Tlc Guest Home II

Allegation investigated: Staff do not provide adequate food service

On 04/05/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent unannounced complaint visit at the facility. California Department of Social Services (CDSS) was met by staff one, Rino Santos - House Manager (S1) and the reason for the visit was explained. The investigation consisted of the following: On 11/14/25 CDSS collected documents listed as follows: Increase in rent for three (3) residents (dated 11/03/25), admission agreements for one (1) resident (dated 05/07/25), physician's report for one resident (dated 05/05/25) and internal notes between facility and one resident (dated 11/03/25) (Party A). CDSS interviewed four (4) residents (R1-R4) and three (3) staff (S1-S3). On 05/05/26 CDSS collected further documents. The investigation revealed the following: Report continues, please see LIC9099-C. Substantiated Interviews revealed that three (3) out of four (4) residents (R2-R4) and all three (3) staff (S1-S3) have denied the allegation has taken place. On 11/14/25 CDSS collected an immediate resolution between party A and the facility (party B), dated 11/03/25. Record reviews have revealed that party B has informed party A of party B's responsibility to care for party A. This document has been signed by both parties. Furthermore, party A has signed the addendum for managed care program participants, dated 05/07/25. This document is an agreement between both parties, which is broken down into five segments, which explains the fee process. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation, “Illegal eviction”, it is being alleged that if party A does not agree with it, they can consider it a 60-day eviction notice, from party B. Interviews revealed that all four (4) residents (R1-R4) and all three (3) staff (S1-S3) have denied the allegation has taken place. Record reviews have revealed that party B has informed party A of party B's responsibility to care for party A. This document has been signed by both parties. Furthermore, party A has signed the addendum for managed care program participants, dated 05/07/25. This document is an agreement between both parties, which is broken down into five segments, which explains the fee process. CDSS was not provided any eviction notice. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation, “Staff do not treat resident with dignity and respect”, it is being alleged that the staff turn the water off while party A is showering. Interviews have revealed that two (2) out of four (4) residents (R2-R3) and all three (3) staff (S1-S3) have denied the allegation has taken place. Based on interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Rino Santos and a copy of this report has been provided. Regarding the allegation, “Staff do not provide adequate food service”, it is being alleged that party B never serve fresh food. Record reviews revealed that food menu indicates a fresh food is provided daily. Interviews revealed that three (3) out of four (4) residents (R1, R2, R4) have agreed the allegation has taken place. On 11/14/25 R1 stated, "They don’t cook everyday. They cook for themselves every day, but it’s not for us. They provide us that later. Four (4) or five (5) days later.". On 11/14/25 S3 has stated, "For residents I will cook salmon and vegetables. The one I'm cooking now is for the staff.", which indicates that fresh food is not always provided to residents in care. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099-D. There has been one (1) deficiency cited during today's visit. Please see LIC9099-D. An exit interview was held with Rino Santos (S1) and a Plan of Corrections (POC) has been developed. A copy of the facilities' appeal rights and this report has been provided.the state’s words, verbatim · CDSS document, May 5, 2026 · control 11-AS-20251104083731

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(5) · Plan of correction due date: May 12, 2026

87555(b)(5) General Food Service Requirements (b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. This has not been met as evidenced by: Based on record reviews and interviews conducted the licensee did not ensure that an appropriate variety of foods has been provided to three (3) residents, #1, #2, & #4 which poses a potential health risk to residents in carethe state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: CDSS and S1 have agreed that the facility will update their meal plan, with input from residents in care; on, or before, the POC due date. Facility will email updates to LPA at MARIO.LEON@DSS.CA.GOV

Allegation investigated: Resident sustained a pressure injury due to staff neglect

