Treasure

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Required - 1 Year

On August 27, 2025 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a 1-year annual inspection and met with Jennifer Covington and explained the purpose of the visit. LPA Avila and Administrator toured facility together to ensure the health and safety of residents in care. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in a locked area. Water temperature measured within the required range. Bedrooms: The LPA observed resident bedrooms furnished with at least one night stand, bed, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Bathrooms: The LPA observed the resident bathrooms to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene products. Common Areas: These included but are not limited to the living area, activity area, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. In the areas toured no immediate health, safety, or personal rights violations were observed. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no firearms or bodies of water on the premises. Record Review: A review of facility files was initiated. The LPA observed documentation of the Infection Control, Disaster prevention and last fire drill. Facility records are stored inaccessible to residents. The LPA reviewed four (4) staff, and five (5) resident files. All documents reviewed appeared complete and current. Medications: During the facility visit a medications review was initiated. Medications are centrally stored and locked in a cabinet inaccessible to residents in care; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record log. No errors observed during the medication review. No deficiencies cited during today's visit. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 27, 2025

Allegation investigated: Staff don't meet residents' hygiene needs.- SUBSTANTIATED

/16/2025 01:45 PM Licensing Program Analyst (LPA) Rebecca Knight made an unannounced visit to the facility and met with administrator Casey Foster. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the administrator and staff. LPA reviewed the following documents: Admission Agreement, IPP, Physician’s Report, care plan for 1 client, hourly check sheet, daily task sheet, staff schedule for May 2 - 5 2025, staff list with telephone numbers, photograph. Continued on LIC9099-C Substantiated Staff don't meet residents' hygiene needs.- SUBSTANTIATED It was reported that a resident was found soiled from head to toe with urine and feces. LPA reviewed Resident 1’s LIC602 Physician’s Report which states that R1 is incontinent. LPA reviewed R1’s Individual Program Plan which states that R1 requires full assistance in all of their personal care and daily living needs. IPP further states that R1 is frequently incontinent. LPA reviewed the facility’s daily checklist and it is documented on 05/04/2025 6:00 PM to 4:00 AM shift under the item “Check MC MW RD & KLM When starting and leaving your shift.” A staff had initialed this as being completed (in blue ink), but there is a note written in black ink “both MC & MW were soaked x10”. LPA reviewed hourly logs for Resident 1 (R1) for the dates of 05/02/2025 through 05/05/2025. On 05/02/2025 07:40 AM R1 “showered/wet/old BM”. 05/04/2025 05:00 AM “R1 soaked”. LPA reviewed a photograph that showed R1 standing up wearing a white shirt, the shirt had urine stains that extended to R1’s chest. Staff interviewed stated they have occasionally found R1 had not been toileted when they came on shift in the morning. Administrator stated that staff had reported this incident to her and sent her photographs of the incident. This allegation is substantiated. Based on interviews, documents and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Casey Foster.the state’s words, verbatim · CDSS document, Jun 16, 2025 · control 59-AS-20250505105758

From the deficiency page — Deficiency type: Type B · Section cited: CCR 876259(b(3) · Plan of correction due date: Jun 30, 2025

876259(b)(3) Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, 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 is not met as evidenced by: Based on interviews and document review the facility did not keep 1 of 6 residents clean and dry.the state’s words, verbatim · CDSS document, Jun 16, 2025

Plan of correction: Licensee agrees to formulate a plan to ensure that all residents are toileted as needed to keep them clean and dry. Licensee shall submit the plan to LPA as proof of correction. POC due to LPA by 06/30/2025.

Type of visit: Case Management - Incident

04/24/2025 02:30 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Anna Castillo-Virgen and explained the purpose of the visit. On 04/10/2025 LPA visited the facility to start the investigation, the purpose of today’s visit is to deliver the results of the investigation regarding an incident report that was received by licensing on 04/02/2025. It was reported that on 3/15/2025 at approximately 12:00 PM Staff 1 (S1) was working with Client 1 (C1) in the dining room at the dining table. C1 was very antsy and would frequently get up and down out of the chair to walk and pace. S1 would redirect C1 back to their chair to prevent a fall and work closely with C1 utilizing a gait belt for support. Staff 2 (S2) claims they heard S1 say to C1 "you're so annoying," and telling C1 to "Shut the F up.” S2 claims they heard S1 say this to C1 four times. During the investigation it was learned that there were three staff who were on duty at the time of the incident. LPA conducted interviews with all staff who were present on the date and time of the incident as well as staff who were not present. LPA reviewed staff schedule for the date and time of the incident. There were multiple inconsistencies during the interviews. The preponderance of evidence standard has not been met. No deficiencies were cited as a result of the investigation. Exit interview conducted and a copy of the report was provided to with administrator Tamra Leak.the state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Case Management - Incident

