Tierrasanta Vernanel Care Home

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management Visit to discuss information regarding Administrator information for the facility. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Nelly Panao. While at the facility, the LPA discussed with the licensee the steps taken to address the previously cited deficiencies and verified the implementation of the agreed-upon corrections. The LPA reviewed staff records to confirm that all employees have obtained criminal record clearances or exemptions prior to working with residents and observed the facility to ensure that appropriate guarding and supervision measures are in place for resident safety. LPA also obtained documentation to clear the plan of corrections for the deficiency regarding the designation of an administrator. The LPA also checked the health and safety of Resident #1 (R1) and observed that the resident appeared to be in good condition with no immediate health or safety concerns noted during the visit. An exit interview was conducted with Licensee Nelly Panao, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 23, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Licensee Nelly Panao. LPA toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. The client files which LPA reviewed contained required documents. Confidential records were stored in locked areas. Staff/Volunteer records reviewed; Staff #1(S1) did not have required document. Three (3) of Four (4) volunteer/staff did not have first aid/CPR training. S1 did not have current or pending CCLD Administration Certificate. One(1) of four(4) Staff/Volunteers did not have background clearance. Four(4) deficiencies were deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Licensee Nelly Panao, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 16, 2026

Allegation investigated: -Licensee did not meet resident’s incontinence care needs. -Licensee did not ensure resident had clean linen. -Licensee did not maintain facility cleanliness.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Nelly Panao. The Complainant alleged that Licensee did not meet Resident #1’s (R1’s) incontinence care needs, that Licensee did not ensure R1 had clean linen on their bed, and that Licensee did not maintain facility cleanliness. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved multiple unannounced facility tours/welfare check and interviews of relevant residents, staff, and outside sources. The Department also reviewed pertinent facility and hospice agency care records. [CONTINUED ON LIC 9099-C, 1 of 3] Substantiated [CONTINUED FROM LIC 9099] Staff #1 (S1) was the primary caregiver at the facility during the complaint time frame, with Staff #2 (S2) serving as their back up. However, starting 04/14/2025, S1 ceased their direct care tasks, and S2 took over as the primary caregiver at the facility. Interviews of staff and outside sources, corroborated by hospice records, showed: R1 moved in on 03/28/2025 under the concurrent care of hospice. R1 spent all day in bed and was unable to turn/reposition themselves in bed. R1 was both incontinent of bowel and bladder and fully depended on staff to check/change their incontinence briefs. Per R1’s hospice nurses, R1 was supposed to have their briefs checked at least once every two (2) hours. S1 told CCLD that during the complaint timeframe, they typically checked/changed R1’s briefs five (5) times per day (i.e., around 8:00 AM, 10:00 AM/11:00 AM, 3:00 PM, 7:00 PM/8:00 PM, and 11:00 PM, respectively). However, interview of R1 showed they were only changed three (3) times per day (i.e., morning, midday, and evening). Interview of S2, who took over for S1 starting 04/14/2025, showed that they too were only checking/changing R1’ briefs three (3) times per day, prior to CCLD starting is complaint investigation. Several hospice personnel who regularly visited R1 at the facility described having at least one site visit during which they observed R1 wet/soiled upon arrival, having to change R1 themselves (instead of facility staff doing it). Multiple hospice personnel said they observed R1’s briefs saturated to the point that urine and/or feces escaped from R1’s brief and stained their bed. One medical professional saw dried feces stuck to R1’s thigh and hip. One non-medical visitor said that out of six (6) visits they made, R1’s brief had a urine and/or fecal odor during five (5) of those visits. S1 admitted to CCLD that they physically struggled to turn/move R1 in bed (which is needed to change R1’s briefs). S1 had also expressed the same to R1’s hospice agency. S2 also admitted to CCLD that they too struggled to move R1 in bed, and that R1 required the joint-assistance of two caregivers to have their brief changed in bed. This latter point was reiterated in the 30-day eviction notice which Licensee issued to R1 and their responsible person on 05/12/2025. [CONTINUED ON LIC 9099-C, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] Hospice records and interviews revealed multiple personnel had concerns regarding the