contact. Plan/proof of correction to be submitted to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69 · Plan of correction due date: Aug 8, 2024

HEALTH AND SAFETY CODE Each RCFE... shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the... training requirements listed on page one of this report. This requirement was not met, as staff who handle medications--including giving pre-poured medications to clients--have not received required medications training. Licensee failed to ensure that required medications training is given to staff who handle clients' medications, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Proof of required medications training for staff SA and JQ will be sent to CCLD BY DUE DATE

Allegation investigated: - Resident's call button is not answered in a timely manner by facility staff - Client file is not maintained - Client did not receive medications as prescribed

Based on LPA Jeung's observations on 9/13/23--as well as information from witnesses--these allegations are substantiated. The preponderance of evidence standard has been met. During facility inspection on 9/13/23, emergency call system was not installed in 3 out of 5 client rooms on ground level. This included the room where former client #1 was residing in room #7. On 9/1/23, client #1 was alleged to have fallen at 2am and called out for staff assistance, as there was no emergency call button. Client waited for over an hour until male staff responded and helped client to get up from the floor. ****Type A Deficiency citation was issued on 9/13/23. See Facility Evaluation Report***** As noted on Facility Evaluation Report on 9/13/23, there is no client file maintained for client #2, who shares second floor room #3 with client #1. Client #2 was admitted on 9/1/23. Continued on next page. Substantiated Continuation: Client #1 was admitted on 8/31/23 after 5pm, but it cannot be confirmed that medications were brought to facility upon admission. On 9/13/23, LPA observed Rx medications for 18 days (almost 3 weeks) in bubblepacks. Of the 18 days of Rx medications observed in bubblepacks, it appears that client was given medications for 6 out of the 12 full days that client has been a resident. Client #1 reports that she was not given medications for the first 3 days; on the 4th day, staff gave her medications. It is observed that daily doses of pills are contained in bubblepacks printed with dates and times; however, some medications for future dates are missing, so staff are not giving medications on the dates indicated on bubblepacks. Deficiencies of the California Code of REgulations, Title 22 are cited on a following page. It cannot be determined if the hygiene needs of client #3 were met by staff. LPA observed client during initial complaint visit on 9/13/23 and did not detect that staff neglected her hygiene needs. Client was discharged in November 2023.the state’s words, verbatim · CDSS document, Jul 18, 2024 · control 14-AS-20230908153602

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 26, 2024

87465(a)(4) INCIDENTAL MEDICAL CARE The licensee shall assist residents with self-administered medications as needed. This requirement was not met, as client #1 was not provided with Rx medications for first 3 days of admission on 8/31/23. Licensee failed to ensure that clients are given medications as prescribed by MD, which poses an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 18, 2024

Plan of correction: Plan of correction to be submitted to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(a) · Plan of correction due date: Jul 26, 2024

87506(a) RESIDENT RECORDS The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met, as facility had not maintained a file for client #2 during initial complaint visit on 9/13/23. Licensee failed to maintain a current record for client #2, who was admitted on 9/1/23, This posed an immediate health, safety, or personal rights risk to client in care.the state’s words, verbatim · CDSS document, Jul 18, 2024

Plan of correction: Plan of correction shall be sent to CCLD BY DUE DATE, and shall include how this will be avoided in future.

Type of visit: POC

On May 10, 2024, at 12:32 PM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the plan of correction visit. LPA Calandra was greeted by Julio Yapp, Caretaker. LPA Calandra called Administrators, Charlene Pamintuan and Juliet Pacado, but neither were available to join the visit. LPA Calandra toured the physical plant (speficially the backyard) and verified that the plans of correction had been completed. No deficiencies were cited during today's visit. The Plan of Correction letter was delivered to Julio Yapp, Caretaker. This report was reviewed with Julio Yapp, Caretaker and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, May 10, 2024

Type of visit: Case Management - Annual Continuation

On April 2, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 4:32 PM, to complete the Annual Inspection. LPA Calandra was greeted by Julio Yapp, Caregiver and explained the purpose of his visit. Charlene Pamintuan and Laymer Pamintuan, Administrators arrived later during the visit. LPA Calandra toured the physical plant and observed that the backyard fence was in severe disrepair and leaning in towards the facility. LPA Calandra also observed wooden boards in the outside passageway obstructing the facility's emergency exit. LPA interviewed 3 residents and 3 staff. Type B citations were provided for the backyard fence and wooden boards. Deficiencies are cited under the California Code of Regulations. Failure to correct said deficiencies may result in additional civil penalties. This report was reviewed with Charlene Pamintuan, Administrator and a copy of the report along with appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Apr 2, 2024

Type of visit: Required - 1 Year

On March 21, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:45 AM to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Julio Yap, Caretaker and explained the purpose of his visit. Laymer Pamintuan, Administrator and Charlene Pamintuan, Administrator, and Juliet Pacaldo, Licensee/Administrator joined the visit later. LPA Calandra toured the physical plant. This is a 2 story building which consists of 7 bedrooms and 3 bathrooms, a kitchen, living room, dining room, office, laundry room, backyard, and front entry area. The fire extinguishers were observed to be fully charged and last checked on September 7, 2023. No accessible bodies of water or hazards were observed in the backyard or hallways. The facility was maintained at a comfortable temperature of 72 degrees Fahrenheit. Fire Alarms and Carbon Monoxide detectors were observed to be fully functional. Water temperature was measured above the required 125 degrees Fahrenheit. In the presence of the LPA, Laymer turned down the temperature of the water. LPA Calandra reviewed 5 resident files. All were observed to be complete. LPA Calandra also reviewed 5 staff files. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records(CSMR) kept at the facility. The Annual Inspection will be completed at a later date. No deficiencies were cited during today's visit. This report was reviewed with Administrator, Charlene Pamintuan and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Mar 21, 2024

Type of visit: Case Management - Deficiencies

LPAs Calandra and Jeung observed deficiencies of the California Code of Regulations, Title 22, which are cited on a following page.the state’s words, verbatim · CDSS document, Oct 2, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Oct 3, 2023

FIRE SAFETY All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met, as a wall is erected between first 2 rooms. Fire clearance was approved for one large room. There is a window in one of the rooms, but not the room closest to the street. Licensee failed to ensure conformity with fire clearance, which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: Wall separating first 2 front rooms on ground level will be eliminated. Proof of correction to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87307(d)(6) · Plan of correction due date: Oct 3, 2023

PERSONAL ACCOMMODATIONS/SVCS All outdoor and indoor passageways and stairways shall be kept free of obstruction. In the ground level passageway leading from street to backyard, there are boxes, filled plastic bags and tables obstructing free and clear exiting. In addition, overgrowth of plants limits the width of passageway to backyard. Licensee failed to ensure that passageway is free of obstruction, which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: Ground level passageway shall be free of obstructions and access to backyard shall be available to wheelchairs. Proof of correction to be sent to CCLD BY DUE DATE.