Tessa's Place 1

Allegation investigated: Resident sustained multiple falls while in care. Staff did not seek medical attention for resident in care.

Licensed Program Analyst (LPA) Jessica Cho arrived at the facility unannounced and met with Administrator (Admin) Mark Cruz to deliver findings for the above complaint allegations. During the investigation, the Department conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Resident sustained multiple falls while in care: Interviews conducted indicated Resident #1 (R1) sustained multiple falls while in care both witnessed and unwitnessed. Based on records reviewed, R1 needed max assistance for all Activities of Daily Living (ADLs) and mobility due to cognitive decline. Staff did not have a fall prevention plan in place to assist R1 in safe mobility. Therefore, the allegation resident sustained multiple falls while in care is substantiated *** Report continued on 9099-C*** Substantiated Staff did not seek medical attention for resident in care: Interviews conducted indicated that R1 was having severe pain and unable to walk or sit comfortably. Staff did not seek medical attention for R1 stating that hospice looked at R1 and said, “R1 is fine”. R1 had several falls since moving in to the facility that staff did not seek medical attention for due to R1 being on hospice. Therefore, the allegation staff did not seek medical attention for resident in care is substantiated. Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted with Administrator Mark Cruz, and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 18, 2026 · control 22-AS-20220202131436

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87459(a)(7)(D) · Plan of correction due date: Aug 25, 2026

87459 Functional Capabilities (a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to: (7) Physical condition, including: (D) Walking with or without equipment or other assistance. This requirement was not met as evidenced by: Based on interviews and records, facility did not have a fall prevention in place for R1 who requires max assist for all ADLs and mobility which poses a potential Health, Safety, and/or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 18, 2026

Plan of correction: Administrator Cruz stated a plan will be developed, proof of in-service with staff, and submit an Acknowledgement of Understanding of the said regulation to LPA via email by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Aug 25, 2026

87465 Incidental Medical Needs (a)(1) - The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. Based on interviews and record review, facility did not seek medical attention for R1 due to R1 being on hospice which poses a potential Health, Safety, and/or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 18, 2026

Plan of correction: Administrator Cruz stated proof of an in-service training reviewing PIN 25-06-ASC regarding placing 911 calls in the event of an incident/emergency for hospice residents and an Acknowledgement of Understanding of the said deficiency will be submitted to LPA by POC due date.

Allegation investigated: Staff admitted resident against their will. Staff chemically restrained resident.

Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to deliver the findings on the above allegations. LPA met with Administrator Mark Cruz and explained the purpose of the visit. An initial complaint investigation visit took place on May 21, 2026. During the visit, LPA accompanied by staff, conducted a tour of the facility's physical plant. LPA requested and obtained the resident roster, staff roster and the following documents for Resident 1 (R1); admission agreement dated April 24, 2026, Medical Assessment for Residential Care Facilities dated November 20, 2025, Physician’s Report dated April 24, 2026, Emergency Information, Move-in notification letter dated April 24, 2026, ISP dated December 21, 2025, and Power of Attorney for Health Care dated April 30, 2026. Five staff, including administrator, four witnesses, and six resident interviews were conducted. The investigation revealed the following: Continued on LIC9099-C. Unfounded Regarding the allegation that Staff admitted resident against their will, it was reported that R1 does not have Dementia, lives on their own, and is not conserved. R1 moved into the facility on April 24, 2026, and moved out of the facility on April 30, 2026. LPA reviewed the admission agreement for R1. R1’s responsible party signed the admission agreement on R1’s behalf. R1 was previously living on their own with In-Home-Supportive Services. Per review of medical assessment dated November 20, 2025, R1 is diagnosed with Alzheimer’s Disease, history of hysterectomy, osteopenia, urinary incontinence, and major depressive disorder. R1 also experienced disorientation, is unable to bathe or groom self, has bladder incontinence, unable to administer own medication, and is non-ambulatory due to medical condition. R1 lived independently with In Home Supportive Services until a hospital visit on April 24, 2026. Witnesses reported that R1 was discharged from the hospital to the facility because the hospital would not discharge R1 to their own home. LPA attempted to interview the hospital social worker, but they refused to answer any questions. Two out of six residents interviewed, including R1, stated R1 was admitted against their will by family. R1 reported they did not want to move to the facility but were made to do so by a family member. 1 out 5 residents reported that they thought R1 was moved into the facility against their will by their family. 4 out of 5 residents interviewed had no knowledge of the incident. Three out of five staff stated the family admitted the resident to the facility. Two out of five staff had no relevant information regarding this allegation. LPA interviewed 4 witnesses who had knowledge of the allegation, 2 family members, a friend of R1 and R1’s former IHSS worker. The IHSS worker reported that the family moved the resident into the facility. The IHSS worker reported that R1 did not have the ability to live on their own. LPA interviewed 2 family members of R1 who reported that R1 was not equipped to live on their own, so they moved R1 into the facility. None of the evidence gathered supports the allegation. None of the evidence gathered supports the allegation because the facility staff did not seek R1 as a client because R1’s family members and the hospital acted to move R1 into the facility. Regarding the allegation that staff chemically restrained resident, it was reported that staff used medication to sedate resident. It was alleged that the sedative, Depakote, was used to restrict R1’s movements. Per medical assessment dated November 20, 2025, R1 was not prescribed Depakote at the time. Per physician’s report dated April 24, 2026, R1 was prescribed Divalproex (Depakote) 125 mg for restlessness, anxiety, and agitation. This medication was prescribed to R1 while they were at the hospital. R1 was admitted to the facility with a list of medications, which included Divalproex (Depakote) 125 mg. Six out of six staff interviewed stated medication is administered according to the physician’s orders. Continued on LIC9099-C. R1 reported that the medication the facility administered was not prescribed. A review of R1’s medication records shows all of their prescribed medications were from their last hospital visit. 