condition of R1’s bed. One professional said they found R1’s bed “completely dirty” upon their arrival, across six (6) different site visits, and that they personally changed R1’s bed linens each time. They saw food both on R1’s body and on their bed. On one occasion, they saw R1 laying on top of a Scotch tape dispenser that had stuck to R1’s back. A second professional on a different day described seeing R1 laying on top of a large metal flashlight, a TV remote, colored pencils, and a pencil pouch. They saw multiple stains, including urine and fecal stains, on R1’s bed linen. A third professional on a different day described seeing R1 laying on top of a pack of pretzels that had “fully imprinted” into R1’s back. They added that very near R1’s body (but not directly under them) was also an Icebreakers mint container, phone chargers, and an empty bottle of hand sanitizer. The Mayo Clinic’s encyclopedic entry titled “Bedsores (Pressure Ulcers)” states, “Skin becomes more vulnerable with extended exposure to urine and stool,” and that “constant pressure on any part of the body can lessen the blood flow to tissues” which also contributes to skin breakdown. Review of hospital and hospice agency records showed: R1 moved into the facility with an existing Stage 2 pressure ulcer on their sacrum. However, per hospice nursing assessment, on 05/01/2025, R1’s sacral pressure ulcer worsened to Stage 3. Hospice records and interviews revealed multiple personnel had concerns regarding the cleanliness of R1’s bedroom: During a visit, one professional saw multiple pieces of trash and multiple opened/uneaten chocolates on R1’s bedroom floor; they clean up R1’s floor and threw away other expired food seen in R1’s bedroom. A second professional said that R1’s room was so cluttered with objects that it was difficult to walk through R1’s room or even set their workbag down. A third professional reiterated the clutter in R1’s room and said R1’s bedside table was “sticky” and R1’s furniture was dusty. One non-medical visitor said they and another visitor sometimes saw dust on R1’s furniture, which they personally wiped clean. They also threw away expired food seen in R1’s room. [CONTINUED ON LIC 9099, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] A separate outside source revealed: Resident #3’s (R3’s) bed linens were also not consistently clean; they saw stains on R3’s pillows, bedsheets, and mattress during the complaint timeframe. This person said R3’s bedroom floor was “very dirty,” and that they personally cleaned it as a result. They also said that the facility’s shared bathroom was not kept clean during the complaint timeframe, and that there was evidence of insects at the facility. During his 06/03/2025 site visit, LPA himself observed a few gnats flying in the dining room area. Based on records and interviews, a preponderance of evidence exists to show that Licensee did not meet R1’s incontinence care needs, that Licensee did not ensure resident had clean linen, and that Licensee did not maintain facility cleanliness. These allegations are therefore Substantiated, and three (3) deficiencies were cited for them per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D pages). Since one of the deficiencies contributed to the worsening of an injury to R1, an Immediate Civil Penalty of $500 was charged/assessed (refer to the LIC421-IM page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Licensee Nelly Panao, to whom a copy of this report, the LIC 9099-D pages, the LIC421-IM page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 08-AS-20250417130623

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Jun 3, 2025

87625 Managed Incontinence: “(b) …the licensee shall be responsible for the following: “(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 1 of 3 residents (R1) who was incontinent was kept clean and dry and free of odors from incontinence. This posed an immediate health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, Licensee has issued a 30-day eviction notice to R1. Licensee has also doubled the number of caregivers on duty, as witnessed by LPA. These actions resolve the deficiency. Until R1 moves out, Licensee agreed to maintain the current staffing levels to ensure that R1’s briefs are checked/changed and that R1’s body is repositioned in bed, at least once every two hours.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Jun 3, 2025

87307 Personal Accommodations and Services: “(a)(3) …The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads…” This requirement is not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 2 of 3 residents (R1 and R3) had clean linen. This posed a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, R3 has moved out and Licensee has issued a 30-day eviction notice to R1. Going forward, Licensee agreed to ensure that all residents have their bed linens changed at least once per week, but also more often as necessary to ensure that linens are always clean. This action resolves the deficiency.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 3, 2025

