Versa-Care Home I

Allegation investigated: Resident developed an unstageable pressure injury due to staff neglect

An unannounced complaint investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Administrator (AD) Cherry Aguila and discussed the purpose of the inspection. During the course of the investigation interviews were conducted with two facility staff, Resident 1 (R1), and Witness 1 (W1), and a review of R1’s Service Provider’s (SP’s) medical records and Home Health records was conducted, and the following was revealed: During their interview, two of two staff stated they were initially unaware of R1’s additional pressure injuries, other than the initial injury to their leg caused by a foot brace. Per Staff 1 (S1), R1 communicates with some facial expressions and is dependent on staff for activities of daily living, such as toileting, and showering. S1 stated they were not initially aware that R1 had developed additional pressure injuries and stated they did not know when the injuries developed. (Cont. LIC9099-C) Substantiated Per S1, they only saw a line on R1’s backside and stated although they did not document, they would reposition R1 every two hours. During their interview, S2 stated R1 had been receiving home health services and stated they did not know why these services were terminated and had contacted the Home Health agency and had been informed all visits were completed, and they would have to contact R1’s SP. Per S2, R1 was without home health for approximately three weeks (September 11, 2025 through September 25, 2025), however, S2 stated several Social Workers (SWs) would come to visit and in September 2025, R1 did not have any wounds. S2 stated the only issue had been with R1’s feet and the podiatrist prescribed “booties” which caused R1 to sustain a crease on their leg. Per S2, the crease was not open but was “black and blue.” S2 stated they had photographed it, however, was unable to provide the Department with the photograph. S2 stated that by the beginning of October 2025, the wound became a laceration which did open, and a wound nurse began treating it on September 29, 2026. Per S2, they were instructed by the nurse not to agitate or treat the injury. S2 stated they provided a sponge bath to R1 every week and they made sure the laceration dressing was kept dry and that the injury was always bandaged, and neither S2, nor other facility staff visibly saw the injury. S2 stated they had no reason to think R1 was in any immediate danger because R1 was eating well, and they saw no grimace regarding the crease wound. During their interview, W1, a Social Worker, stated they conducted a visit on September 29, 2025, to the facility and observed a blackened sore on R1’s right heel and noted a cotton wrap around R1’s left calf. Per W1, S1 stated R1 had “tiny, small sores” on their back and a worsening sore on their heel and reported that a podiatrist had recommended a heel protector, which was applied on September 16, 2025, however, by September 17, 2025, the heel sore had worsened. Per W1, R1’s SP was not informed of the sores until September 26, 2025, nine days after the initial observation. W1 confirmed that had been a lapse in home health services for approximately three weeks as R1’s SP does not have its own staff to check on R1 weekly, therefore, a SW would conduct a visit periodically, and a home health care nurse would visit two times a month. Per W1, an air mattress was ordered by R1’s SP to alleviate the pressure of the pressure injuries and when they inquired about the low-air-loss mattress and Hoyer lift, which had also been ordered by R1’s SP, S1 informed them the mattress had been returned because R1 "did not like it” and S1 was unsure whether the current Hoyer lift belonged to R1. W1 confirmed that the air loss mattress was transported and delivered on July 2, 2025, and the facility declined to receive it, although they signed for it, and the Hoyer lift had been provided to assist with transfers. Per W1, the Hoyer lift was not utilized as R1 had not been out of bed for two months and stated facility staff have been educated multiple times to inform R1’s SP of health changes. (Cont. LIC9099-C) Per W1, a second mattress was subsequently ordered and installed a day after it was received, however, R1’s SP was not satisfied with the care being provided and subsequently removed R1 from the facility’s care. During their interview, R1 was not aware of the day of the week or the time and was unable to confirm or deny allegation and stated they did not have any issues while living at the facility. Per review of medical records, R1 has dementia and is dependent on staff for activities of daily living, such as toileting, bathing, grooming and showering. A review of Home Health Medical Records for R1 revealed the following: On September 23, 2025, R1 was discharged from home health services due to the end of episode. On September 26, 2025, R1 resumed care after an assessment and was noted to have developed two unstageable pressure injuries. The Home Health Nurse (HHN) conducted an assessment, a skilled observation, interviewed R1, and noted R1 is completely immobile and requires total assistance for all movements. S1 reported prior ecchymosis from foot brace and area appeared worsened due to immobility and continuous pressure. HHN instructed S1 on importance of frequent repositioning and reinforced need to avoid use of tight devices to prevent further injury. On October 2, 2025, it was noted that HHN had instructed and taught R1 on pressure ulcer of right heel, which was unstageable, performed medication reconciliation, and drug regimen review. Based on review of R1’s records and the facility visitor log, there is no evidence that R1 was seen by a HHN between August 22, 2025, and September 25, 2025. On September 26, 2025, W1 visited R1 and observed the onset of a pressure ulcer on R1’s back. During a subsequent visit on September 29, 2025, S1 informed W1 that R1 had developed small sores on the back and a worsening sore on the heel. S1 stated that a podiatrist had recommended a heel protector, which was applied on September 16, 2025, but S1 observed that the heel sore continued to worsen. A review of the records found no documentation that additional wound care or treatment was provided to R1 until the HHN resumed services on September 27, 2025, after the facility reported R1’s skin condition to R1’s SP on September 26, 2025. HHN continued treating R1’s pressure wounds until October 2, 2025, and noted a stage 3 mid back wound, unstageable right heel and left heel wounds, and deep tissue injuries on left and right lower shins. R1 was transferred to a Skilled Nursing Facility (SNF) on October 3, 2025. It was noted on the SNF’s records that on admission, R1 had pressure wounds on left shin, left heel, right and left medial thighs, and spine (unstageable). (Cont. LIC9099-C) Based on the investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations (see LIC9099-D), and an Immediate $500 Civil Penalty is being assessed (see LIC421IM). Additional Civil Penalty is pending determination as per Health & Safety Code 1569.49(f). An exit interview was conducted, and a copy of this report and appeal rights was provided at the end of inspection.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 22-AS-20251006141004