*** The original LIC9099 report dated 05/01/2025 is being revised to include additional information not previously documented. The updated LIC9099 report, dated 10/01/2025, will supersede and replace the original document. *** On 05/01/2025, at 9:30 a.m., the Department conducted a subsequent visit to gather information regarding the above allegations and deliver findings. The Department met with staff #1 (S1) Caregiver Leo Sumalpong and explained the purpose of today's visit. LPA was granted entry to the facility. Investigation consisted of the following: On 05/01/2025, at 10:00 a.m., the department requested, reviewed and obtained copies of Resident Roster (Dated 03/18/2025), Personnel Report (Dated 03/15/2025), Admission Agreement (Dated 04/23/2024), Identification and Emergency Information (Dated 04/23/2024), Physician's Report (Dated 05/14/2024), Medical Assessment (Dated 03/05/2024), Medication Administration Records (MARs) (05/02/2024-08/19/2024), See continued LIC9099-C page 2 Substantiated Continued LIC9099-C page 2 **This report has been amended to clarify findings. It does not supersede the report delivered on 10/01/2025. ** Functional Capability Assessment (Dated 04/23/2024), Preplacement Appraisal Information (Dated 04/23/2024), Consent Forms (04/23/2024), 30-Day Notice from Resident (Dated 07/19/2024), and RN Sign-In Sheet (Dated 05/24/2024-07/10/2024). The Department also requested and received the following: Optum Health Service Medical Record for R1, Physicians Choice Home Health Medical records for R1, and Torrance Memorial Medical Center records for R1. On 10/24/2024 and 05/01/2025, the department toured the facility's buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. No signs of neglect or abuse were observed during today's visit. Interviews were conducted with Staff Members #1-5 (S1-S5) as well as residents #2-4 (R2-R4) and witness 1 (W1). Resident #1 (R1) is no longer residing at the facility. The Department was able to interview the resident by telephone. The investigation revealed the following: Allegation: Resident sustained a pressure injury due to staff neglect. It is being alleged that resident 1 (R1) sustained a pressure injury on the right heel while at the facility. On 05/01/2025, Resident #1’s (R1) records were requested and reviewed. R1 was admitted to the facility per the admissions agreement dated 05/01/2024. The Physician’s Report, signed on 05/01/2024, indicated no pressure injuries upon entry to the facility. Home Health records dated 04/23/2024 show that R1 was under the care of Optum Home Health. On 06/04/2024, notes from Physician’s Choice Home Health indicated that R1 had no pressure injuries at the time of that visit. On 06/26/2024, Optum Home Health documented notes show R1 had an unstageable pressure injury on R1’s right heel. R1 received wound treatments on 07/01/2024, 07/02/2024, and 07/03/2024, as documented in Physician’s Choice Home Health medical records. On 07/03/2024, R1 was admitted to Torrance Memorial Medical Center with the following diagnoses: Stage 2 pressure injury on the sacrum, suspected deep tissue injury on the left heel, and an unstageable right foot ulcer with suspected necrosis. See continued LIC9099-C page 3 Continued LIC9099-C page 3 The Department interviewed five staff members #1-5 (S1–S5) and one witness (W1) regarding concerns about Resident #1’s (R1) foot wound. • S1 stated that R1 had a wound care nurse, but did not know the details of the wound care. • S2 reported that R1 had their own nurse who treated a foot wound. S2 was unaware of the wound’s staging and alleged that R1 had the wound upon arrival at the facility. • S3 stated that he observed a pressure injury on R1’s foot and informed R1. S3 also alleged that the wound was present when R1 arrived at the facility. • S4 confirmed that R1 had a wound on the right foot upon arrival and was seen by a nurse, but did not know which home health agency provided care. • S5 stated that R1 had their own nurse and was unaware of the wound’s staging. • W1 reported that the Clinical Coordinator from Physician's Choice Home Health noted R1 developed a pressure injury on the right heel during their time at the facility, as documented on 06/26/2024. All staff interviewed acknowledged that the resident had a pressure injury; however, none were aware of the wound’s staging or which home health agency was providing care. When a resident presents with a pressure injury, staff should receive training on appropriate wound site management and any necessary repositioning protocols. Based on the information gathered, it appears that such training may not have occurred in this instance. See continued LIC9099-C page 4 Continued LIC9099-C page 4 On 05/01/2025, between 2:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with three residents #2-4 (R2–R4) regarding the allegation, and 3 out of 3 residents stated they did not observe any resident who appeared to require wound care. 3 out of 3 residents stated that the facility is fully staffed, they were happy living here, and confirmed they are receiving the necessary care and supervision. All three residents (3 out of 3) denied the allegation and stated that their daily care needs were being met. Regarding the allegation “Resident sustained a pressure injury due to staff neglect,” based on record reviews and interviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D, and an immediate $500 Civil Penalty is assessed. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to facility staff.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 11-AS-20241008101957