87303 Maintenance and Operation: “(a) The facility shall be clean…at all times.” This requirement was not met, as evidenced by: Based on interviews, Licensee did not ensure that the facility was clean at all times. This posed a potential health and personal rights risk for 3 of 3 residents [R1, Resident #2 (R3), and R3] in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: Licensee agreed to hire a third-party professional housekeeper/cleaner to perform one deep clean of the facility, to include all bedrooms and common areas and bathrooms. Licensee agreed to send a copy of the paid receipt/invoice to LPA, by the POC due date.

Allegation investigated: -Licensee did not protect resident from another resident’s sexual abuse. -Licensee did not safeguard resident personal property.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Nelly Panao. The Complainant alleged that Licensee did not protect Resident #2 (R2) from being sexually abused by Resident #1 (R1), and that Licensee did not safeguard resident personal property. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved multiple unannounced facility tours/welfare check and interviews of relevant residents, staff, and outside sources. The Department also reviewed pertinent San Diego Police Department (SDPD) records and facility care records. [CONTINUED ON LIC 9099-C, 1 of 4] Substantiated [CONTINUED FROM LIC 9099] Staff interviews aligned to show: During the complaint allegation time frame, Staff #1 (S1) was the primary caregiver at the facility. Staff #2 (S2) was the only other caregiver, but they worked far fewer hours. They also showed that R1, who had lived at the facility since mid-2020, was diagnosed with Dementia and tended to wander around the facility and its outside yards, sometimes naked, requiring staff redirection. R1 would also open housemates’ bedroom doors and stare at them. R1’s LIC602 Physician’s Report confirmed their dementia and wandering diagnoses. Interviews of staff, corroborated by police records and California’s Megan’s Law database, showed R1 was also a Registered Sex Offender (RSO). Meanwhile, R2, who moved into the facility on the evening of 09/17/2021, was vision-impaired but retained 10% eyesight in their right eye. R2 was diagnosed with major depressive disorder with psychotic features. However, per their LIC602 Physician’s Report, their doctor determined that R2 was not confused/disoriented, was able to follow instructions, and was able to communicate their needs. LPA met R2, determining that they were alert, oriented, and coherent enough to be qualified as a reliable historian. Per interview of R2: Around 6:00 AM or 7:00 AM on 09/18/2021 (which was their first morning living at the facility), they were sitting on the edge of their bed when R1 entered their bedroom and sat beside them. R1 solicited R2 for sex, which R2 refused. R1 then repeatedly touched R2 between their legs and squeezed R2’s breasts. R2 cried out for help. This went on for 20-30 minutes before an unknown person came to the room and redirected R1 away. R2 said there was a separate day during February 2022 when R1 tried to force their way into R2’s bedroom. Resident #3 (R3), who was visiting with R2 at the time, used their body weight to hold the door closed, until R1 gave up and walked away. Interview of R3 corroborated that second event. LPA did not interview R1. R1 had moved out by the time the complaint was filed with CCLD. Subsequent SDPD records showed their police officers tried interviewing R1, but quickly concluded R1 was too disoriented/confused to be a reliable historian. [CONTINUED ON LIC 9099-C, 2 of 4] [CONTINUED FROM LIC 9099-C, 1 of 4] In their own interviews, neither S1 nor S2 heard/witnessed any part of the 09/18/2021 incident between R1 and R2. S1 and S2 each denied being the person who redirected R1 away from R2. S1 said R2 told them about the incident shortly after, but S1 did not believe it really occurred, because they knew R2 to be nearly blind and to sometimes experience hallucinations. S1’s description of the incident from R2 closely matched what R2 told LPA. S1 did not report the alleged incident to either R1’s responsible person (RP) or R2’s RP, or to CCLD, the Long-Term Care Ombudsman (LTCO), or SDPD, as required. [Not meeting reporting requirements will be addressed in a separate case management visit report.] At the time of the incident, the other residents in care were Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5). LPA met each, determining that R3 and R4 were alert, oriented, and coherent enough to be reliable historians, while R5’s cognition was less strong. Per their interviews, these residents did not personally hear/witness the 09/18/2021 incident between R1 and R2. They denied themselves being physically/sexually abused by R1. However, R3 stated that R1 often prowled the facility’s yards at night, and on “half a dozen” nights tried unsuccessfully to open the side door which led from the outside directly into R3’s bedroom, being deterred when R3 yelled at them. R4 said R1 made vulgar sexual comments towards them personally. R4 confirmed that R1 on multiple nights tried unsuccessfully to enter their own bedroom from the outside using their side door. R4 said they made S1 aware of this troubling behavior. R4 also corroborated the day that R1 tried to force their way into R2’s bedroom and R4 stopped them. S1 told LPA they knew R1’s behaviors made multiple other residents uncomfortable, but