2 of R1’s family members reported that during R1’s hospital visit on April 24, R1 was prescribed anti-anxiety (Divalproex (Depakote) 125 mg) medication to calm them down. A review of records shows the hospital did prescribe Divalproex (Depakote) 125 mg to R1 during their visit. The facility had no control over what medications were prescribed to R1 while they were at the hospital. None of the evidence gathered supports the allegation. Based on the evidence gathered, the allegation is deemed Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has therefore dismissed the complaint. An exit interview was conducted with the Administrator and a copy of this LIC9099 report was left at the facility. Based on review of R1’s admission agreement, residents may have a cell phone. Residents may also use the facility phone at no charge. R1 reported that they used the facility phone because when they moved in, they did not have their cell phone. 5 out of 5 staff members interviewed reported that R1 moved to the facility without their cell phone. R1 stated that they believed their phone was withheld by a family member but could not recall which family member. 5 out of 5 staff members reported that after R1 moved in they had their cell phone but did not know who gave it to them. The Administrator reported that R1’s family member brought them their phone but none of the other witnesses could corroborate this report. R1 did not remember who brought them their cell phone but once they received it, they could call anyone they wanted. 5 out 5 staff members reported they never withheld R1’s cell phone. 1 out of 5 residents reported that they have never been denied the use of their cell phone. 2 out of the 5 remaining residents stated they are able to use their cellphones. The 2 remaining residents did not answer the question and did not acknowledge the question with any type of response. Based on the evidence gathered during the investigation, the allegations are found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the present report was provided to a facility representative. Regarding the allegation that staff denied resident freedom of movement, it was alleged that the facility isolated R1 from family and friends and placed R1 on a “lockdown”. Per review of admission agreement, the facility encourages regular visits and appointments are not necessary. R1 reported that staff did not allow them to go outside. Resident 2 (R2) reported that they saw R1 go outside of the facility with their family and friend. One out of five staff interviewed (Staff 1) reported that R1 was not allowed to leave the facility with anyone unless the responsible party permitted it. Staff 1 (S1) reported that one of R1’s family members came to visit the facility, and they wanted to take R1 out of the facility to go eat. S1 reported that they did not let R1 leave the facility with their family member for 45 minutes until they called R1’s responsible party. All witnesses present verified that the phone call lasted around 45 minutes. R1’s responsible party finally allowed R1 and their family member to leave the facility. R1 and the family returned a few hours later. R1 is not conserved and there are no restraining orders barring anyone from seeing R1. The Administrator was not aware that S1 didn't allow R1 to leave with their family member. R1 was not allowed to leave the facility with their family member who was not legally barred from visiting them. Based on evidence gathered through interviews and document review, the preponderance of evidence has been met, therefore, the above allegation is found to be Substantiated. Violations are being cited per Title 22 of California Code of Regulations. See LIC 9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator and a copy of this LIC9099-D, along with a copy of the Appeal Rights were left at the facility.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 22-AS-20260520083259