04/10/2025 09:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Anna Castillo-Virgen. Today’s visit is regarding an incident report that was received by licensing on 04/02/2025. It was reported that on 3/15/2025 at approximately 12:00 PM Staff 1 (S1) was working with Client 1 (C1) in the dining room at the dining table. C1 was very antsy and would frequently get up and down out of the chair to walk and pace. S1 would redirect C1 back to their chair to prevent a fall and work closely with C1utilizing a gait belt for support. Staff 2 (S2) claims they heard S1 speaking roughly to C1. This incident needs further investigation. No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to with administrators Casie Foster, Anna Castillo-Virgen and licensee Tamra Leak.the state’s words, verbatim · CDSS document, Apr 10, 2025

Allegation investigated: Staff did not provide adequate supervision to resident in care resulting in injuries.- UNSUBSTANTIATED Staff leave residents sitting on their wheelchair for an extended period of time.- UNSUBSTANTIATED

/28/2025 09:18 AM Licensing Program Analyst (LPAs) Rebecca Knight and Kayla Adkison, made an unannounced visit to the facility and met with administrator Anna Castillo-Virgen. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA conducted interviews and reviewed the following documents: Admission agreement, IPP, Needs & Services plan, LIC600 Physicians Report, Care Plan, care notes, physical therapy evaluation, related incident reports, communication log for 1 resident, staff list with telephone numbers. Continued on LIC9099-C Unsubstantiated Staff did not provide adequate supervision to resident in care resulting in injuries. - UNSUBSTANTIATED It was alleged that there is a resident in the home that requires 24/7 assistance, is fall risk. Alleges this resident falls daily and has been wounded as a result of the falls. Alleges the company has not looked further into placing the resident in another home where they can get the proper assistance they require. On 11/20/2024 R1 was evaluated by a physical therapist (PT) from Butte Home Health & Hospice. The PT determined R1 was not a candidate for skilled Physical Therapy intervention due to their inability to follow instructions or learn techniques for improved balance. For this reason, the PT provided their professional opinion that the best solution for preventing R1 from future falls and possible hospitalization is for the arrangement and funding for a one-on-one caregiver situation. The licensee provided a detailed outline of communications with Far Northern Regional Center (FNRC) concerning the need for intensive staffing for R1 or the need to transfer R1 to a higher level of care. This communication started on 08/22/2024. On 09/23/2024 the licensee met with FNRC and a supervisor agreed that R1 should have intensive staffing which should be 24 hours a day. On 10/23/2024 licensee took R1 to a medical appointment for gait training. 11/14/2024 Zoom meeting held with FNRC and licensees regarding intensive staffing request for R1. Licensee submitted the following incidents reporting falls for R1 on the dates of 08/09/2024, 10/03/2024 R1 fell and was transported to the ER for evaluation, no injuries were sustained, first aid provided. On 11/03/2024, and 11/26/2024 R1 fell, did not sustain significant injuries, was provided first aid at the facility. Staff interviews revealed that R1 has had falls but has not been injured as a result, has sustained some cuts and bruises. Staff provided first aid to R1. Staff stated that R1 started 1:1 (intensive staffing) in December 2024 after the facility received approval from FNRC. It was determined that starting in August 2024 the facility had been working with FNRC to obtain intensive staffing for R1 due to increase in falls. Intensive staffing for R1 started in December 2024 and R1 has not sustained any falls since. The licensee showed due diligence in obtaining required services for R1. This allegation is unsubstantiated. Continued on LIC9099-C Staff leave residents sitting on their wheelchair for an extended period of time - UNSUBSTANTIATED It was alleged that staff let the residents sit at the dinner table for long periods of time in their wheelchairs rather than taking them to the restroom or back to bed. All staff interviewed stated that residents are encouraged to sit up for ten to twenty minutes after they have a meal to encourage good digestion. The residents stay at the table and socialize or watch TV together. It was determined that ten or twenty minutes is not an extended period of time for a resident to sit in a wheelchair after a meal. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Anna Castillo-Virgen and licensee Tamra Leak.the state’s words, verbatim · CDSS document, Jan 28, 2025 · control 59-AS-20241211085810