S1 did not issue a 30-day eviction notice for R1 or inform their RP of their housemates' allegations against R1. Interviews of S1 and residents, corroborated by police records, showed: Multiple residents directly approached R1’s RP to inform them of their individual fears/concerns regarding R1. This was also how R1’s RP became aware of the 09/18/2021 incident between R1 and R2. Upon receiving this information, R1’s RP notified SDPD, who on 02/11/2022 visited the facility to open an investigation. Police wrote that R2 and R4 lived in “extreme fear” of R1, with R2 having to barricade their bedroom door at night and R4 losing sleep. With R1’s impaired cognition, police officers deemed R1 a “danger to others” and that same day arranged for R1 to be transported to the hospital on a Welfare and Institutions Code 5150 psychiatric hold. From there, R1’s RP arranged for R1 to discharge elsewhere; R1 did not return to Tierrasanta Vernanel Care Home. [CONTINUED ON LIC 9099-C, 2 of 4] [CONTINUED FROM LIC 9099-C, 1 of 4] Per the police report: R1 was so disoriented to other persons that R1 previously made sexual comments towards their own RP and tried to grope them too. The statements S1, R2, R3, and R4 individually gave to SDPD were consistent with their later statements to CCLD. During questioning, S1 told LPA that former Resident #6 (R6), who had moved out prior to the complaint time frame, previously told a hospice agency staff that someone had come into their bedroom and touched their legs and chest. S1 stated they did not witness this incident and did not believe it really occurred, since they claimed R6 had Dementia and sometimes experienced hallucinations. S1 did not report the alleged incident to either R6’s responsible person (RP), CCLD, the Long-Term Care Ombudsman (LTCO), or SDPD, as required. S1 denied there being other instances of possible abuse between R1 and R6. CCLD subsequently reviewed a series of dated handwritten progress notes written by S1, which revealed: On 06/13/2021, S1 personally witnessed R1 inside R6’s bedroom, touching R6’s face and breast without their consent, requiring S1 to redirect R1 away from R6. There were also two successive incidents when R1 entered R6’s bedroom (unwitnessed by S1 but which R6 later reported to them): R6 said on 07/30/2021, R1 was touching them without their consent. R6 said on 09/13/2021, R1 removed R1's own pants and exposed their genitals to R6, who shoved R1 away from them. [False/Misleading Statements and Not Meeting Reporting Requirements will be addressed in a separate case management visit report.] LPA did not interview R6. They had already moved out by the time the complaint was filed with CCLD, and by the time LPA established contact with R6’s RP, he learned that R6 had since died. R6’s RP confirmed not being informed of allegations/instances of physical/sexual abuse against R6. R6’s RP also denied R6 having Dementia or hallucinations during the time they lived at the facility. Per R6's LIC602 Physician's report, R6 did not have either Mild Cognitive Impairment or Dementia. Their doctor also determined that R6 was not confused/disoriented, was able to communicate their needs, and was able to follow instructions. R4 told LPA that R1 stole $80 from their purse. R4 said they told S1 about this. S1 said they later checked R1’s pants pockets during laundry but never found money. R3 told LPA that R1 had taken their own belongings on several occasions, most of which resulted in them recovering the missing items. However, there was a bottle of mouthwash and two sweaters which R3 never got back. Records review and manager interview showed: Licensee did not maintain a written Theft and Loss Record for the facility, as required. [CONTINUED ON LIC 9099-C, 4 of 4] [CONTINUED FROM LIC 9099-C, 3 of 4] Licensee also did not maintain a written Personal Property Inventory for R1 through R6, as required. Licensee did not report these losses to the responsible persons for either R1 or R3, nor compensate/reimburse the residents for these losses. Based on records and interviews, a preponderance of evidence exists to prove the Licensee did not protect a resident (R2 and R6) from another resident’s (R1’s) sexual abuse, and that Licensee did not safeguard resident personal property. Both allegations are therefore Substantiated, and two (2) deficiencies were cited for them per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Licensee Nelly Panao, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099-A] Interviews of staff and residents, and SDPD records, generally aligned to show: On 02/02/2022, Resident #2 (R2) gave a packet of cookies to R3. R1, who was diagnosed with Dementia, claimed that the cookies belonged to themselves. This was the basis for an ensuing argument between R1 and R3, which took place in the facility’s dining room. R1 hit R3 with a cane, once on the shoulder, and once on the head. Staff #1 (S1) responded quickly to break up the altercation, separating R1 from R3 until police arrived. SDPD subsequently transported R1 to the hospital on a Welfare and Institutions Code 5150 hold. R3 said the hits were not hard and denied experiencing pain or injury. Based on records and interviews, a preponderance of evidence does not exist to support that Licensee did not protect R3 from being hit by R1. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Licensee Nelly Panao, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 08-AS-20220216163808