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Oct 22, 2025

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidenced by:Resident #1 (R1) sustained a pressure injury on the right heel while residing at the facility. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: The licensee agrees to ensure that staff receive training on Observation of the Resident and will submit documentation verifying that staff have been re-trained by the Plan of Correction (POC) due date of 10/22/2025.

Type of visit: Required - 1 Year

On 09/10/25, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with staff one, Rino Santos - house manager (S1). LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly adults ages 60 and above. The facility is approved for (2) hospice residents and the facility currently has (2) hospice residents in care. The facility is a single-story structure, located in a residential neighborhood. It consists of the following: (4) residents' rooms, (2) bathrooms, (1) staff bedroom, a living area, a dining area, a kitchen, a shaded outside seating area, with an attached garage. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. During LPA's inspection, LPA noticed food items left on the stove, out of the refrigerator. LPA also observed the facility needing repairs of the wall in bedroom number three (#3). Bed linens, comforters, and bath towels were adequately stocked during today's visit. Bathrooms were operational and no mold was observed in bathroom numbers one (#1) and two (#2) showers. Bathroom #1 and #2 are in need of repair, as the maximum water temperature was measured at ninety-six point eight (96.8)°F (Degrees Fahrenheit), which is below title 22 regulation. LPA observed cleaning detergents stored properly and out of reach to residents in care. Water temperature was measured at 107.6°F (degrees Fahrenheit) in the kitchen and a comfortable temperature of 73.4 degrees F was maintained in the facility. Report continues, see LIC809C. LPA observed the facility to be fully furnished at the time of the visit. Storage areas for personal hygiene and sharp objects were observed to be appropriately stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was adequately maintained. LPA observed two pots of food, one (1) for clients and the other for staff. Neither item is being stored appropriately as they are outside of the refrigerator. A fire extinguisher was fully charged, with mandated yearly maintenance tag dated as 04/29/2025. LPAs observed First Aid Kit was maintained. A working landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas. There have been three (3) deficiencies cited during today's visit, see LIC809D. An exit interview was held with Rino Santos, House Manager, and a copy of the facilities' appeal rights and this report were provided.the state’s words, verbatim · CDSS document, Sep 10, 2025

Allegation investigated: Resident sustained a pressure injury due to staff neglect