From the deficiency page — Deficiency type: Type A · Section cited: CCR 97468.1(a)(6) · Plan of correction due date: Jul 23, 2026

(a) Residents in all residential care facilities for the elderly shall have [..] the following rights: (6) To leave or depart the facility at any time and to not be locked into any room, [...], or on facility premises by day or night. [...] This requirement was not met as evidenced by: Based on interviews, the licensee did not allow R1 to leave the facility premises until permission was granted by responsible party, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: Licensee agrees to train all staff on CCR 87468.1(a)(6) and Licensee agrees to sign a statement of understanding for CCR 87468.1(a)(6). Licensee to submit proof of correction documentation to CCLD by POC due date.

Allegation investigated: Resident sustained an unexplained injury while in care. Staff mismanaged resident's medication. Staff did not inform resident's authorized representative of a change in health condition. Staff did not ensure that resident's hygiene needs were met.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Jessica Cho regarding the allegations mentioned above and for the purpose of delivering findings. LPA Cho met with Administrator Mark Cruz and explained the purpose of the inspection by telephone at 3:51pm. Regarding the allegation, Resident sustained an unexplained injury while in care, the following was revealed: It is alleged Resident 1 (R1) sustained bruising on their right arm and a swollen or sprained left ankle and Staff 1 (S1) was unaware of how R1 became injured. Interviews were conducted with one staff and one witness. LPA attempted to conduct additional interviews with current facility residents, however, there are no facility residents remaining from the original date when the complaint was received. R1 could not be interviewed due to their passing on June 30, 2022. During interview, R1’s responsible party, Witness 1 (W1) stated that on April 28, 2021, R1 had a fall and had a bruise over their left eye on their forehead, discoloration on their left eye lid, and a scrape on their nose. Per W1, they advised the Hospice Agency providing care for R1 and they responded to check on R1. Unsubstantiated W1 stated they were informed that in order to have R1 further evaluated, they would have to remove R1 from hospice care; therefore, W1 stated they did not take R1 to the hospital or call R1’s neurologist. W1 was unable to provide additional evidence of alleged injuries. Per W1, on August 28, 2021, they visited R1 at the facility and upon removing R1’s left shoe, they observed R1’s ankle was swollen and asked S1 if R1 had fallen but S1 was unable to confirm or deny if R1 had fallen. W1 was unable to provide additional evidence of R1’s swollen ankle. Per W1, they also observed three bruises on R1’s right forearm and stated they were caused by a caregiver, however, W1 was unable to identify the caregiver. During interview, Administrator (AD) denied the allegation and stated R1 was never hurt at the facility and they “only saw one discoloration” that was caused by R1 trying to open the screen door and that had been reported to W1. Per AD, S1 had not been employed by the facility since September 2021, and they no longer had any contact information for them, thus S1 could not be interviewed to verify W1’s statements. LPA also attempted to contact Hospice Agency providing care to R1, however, the Agency is no longer operating. Regarding the allegation, Staff mismanaged resident's medication, the following was revealed: It is alleged that on August 27, 2021, facility staff received an antibiotic for R1 from the pharmacy but placed the medication away in a cabinet and did not start the dosage when received. During interview, W1 stated that on August 27, 2021, they were contacted by a Hospice Nurse who informed them they were able to obtain a urine sample from R1 and determined R1 had a Urinary Tract Infection (UTI) and the doctor wanted to prescribe antibiotics. W1 stated they agreed and personally called the pharmacy. Per W1, they were informed the medication would be delivered to the facility prior to the end of the day so that R1 could start the treatment. W1 stated that on August 28, 2021, they visited R1 at the facility and asked if R1 had their antibiotic that morning. Per W1, S1 informed them they had never received the medication from the pharmacy the night before. W1 stated they immediately called the pharmacy and asked why the antibiotic had not been delivered. Per W1, they were informed the medication had been delivered and given to an unidentified female staff at the facility. W1 stated they requested the closet where medication was stored be checked and staff retrieved two brown bags, one of which one was folded and stapled closed and contained R1’s antibiotic medication. Per W1, they informed Licensee that S1 had not given R1 their antibiotic medication and had not even opened it after it was delivered the night before. W1 stated they advised Licensee they would be removing R1 from their care and on August 29, 2021, they moved R1 to another facility. During interview, AD stated that due to R1 being moved out of the facility on August 29, 2021, they were unable to recall if the medication had been received