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jun 3, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from… mental, physical, or sexual abuse.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 2 of 6 residents (R2 and R6) were free from, mental, physical, or sexual abuse. This posed an immediate safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: By the date CCLD received the complaint, R1 had already moved out of the facility, resolving the immediate risk. Licensee agreed to have all current staff receive remedial education on Resident’s Personal Rights (as articulated in LIC613-C), Incident Reporting Requirements (as articulated in CCR 87211) and California Mandated Reporting Requirements (as articulated in SOC341A) through a third-party training source, and to E-mail proof of completion to LPA, by 07/03/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a) · Plan of correction due date: Jul 3, 2025

87218 Theft and Loss: “(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. This posed a potential personal rights risk to 6 of 6 residents (R1 through R6) in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, R1 through R6 no longer live at the facility. Licensee agreed to: a) gather LIC621 Personal Property Inventory forms for all current residents, b) prepare and maintain one ongoing LIC9060 Theft and Loss Record, c) write and post a Theft and Loss Policy (with investigative procedures), and d) train all current staff on the Theft and Loss Policy. Licensee agreed to E-mail to LPA completed/signed copies of the LIC621’s, the LIC9060, the Theft and Loss Policy, and the staff training sign-in sheet, by the POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies which were identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Nelly Panao. Records and interviews showed: On 06/13/2021, Staff #1 (S1) directly witnessed Resident #1 (R1) sexually groping/molesting Resident #6 (R6). [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] Licensee did not personally witness, but was still later told by R6: On 07/30/2021, R1 touched R6 inappropriately. On 09/13/2021, R1 exposed their genitals to R6, without R6's consent. Thereafter, Resident #2 (R2) told Licensee that R1 entered their own bedroom and sexually groped/molested R2 on 09/18/2021, during which time R2 cried out for help for 20-30 minutes. The incidents did not result in physical injuries to either R6 or R2. Despite having constructive knowledge of the above incidents/allegations, Licensee did not report any of them to either CCLD, the Long Term Care Ombudsman (LTCO), or police within the required time frame of twenty-four hours, as required. Licensee also did not submit written incident reports for these same events to CCLD and the responsible persons for R1, R2, and R6, within seven (7) days of incident occurrence, as required. During CCLD’s subsequent complaint investigation: Licensee/S1 was made false/misleading statements to the Department about the extent of their knowledge of R1’s abuse against R6, as evidenced by discrepancies between their verbal statements to CCLD, verses S1’s earlier own dated and handwritten progress/care notes on R1 and R6. [CONTINUED ON LIC 809-D] [CONTINUED FROM LIC 809] Records review, confirmed by manager interview, showed: Licensee did not have on file a completed and signed written Pre-Placement Appraisal (or equivalent document) for R2 and Resident #5 (R5). While Licensee did have a Pre-Placement Appraisal document on file for R1, it was dated the same day of R1’s move-in to the facility. Staff interviews showed that R1 was not interviewed or assessed, and their responsible person was not meaningfully interviewed, prior to R1 physically arriving at the facility. Licensee was thus unaware at time of move-in that R1 was a registered sex offender (RSO) and the risk they would be inheriting. Per their LIC602 Physician’s Report, R1 was diagnosed with Dementia and tended to wander. R1’s physician determined that R1 was not safe to leave the facility unassisted. Care records showed: R1 moved in on 05/05/2020 and eloped from the facility later the same day during waking hours without staff seeing; police had to be called. Staff and resident interviews aligned to further show: During R1’s residency at the facility (which ended in February 2022), there were many subsequent occasions of R1 going into the facility’s outdoor yards at night without staff being aware, harassing multiple housemates by peering into their bedroom windows and unsuccessfully trying to enter their bedrooms using their side doors. A preponderance of evidence existed to show that facility staff did not provide consistent supervision/observation to R1, R2, and R6. Licensee also did not maintain staff alert devices on exterior doors (which was required when caring for persons with Dementia who are at risk for elopement, such as R1). Six (6) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Licensee Nelly Panao, to whom a copy of this report, the LIC 809-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Jul 3, 2025