** The original LIC9099 report dated 05/01/2025 was revised to include additional information not previously documented. The updated LIC9099 report, dated 10/01/2025, will supersede and replace the original document shown below. *** On 05/01/2025 at 9:30 a.m., the Department conducted an initial visit to gather information regarding the above allegations. The Department met with staff 1 (S1) Caregiver Leo Sumalpong and explained the purpose of today's visit. LPA was granted entry to the facility. Investigation consisted of the following: On 05/01/2025, at 10:00 a.m., the department requested, reviewed and obtained copies of Resident Roster (Dated 03/18/2025), Personnel Report (Dated 03/15/2025), Admission Agreement (Dated 04/23/2024), Identification and Emergency Information (Dated 04/23/2024), Physician's Report (Dated 05/14/2024), Medical Assessment (Dated 03/05/2024), See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Medication Administration Records (MARs) (05/02/2024-08/19/2024), Functional Capability Assessment (Dated 04/23/2024), Preplacement Appraisal Information (Dated 04/23/2024), Consent Forms (04/23/2024), 30-Day Notice from Resident (Dated 07/19/2024), and RN Sign In-Sheet (Dated 05/24/2024-07/10/2024). Interviews were conducted with Staff Members #1-2 (S1-S2) as well as residents #2-4 (R2-R4). Resident #1 (R1) is no longer residing at the facility. The Department was able to interview the resident by telephone. On 10/24/2024 and 05/01/2025, the department toured the facility's buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. No signs of neglect or abuse were observed during today's visit. The investigation revealed the following: It was reported to the Department that resident sustained a pressure injury on the right heel while at this facility. The resident didn’t notice the injury until mid-June 2024. The CNA, who assists the resident and provides showers, stated it was difficult to see the area and assumed the resident was aware of the injury, saying, "I thought you knew." It was report that the resident visited a podiatrist (name not provided), who advised the resident to go to the emergency room. The resident went to the ER (hospital name not provided) on 07/03/2024, where they were given a medication ball containing antibiotics. the resident reportedly remained on antibiotics for six weeks and received wound care three times a week. It was also reported that due to presence of a “big black thing” covering the resident's heel, the doctors were unable to determine the stage of the wound, as they could not see beneath it. The condition reportedly did not improve, and the resident recently had to return to the ER. The name of the hospital was not disclosed, and no hospital records or discharge documents were provided. S1 and S2 stated the resident did not sustain a pressure injury due to staff neglect. 2 out of 2 stated the resident had his own private nurse and denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation: Resident sustained a pressure injury due to staff neglect It was alleged resident sustained a pressure injury as a result of staff neglect. On 05/01/2025, between 10:00 a.m. and 12:45 p.m., the Department interviewed two staff members #1 and #2 (S1-S2), regarding the allegation. S2 stated the resident submitted a 30-day notice on 07/19/2024, indicating their intention to move out and actively looking for other accommodation. During that time, the facility did not observe any signs of discomfort or concerns related to the resident's care or needs. S2 also reported that the resident had a private nurse who visited three times a week to treat a wound on the resident's right heel. The documentation did not specify the stage of the wound. Both staff members interviewed (2 out of 2) confirmed that the facility does not admit or retain residents with pressure injuries above Stage 2, in accordance with Title 22 regulations. S2 stated they have been in business for over 30 years and strictly adhere to wound care regulations. S1 and S2 denied the allegation. On 05/01/2025, between 2:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with three residents #2-4 (R2–R4) regarding the allegation, and 3 out of 3 residents stated they did not observe any resident who appeared to require wound care. 3 out of 3 residents stated that the facility is fully staffed, they were happy living here, and confirmed they are receiving the necessary care and supervision. Residents (3 out of 3) denied the allegation and stated that their daily care needs were being met. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, May 1, 2025 · control 11-AS-20241008101957

Allegation investigated: Staff are not properly cleaning the floors Staff did not ensure the facility was free of pests