Type of visit: Required - 1 Year

On 08/06/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Tamra Leak and explained the purpose of the visit. LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free. LPA observed all resident bedrooms to have all the required furnishings, windows with screens and working lights. LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, trash can with lids and 20-second hand-washing poster. LPA observed the facility to have the required 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 114 F. LPA observed the medications to be locked and inaccessible to residents. LPA observed one (1) fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed a completed first aid kit ready for emergency use. LPA observed a completed emergency disaster plan with the required emergency disaster drills conducted within the last 12 months. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA reviewed a total of six (6) residents' files and four (4) staff files which contains all of the required documentation. Several topics were discussed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Aug 6, 2024

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

LPA Jaynae Boyles and LPM Lauren Crocker made an unannounced visit to the facility today to amend the report dated 9/21/2023 as a result of the facility's appeal to the cited deficiencies on that date. Met with facility staff, Ana Castillo-Virgen . There was 1 deficiency that was overturned with a civil penalty attached that was also dismissed. The report was updated to reflect these changes via the appeal. A copy of the updated report was left at the facility for review.the state’s words, verbatim · CDSS document, Apr 3, 2024

Allegation investigated: Staff did not follow the resident’s care plan. Staff did not allow a resident to go on an outing. Staff did not seek medical attention for a resident in care. Staff spoke to residents in an inappropriate manner. Staff left residents in a soiled diaper for a long period of time.

/19/2024 Licensing Program Analyst (LPA) Jaynae Boyles made an unannounced visit to the facility and met with Assistant Administrator, Ana Virgen. The purpose of this visit is to deliver the results of a complaint investigation. During the interview process, the Administrator, five staff members and one resident (R1) were interviewed. During the review of records, LPA reviewed the files of two residents, including Incident reports, Medical Records, and Individual Program Plan. Continued on LIC 9099C Unsubstantiated LPA investigated the allegation, “Staff did not follow resident's care plan.” The Administrator reported that all care plans are created collaboratively with staff and adjusted when there is a change in condition for the residents in care. LPA observed 2 resident files which had current Individual Program Plans in the file. LPA investigated the allegation, “Staff did not allow a resident to go on an outing.” During the investigation, it was reported by all staff persons that all residents have the opportunity to attend regular scheduled outings and if these outing are missed they are rescheduled for the resident. LPA investigated the allegation, “Staff did not seek medical attention for a resident in care.” During the investigation, it was reported by all staff persons the protocol for when residents fall or when there is a change in condition for a resident. All staff appeared to be well versed in the policy and procedures for ensuring timely medical care for residents. LPA investigated the allegation, “Staff spoke to resident in an inappropriate manner.” During the investigation, it was reported by all staff persons that no staff members use inappropriate language toward residents in care or have they observed staff members speaking inappropriately toward residents in care. R1 stated that no staff member has ever spoken inappropriately towards her or any other residents. LPA investigated the allegation, “Staff left resident in a soiled diaper for a long period of time”. During the investigation, it was reported by all staff persons that residents with incontinence are checked hourly. The administrator reported that there are more staff at this facility to ensure that residents with incontinence have more attention to ensure that they are changed frequently. This agency has investigated the complaint alleging “Staff did not follow resident's care plan, Staff did not allow a resident to go on an outing, Staff did not seek medical attention for a resident in care, Staff spoke to resident in an inappropriate manner, Staff left resident in a soiled diaper for a long period of time”. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to the assistant administrator, Ana Virgen.the state’s words, verbatim · CDSS document, Jan 19, 2024 · control 59-AS-20231129092136

Type of visit: Case Management - Other

LPA Boyles and Avila arrived at the facility unannounced to deliver an amended annual inspection. Copy of the report was provided to the assistant administrator.the state’s words, verbatim · CDSS document, Jan 19, 2024