87211 Reporting Requirements: “(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not report suspected physical abuse affecting 2 of 6 residents (R2 and R6), but not resulting in serious bodily injury to either, to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours. This posed a potential safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, R1, R2, and R6 each no longer live at the facility, their responsible persons have since been told of the incidents, law enforcement and the ombudsman have been told of the incidents, and CCLD has investigated these matters. Licensee agreed to have all current staff receive remedial education on California Mandated Reporting Requirements (as articulated in SOC341A) through a third-party training source, and to E-mail proof of completion to LPA, by the POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Jul 3, 2025

87211 Reporting Requirements: “(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. (D) Any incident which threatens the welfare, safety or health of any resident…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not submit a written report to the licensing agency and the persons responsible regarding incidents which threatened the welfare and/or safety of 3 of 6 residents (R1, R2, and R6), within seven days of incident occurrence. This posed a potential safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, R1, R2, and R6 each no longer live at the facility, their responsible persons have since been told of the incidents, and CCLD has investigated these matters. Licensee agreed to have all current staff receive remedial education on Incident Reporting Requirements (as articulated in CCR 87211) through a third-party training source, and to E-mail proof of completion to LPA, by the POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Jun 3, 2025

87207 False Claims: “No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility…” This requirement was not met, as evidenced by: Based on records and interviews, during a formal CCLD investigation, Licensee made a false or misleading statement regarding the extent of their knowledge of abuse against 1 of 6 residents (R6). This posed a potential safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date deficiency issuance, R1 and R6 each no longer live at the facility, and CCLD has investigated these matters. No Plan of Correction was formed. Licensee was advised that repeat violations of this regulation may result in civil penalties and/or administrative action.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87457(c) · Plan of correction due date: Jun 3, 2025

87457 Pre-Admission Appraisal: “(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria…” This requirement was not met, as evidenced by: Based on records and interviews, for 3 of 6 residents (R1, R2, and R5), Licensee did not meet/interview the resident and their responsible person to determine the resident’s suitability for admission, prior to admission. This posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, R1, R2, and R5 no longer live at the facility. No Plan of Correction was formed. Licensee was advised that repeat violations of this regulation may result in civil penalties.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jun 3, 2025

87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that for 3 of 6 residents (R1, R2, and R6) were regularly observed. This posed a potential safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, R1, R2, and R6 no longer live at the facility. No Plan of Correction was formed. Licensee was advised that repeat violations of this regulation may result in civil penalties.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(d) · Plan of correction due date: Jun 3, 2025