On 10/24/24, the Department conducted a subsequent unannounced visit to the facility listed above. The Department met with House Manager, Rino Santos, and the purpose of today’s visit was explained. During today’s visit the Department toured the facility, and interviewed Resident R4. On 10/09/24, the Department conducted an initial unannounced complaint visit to the facility listed above. The Department met with House Manager, Rino Santos, and the purpose of the visit was explained. During the initial visit, the Department toured the facility, interviewed Staff S1-S3, interviewed Residents R1 and R2, interviewed Residents R3’s Responsible Person (W1), and received documents pertinent to the investigation. The following documents were received and reviewed Resident Roster, Staff Roster, Terminix receipts, and staff training. The investigation revealed the following: Unsubstantiated Allegation: Staff are not properly cleaning the floors The complaint allegation alleges that staff spray the floors with cleaning product and then uses a dust mop to wipe, the floors are cleaned once a week, and resident contracted bacteria on foot due to floors not being cleaned. During the facility inspection, the Department observed the facility to be clean and sanitary. All floors and walls were observed clean and in good repair. During interviews with Staff S1-S3, were asked how often the floors are cleaned, three (3) out of three (3) stated the floors are cleaned daily and multiple times if needed. Additionally, during interviews with Staff S1-S3, were asked how they clean the floor, three (3) out of three (3) stated they use a mop and a cleaning solution with bleach. During interviews with Residents R1, R2, and R4, where asked if the floors in the facility are kept clean, three (3) out of three (3) stated yes, the floors and the facility are clean. During an interview with a Resident R3's Responsible Party (W1), was asked if the floors in the facility are kept clean, they stated the whole facility is clean. Allegation: Staff did not ensure the facility is free of pests The complaint allegation alleges that the facility has cockroaches. During the facility inspection, the Department did not observe any insects or residue of insects in the facility. During record review, the Department received and reviewed copies of receipts from pests control company dated on 03/25/24, 05/04/24, 07/16/24, 07/23/24, and 08/17/24. The report indicates they are treating for ants, roaches, and spiders. The most current report indicated there were only dead roaches found. During interviews with Staff S1-S3, were asked if they have seen cockroaches inside the facility, one (1) out of three (3) stated they have seen a cockroach inside the facility. Additionally, during interviews Staff S1-S3, were asked how they keep the facility free of pests and insects, three (3) out of three (3) stated they make sure it is cleaned and a pest control company comes out twice a month to treat. During interviews with Residents R1, R2, and R4, were asked if the facility is kept free of insects, three (3) out of three (3) stated they have not seen insects inside the facility. During an interview with a Resident R3's Responsible Party (W1), was asked if the facility is kept free of insects, they stated they have not seen any insects in the facility. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was was conducted with House Manager, Rino Santos, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 11-AS-20241002100204

Type of visit: Required - 1 Year

On 08/01/24, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manager, Rino Santos. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly adults ages 60 and above. The facility is approved for (2) hospice residents and the facility currently has (2) hospice residents in care. The facility is a single-story structure, located in a residential neighborhood. It consists of the following: (4) residents' rooms, (2) bathrooms, (1) staff bedroom, a living area, a dining area, a kitchen, a shaded outside seating area, with an attached garage. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. During LPA's inspection, room #1 needs the window sill cleaned and sections of the blinds were observed to need repairs. Room #4's window screen, closest to the TV, needs to be re-screened and sections of the blinds were also observed to need repairs. Bed linens, comforters, and bath towels were adequately stocked during today's visit. Bathrooms were operational and no mold was observed in bathroom numbers one (#1) and two (#2) showers. Bathroom #1's screen is in need of cleaning/disinfection, as the screen was observed dirty. LPA observed cleaning solutions below the sink in bathroom #2. Water temperature was measured at 111.0 degrees F in the kitchen, 108.0 degrees F in bathroom #1 and 106.5 degrees F in bathroom #2. A comfortable temperature of 73.4 degrees F was maintained in the facility. LPA observed the facility to be fully furnished at the time of the visit. Storage areas for personal hygiene and sharp objects were observed to be appropriately stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was adequately maintained. A fire extinguisher was fully charged, with mandated yearly maintenance tag dated as 10/20/2023. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms were available for use and all mandated posters and files were posted. Report continues, see LIC809C. LPAs observed First Aid Kit was maintained. A working landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas. An audit of residents #1-#5 (R1-R5) service files and staff #1-#3 (S1-S3) personnel files appeared to be complete. There have been four (4) deficiencies cited during today's visit, see LIC809D. There has been one advisory note provided, see LIC9102TV. An exit interview was held with Rino Santos, House Manager, and a copy of the facilities' appeal rights and this report were provided.the state’s words, verbatim · CDSS document, Aug 1, 2024

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.