or administered. Per AD, they no longer had any contact information for S1 since their end of employment in September 2021, thus S1 could not be interviewed to verify W1’s statements. During the course of the investigation, LPA obtained a copy of R1’s Centrally Stored Medication and Destruction Record (LIC622) and observed medication in question to be listed with a start date of August 28, 2021, however, LIC622 does not indicate if medication was received or present at the facility on August 27, 2021. Regarding the allegation, Staff did not inform resident's authorized representative of a change in health condition, the following was revealed: It is alleged that W1 was not notified of a change in R1’s condition on at least on occasion. During interview, W1 stated that on August 12, 2021, they visited R1 at the facility and were asked by S2 why a particular routine medication for R1 had been discontinued. W1 stated it had not been discontinued and inquired why S2 was asking. Per W1, S2 informed them that the night of August 7, 2021 had been the last time R1 had received that routine medication and stated they had asked the Hospice Agency why the medication has been discontinued and the Hospice Licensed Vocational Nurse (LVN) had stated the medication had been discontinued two months ago. W1 stated they contacted the owner of the Hospice Agency, who advised them the LVN had been looking at the wrong medication list for R1 and therefore the medication had not been sent by the pharmacy. Per W1, the medication was then delivered to the facility prior to 7:00 p.m. that night and administered to R1. Per W1, they spoke with Registered Nurse (RN) and Manager of LVNs at the Hospice Agency and informed them they did not want that specific LVN to be assigned to R1 any further due to giving the wrong information to facility staff. Per W1, they informed AD that S2 should not be in any trouble due to having been the only one who had attempted to advise the Hospice Agency about the “lack of” medication. W1 further stated that on August 28, 2021, when visiting R1 at the facility, they observed R1 to be “lethargic” and they had not been informed of this change in condition. Per W1, R1 was “very incoherent,” could not lift their head, and appeared “like a woman with osteoporosis.” During the course of the investigation, LPA obtained a copy of R1’s Physician Report (LIC602A) dated May 14, 2021 which indicated R1 had a history of concussions, Traumatic Brain Injury (TBI), generalized body weakness, and was non-ambulatory. During interview, AD denied R1 having any change in condition while they were a resident at the facility and stated the only change of condition had been R1’s appetite, “some days [R1] would eat well and other days not.” Per AD, they always kept W1 informed and even provided them with daily updates on R1. AD stated W1 was “actually always” at the facility and when W1 was not there, would call three to four times per day to speak to staff and R1. AD stated W1 “would even request to go in other resident files” and they would “constantly” have to explain confidentiality requirements and personal rights. During the course of the investigation, former Resident 2 (R2) was interviewed and stated that W1 was very rude. Regarding the allegation, Staff did not ensure that resident's hygiene needs were met, the following was revealed: It is alleged R1’s hygiene needs were not met. During interview, W1 stated that due to incontinence issues, staff should have been bathing R1 daily. Per W1, on August 22, 2021, they visited R1 at the facility and when they arrived, they noticed R1’s hair had not been washed and “was very oily.” W1 stated they asked S1 why R1 had not had a shower and S1 stated they were waiting for the Hospice Nurse to come and give R1 a shower. Per W1, they became “upset” and informed S1 that R1 needed a shower daily and the Hospice Assistants only come twice a week. W1 stated they informed the Licensee they did not want S1 to take care of R1 any further and on August 29, 2021, W1 moved R1 to another facility. During interview, AD stated R1 received two showers from the Hospice Agency per week, plus daily showers from care staff at the facility. Per AD, when being showered, R1 would make facial gestures when staff would get their hair wet and “it was apparent that [R1] didn't like [their] hair wet, so staff respected that”, however, W1 wanted R1’s hair to be washed daily. Per AD, S1 had not been employed by the facility since September 2021, and they no longer had any contact information for them, thus S1 could not be interviewed to verify W1’s statements. LPA also attempted to contact Hospice Agency providing care to R1, however, the Agency is no longer operating. Based on investigations and conflicting information received during interviews conducted, the Department did not find sufficient evidence to support the allegations, “Resident sustained an unexplained injury while in care, Staff mismanaged resident's medication, Staff did not inform resident's authorized representative of a change in health condition, and Staff did not ensure that resident's hygiene needs were met.” Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore at this time the above allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 22-AS-20210907113019