87705 Care of Persons with Dementia: “(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement…” Based on records and interviews, 1 of 6 residents (R1) had Dementia and was at risk for elopement, but Licensee did not ensure the facility had an auditory device (or similar staff alert feature) on its exterior doors. This posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, R1 no longer lives at the facility. The current residents in care are not diagnosed with Dementia or at risk of elopement. No Plan of Correction was formed. However, this does not preclude Licensee from proactively installing such devices on exit doors, in anticipation of future move-ins who may be at risk for elopement.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Nelly Panao. Records review, confirmed by manager interview, showed: Licensee did not sign/execute an Admissions Agreement contract for Resident #1 (R1), with either the resident or their responsible person, as was required by time of move in. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] Licensee did not obtain an LIC602 Physician’s Report (or equivalent Medical Assessment) for R1, as was required by time of move in. Licensee did not complete an LIC603 Preplacement Appraisal (or equivalent document) on R1, as required. Although Licensee maintained an LIC603 for Resident #3 (R3), this document for R3 was completed nearly two weeks after R3 moved in. Interviews of staff and outside sources showed that Licensee did not meet with and assess either R1 or R3 before these residents moved into the facility, respectively. Licensee did not maintain an LIC625 Needs and Services Plan (or equivalent written record of care services that the resident will receive) for either R1, Resident #2 (R2), or R3, as was required within two-weeks of each resident’s move-in date. R1 moved into the facility on 03/28/2025 under the concurrent care of a hospice agency. However, Licensee did not maintain at the facility a current and complete hospice care plan for R1, as required. Per their LIC603 Physician’s Report, R3 required staff assistance with bathing. However, interview of an outside source showed: Licensee’s staff did not consistently provide R3 with bathing help, and on multiple occasions, R3’s responsible person needed to come to the facility to personally bathe R3. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Also, LPA observed that the mattress which Licensee issued to R3 was longer/larger than the box spring which Licensee issued to R3, resulting in the mattress hanging off the edge of the bed by about a foot. The middle of the mattress also did not have good springs. Interviews showed that R3 was dissatisfied with their mattress and had expressed their discontent to facility staff prior to LPA’s inquiry into the matter, but Licensee had not timely remedied the problem. Seven (7) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued Technical Assistance (TA) regarding the Department requiring an updated LIC503 Health Screening for Staff #1 (S1), prior to S1 resuming providing hands-on personal care assistance to residents (refer to the LIC9102-TA page). An exit interview was conducted with Licensee Nelly Panao, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TA page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(a) · Plan of correction due date: Jun 3, 2025

87507 Admission Agreements: “(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not complete an individual written admission agreement with 1 of 3 residents (R1). This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, Licensee has issued a 30-day eviction notice to R1. Therefore, no Plan of Correction was formed. Licensee was advised that repeat violations of this regulation may result in civil penalties. If this 30-day notice is later rescinded, Licensee agreed to immediately coordinate with R1’s responsible person to have an admission agreement signed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(a) · Plan of correction due date: Jul 3, 2025

87458 Medical Assessment: “(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 3 residents (R1), Licensee did not obtain documentation of medical assessment prior to the person’s acceptance as a resident. This posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, Licensee now has an LIC602 Physician's Report for R1 with negative TB screening. This resolves the deficiency.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c) · Plan of correction due date: Jun 3, 2025

87457 Pre-Admission Appraisal: “(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria…” This requirement was not met, as evidenced by: Based on records and interviews, for 2 of 3 residents (R1 and R3), Licensee did not meet/interview the resident and their responsible person to determine the resident’s suitability for admission, prior to admission. This posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, R3 has moved out and Licensee has issued a 30-day eviction notice to R1. Therefore, no Plan of Correction was formed. Licensee was advised that repeat violations of this regulation may result in civil penalties. If this 30-day notice is later rescinded, Licensee agreed to immediately complete and LIC603 Preplacement Appraisal on R1 and add it to R1’s care file.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87467(a) · Plan of correction due date: Jul 3, 2025