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 25, 2026

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in... Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on staff interviews and record review, the Licensee did not comply with the section cited above as R1 developed two unstageable pressure injuries while in care due to staff neglect, which posed an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2026

Plan of correction: AD stated staff training regarding resident care and supervision will be conducted and a written plan of action, ensuring facility staff will provide basic services to residents, will be provided to LPA via email by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nancy Guillen made an unannounced visit for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by care provider after explaining the purpose of the visit. Administrator (AD) Cherry Aguila was notified via telephone and later arrived to assist with the inspection. LPA observed the Administrator certificate was current with an expiration date of November 11, 2026. This is a Residential Care Facility for the Elderly (RCFE) licensed to six non-ambulatory residents with a hospice waiver for six. The facility is a one story home with three resident bedrooms, one staff bedroom, two bathrooms, and an attached garage. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, dining and garage and observed the following: LPA observed residents watching television in the living room and resting in their respective bedrooms. LPA observed three residents in care and two staff present. LPA observed the See Something Say Something Poster (PUB 475) mounted on the wall by the facility entrance. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets with additional linens stored in the hallway storage closet. LPA observed bathrooms were clean and equipped with grab bars and non skid floor mats. LPA observed all windows were appropriately screened. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 125.4 and 127.2 degrees Fahrenheit; a deficiency was cited on today's date. LPA toured the outside of the facility and observed outdoor passageways were free of obstruction. LPA observed the backyard had a shaded sitting area with furniture for resident use. Continued on LIC809C LPA observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Six burner gas stove, microwave, washer, and dryer were all inspected and observed to be operable. LPA observed knives and sharps to be stored in a locked kitchen drawer. Toxic chemicals, cleaning solutions, and disinfectants were observed to be located under the kitchen sink. Medication cabinet was observed centrally stored in a living room closet however, it was left unlocked and accessible to residents in care; a deficiency was cited on this date. LPA observed the facility conducted their last emergency disaster drill on July 3, 2026 and is conducted every 3 months. During record review, LPA reviewed three resident records. All the required documentation were present and current in the resident files reviewed. LPA reviewed two employee records. All employee present have a criminal record clearance and were associated to the facility. LPA observed records reviewed have a current First Aid certificate. Based on the observations made during today’s inspection, deficiencies are being cited. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Jul 21, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Case Management inspection in conjunction with investigation into complaint number 22-AS-20251006141004. LPA met with Administrator (AD) Cherry Aguila and explained the purpose of the inspection. During the course of the investigation, deficiencies were observed. Upon request of Resident 1’s (R1’s) Home Health file, AD was unable to provide any Home Health documentation pertaining to R1. During physical inspection of the facility, LPA observed staff occupy the garage with personal belongings, including toiletries, clothing and shoes, and a couch with bedding folded neatly on top. Based on observations made during this inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Oct 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87506(a) · Plan of correction due date: Oct 8, 2025

Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available... to licensing agency staff. This requirement is not met as evidenced by: Based on AD interview, the Licensee did not comply with the section cited above as AD was unable to provide any documentation pertaining to Home Health for R1, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: AD stated they will obtain a complete and current Home Health record for R1 and a copy will be submitted to LPA via email by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC87307(a) · Plan of correction due date: Nov 7, 2025

Personal Accommodations and Services (a)... The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as staff is currently residing in the garage, which poses a potential safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: AD stated staff will no longer reside in the garage and all their personal belongings removed. AD stated video proof will be submitted to LPA via email by POC date.

Type of visit: Required - 1 Year

On September 3, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit. Upon arrival at the facility, LPA Bentley was greeted and granted entry by Caregiver (CG) Jerome Macasaquit and explained the purpose of the visit. Administrator (AD) Cherry Aquila arrived a short time later and was present throughout the inspection visit. The facility is licensed to operate for six (6) non-ambulatory residents with a Hospice waiver for six (6). The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) resident bathroom, one (1) staff bathroom, living room area, dining area, kitchen, an outdoor covered seating areas, and an attached two car garage. LPA Bentley toured inside and outside of the physical plant with CG Macasaquit. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be operational and clutter free. The water temperature measured at 117.1 degrees F to 117.5 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. LPA Bentley observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency safety drills are being conducted quarterly. First aid kit is maintained and contains all the necessary elements. Continued on LIC 809-C... During the visit, LPA Bentley observed the facility's smoke detectors and carbon monoxide detectors were operational. A working telephone (714-646-9217) remains available, and the facility has a device that can be used for video teleconference purposes. Emergency food, emergency water, and emergency supplies were observed. The facility has a (1) fire extinguisher that was charged, mounted, and serviced on January 14, 2025. Liability Insurance is effective 7/1/2025 and expires on 7/1/2026. LPA Bentley conducted an audit of six (6) resident files (R1-R6), four (4) staff files (S1-S4), and medication and medication administration review. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. (Continued on LIC 809-C) Based on today’s observations deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Cherry Avila.the state’s words, verbatim · CDSS document, Sep 10, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Claudia Gutierrez and William Vanegas made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Dolores Lacwasan. Administrator (AD) Cherry Aguila was contacted by phone and the purpose of the inspection was discussed. AD stated she would be unable to join LPAs for the visit and indicated Staff Lacwasan would be able to assist with the inspection. During the inspection, LPAs and Staff Lacwasan conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following: This is a one-story home with four resident bedrooms, two bathrooms, and attached two-car garage. All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPA observed all windows were screened. The backyard has a shaded sitting area. LPAs observed residents watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 138.3 degrees Fahrenheit; a Deficiency was cited on today’s date. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Carbon monoxide detectors tested operational, and three of six smoke detectors tested operational; a Deficiency was cited on today’s date. Fire extinguisher was observed to be fully charged with service tag dated January 3, 2024. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication cabinet was observed to be locked. LPAs reviewed three of three resident files. Staff files for Staff Lacwasan and AD are not being maintained and were not available for review; a Deficiency was cited on today’s date. (Cont. LIC9099_C) One of three resident files is not being maintained; a Deficiency was cited on today’s date. Staff files did not contain any documentation for initial staff training or staff training conducted; a Deficiency was cited on today’s date. LPAs interviewed residents and staff present. AD arrived at 3:00 p.m. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Sep 9, 2024

The state marks this report as 11 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.