Allegation investigated: Resident's medical records were not available at the facility for EMT review.

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility for the purpose of investigating the above mentioned complaint allegation. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Mark Ryan Cruz and discussed the purpose of the visit. The investigation into the allegation of Resident's medical records were not available at the facility for EMT review revealed the following: During interviews with 1 of 2 staff it was revealed that they implemented colored emergency binders for the facility residents for when emergency personnel arrive at the facility. 1 of 2 staff informed LPA that these binders hold residents emergency contacts, face sheet, POLST, medications list and insurance information. 1 of 2 staff informed LPA that the caregivers on duty around the time of the incident no longer work at the facility and has not worked at the facility since 2022. LPA observed resident emergency records that AD provided for residents in care at the time of the complaint. LPA was unable to contact the reporting party. Continue on 9099C Unsubstantiated Based on information gathered, interviews and records review, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred: therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided at the time of the investigation. Based on the Departments observations and information gathered during the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 was cited on February 2, 2022, in regards to this complaint. An exit interview was conducted with AD Mark Ryan Cruz and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Oct 15, 2025 · control 22-AS-20220207165233

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Mark Ryan Cruz and discussed the purpose of the visit. The facility currently has six residents in care. The facility is a one story home with four resident bedrooms, one staff bedroom, three bathrooms, living room, kitchen, attached two car garage and a backyard. The facility appears clean, safe and sanitary. LPA observed the kitchen to be free of vermin. LPA observed a two day perishable and seven day non perishable food supply on hand. LPA observed the knives to be in a locked box under the kitchen sink and made inaccessible to residents in care. LPA observed a fire extinguisher in the kitchen charged and with a service date of March 5, 2025. LPA observed the centrally stored medication to be in a locked closet by the garage door and made inaccessible to residents. LPA observed an emergency food supply in the locked medication closet. LPA observed the staff room by the garage door to be locked and made inaccessible to residents. LPA observed a locked fridge in the garage that stores refrigerated medications. LPA observed the toxins and chemicals to be in a locked cabinet in the garage. LPA observed the emergency water to be located in the garage. LPA observed the resident rooms to have the required components and furnishings with extra storage space. LPA observed the extra clean linens to be in a cabinet located in the hallway. LPA observed the bathrooms to have toilet paper, paper towels and non slip mats in the shower. LPA tested the water to be between 111-111.3 degrees Fahrenheit. LPA observed the backyard to have a shaded seating area for resident use. LPA observed the backyard to be free of obstructions and debris. LPA and AD tested the fire alarms and smoke detectors and they were found to be operational Continue on LIC809-C LPA reviewed staff files and no discrepancies were observed. LPA reviewed resident files and no discrepancies were observed. LPA reviewed resident medications and no discrepancies were observed. LPA reviewed the last fire drill that was conducted on September 17, 2025. All staff are background cleared and associated to the facility. Based on today’s inspection, no deficiencies were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 8am. During today’s visit, LPA met with Mark Cruz, Administrator (AD). The facility is a single story residence with four resident bedrooms and one staff bedroom. The residence has an approved fire clearance of six non-ambulatory residents of which four may be on hospice. The facility currently has a census of six residents in care with two receiving hospice services. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in three of three resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between109.4 and 116.4 degrees Fahrenheit and all smoke and carbon monoxide detectors were operational. The fire extinguishers are charged and were serviced on March 5, 2025. The facility’s last fire drill was conducted on January 29, 2025. LPA toured the exterior and there were no hazards in passageways and both exterior gates were self-latching. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand and a grocery delivery was arriving on this date. Knives were secured in a locked cabinet and storage container and cleaning supplies were secured in the garage. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. LPA observed the First Aid Kit had required elements and a First Aid Manual. LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present (Continued on LIC 809-C) (Continued from LIC 809) regarding care provided. LPA confirmed that administrator has a current administrator certificate which is pending but will expire November 22, 2026. LPA observed the Emergency Disaster plan, weekly menus and required See Something, Say Something poster in the entryway. At time of entry residents were enjoying breakfast and were socializing. LPA observed activities calendar and was shown pictures by the Administrator of activites. One resident attends a community program Monday through Friday. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Mark Cruz, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Mar 17, 2025

Allegation investigated: Staff did not prevent facility from being hazardous to residents in care. Staff did not ensure facility is kept clean.

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose to conduct the complaint into the above allegations. LPA was greeted and granted entry by Caregiver/Reliever Regine Maglanque. Administrator Mark Cruz arrived on premise and conducted the tour of the facility with LPA approximately 1:20pm. LPA and Admin Cruz inspected the inside and outside grounds and the following was determined: It is alleged that the staff did not prevent the faclity from being hazardous to the residents in care. LPA observed that no trees in the backyard were supported by a wooden pole or rope. It appeared that at the time of the inspection, approximately 1:12pm, the trees were observed to be safe with the severe high wind warning issued in Orange County. LPA walked through the lawn and observed that the right side of the lawn is on an uneven ground. The right side is overwatered evidenced by soft and wet soil which may potentially cause a safety hazard to the residents. Based on the review of the lease agreement signed and dated on October 26, 2020, facility is responsible for watering and maintaining the garden, Unsubstantiated landscaping, trees, and shrubs; however, the lease agreement does not clearly evidence the chain of liability with respect to waterlogging issues. In addition, it is documented on page 5 of the lease agreement that the tenant shall not make any repairs, alterations, or improvements without the landlord's prior written consent. One out of one staff interview reavealed that there were no issues until the heavy rain the past month. Staff also indicated that the water sprinkler system is being controlled. It is alleged that the staff did not ensure facility is kept clean. Facility appeared clean and sanitary. The kitchen and bathroom sinks were also clean and sanitary. The porcelain coating in the sinks of the kitchen and Bedroom #1 are chipped in few areas of the wash basin however does not pose a health risk to the residents in care. Therefore, based on the observations made, interview, and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: Staff did not prevent facility from being hazardous to residents in care and Staff did not ensure facility is kept clean are deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Mark Cruz, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 22-AS-20240311172243