87467 Resident Participation in Decisionmaking: “(a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.” This requirement was not met, as evidenced by: Based on records and interviews, for 3 of 3 residents (R1, R2, and R3), Licensee did not prepare a jointly developed written record of care for the resident within two weeks of the resident’s admission. This posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, R3 has moved out and Licensee has authored an LIC625 Needs and Services Plan for R1. Licensee agreed to write an LIC625 Needs and Services Plan for R2 and to arrange a care conference with their responsible person and any other care stakeholders to review this document. Licensee agreed to E-mail the completed and signed LIC625 to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(b) · Plan of correction due date: Jul 3, 2025

87633 Hospice Care of Terminally Ill Residents: “(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not maintain at the facility a current and complete hospice care plan for 1 of 3 residents (R1) who was receiving hospice care. This posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, Licensee has issued a 30-day eviction notice to R1. Nonetheless, Licensee agreed to contact R1’s hospice agency to request a copy of R1’s written hospice plan of care to maintain in R1’s care file. Licensee agreed to E-mail this document to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87464(f)(4) · Plan of correction due date: Jun 3, 2025

87464 Basic Services: “(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident…such as…bathing…” This requirement was not met, as evidenced by: Based on records and interview, Licensee did not consistently provide 1 of 3 residents (R3) needed assistance with bathing. This posed a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, R3 has moved out. Therefore, no Plan of Correction was formed. Licensee was advised that repeat violations of this regulation may result in civil penalties.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(A) · Plan of correction due date: Jun 3, 2025

87307 Personal Accommodations and Services: “(a)(3) …The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (A) A bed for each resident…Each bed shall be equipped with good springs, a clean and comfortable mattress…” This requirement is not met, as evidenced by: Based on LPA observation and interviews, Licensee did not ensure that 1 of 3 residents (R3) had a mattress that was both equipped with good springs and comfortable. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: As of the date of deficiency issuance, R3 has moved out. Licensee agreed to discard the mattress which was previously issued to R3. This action resolves the deficiency. Licensee was advised that repeat violations of this regulation may result in civil penalties.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, Required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregiver Mike Polinario. Administrator Nelly Panao joined later in the visit. The facility's license shows a maximum capacity of six (6) non-ambulatory residents. The facility is approved for one (1) hospice resident. During today’s inspection there were two (2) residents in care. LPA and Caregiver Polinario toured the interior and exterior of the facility and inspected each room. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Bathroom sink was 105F and kitchen tap read at 116F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food. During the tour, LPA noticed evidence of rodent activity in the pantry area. Cooking, dining equipment, and utensils were present. No toxic chemicals, poisons, or knives were accessible to clients. During the tour, LPA noticed two cups of unsecured medications left next to the dining table. Interviews with staff and Administrator Panao revealed the medications are pre-poured for a resident as only the Administrator holds a key for the medication cabinet. Aside from those doses, medications were labeled, as required, and stored in locked areas. [Continued on LIC 809-C...] [Continued from LIC 809...] No pools or bodies of water exist on the premises. Per caregiver Polinario, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher was serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed two (2) staff and two (2) clients, and interviews did not reveal licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained some of the required documents, and LPA discussed with Administrator Panao of necessary documents. Confidential records were stored in locked areas. Deficiencies were cited during the inspection for unsecured medications and the presence of pests. An exit interview was conducted with Administrator Panao to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jan 27, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Nelly Panao. According to the facility’s license, the facility has a maximum capacity of six (6) clients, all of whom must be ambulatory. During today’s inspection, there were a total of four (4) clients in care, and per medical records, all were ambulatory. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 69 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 103 F, Bathroom #1 sink was 103 F, and Bathroom #2 sink was 103 F. Refrigerator temperature was 40 F and freezer temperature was -2 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC809] No pools or bodies of water on the premises. Per Licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kits (2) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and residents. LPA reviewed multiple staff and resident records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Licensee to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 23, 2024