Villa Bernardo

Type of visit: Required - 1 Year

On 06/18/26, Licensing Program Analyst (LPA) Aziz Faizi made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by caregiver Rommel Abedoza who was informed of the purpose of the visit. The facility is a one-story home with ten (10) bedrooms and three (3) bathrooms, with no attached garage. There are no pools or known firearms on the premises. LPA toured the facility's exterior and observed outdoor pathways were free of obstructions. Outdoor shaded seating area is available for the clients in care. The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. LPA toured the kitchen and observed the facility has a two-day supply of perishable foods and more than a seven-day supply of non-perishable foods, which are stored in a safe and healthy manner. LPA observed knives and sharp instruments secured in locked kitchen cabinets. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 108.6°F. Fire extinguishers equipped throughout the building are maintained in accordance with the department's safety requirements expiring on 02/09/2027. Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate expiring on 08/24/2026. Continued with 809C LPAs reviewed files for three (3) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Three (3) resident files were reviewed and contained all required documentation. All resident medications were securely locked. LPA reviewed medications for three (3) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire/earthquake drill conducted on 05/16/2026, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.the state’s words, verbatim · CDSS document, Jun 18, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analysts(LPA) Janira Arreola conducted an unannounced visit to the facility to conduct a case management health and safety check. LPA met with Staff, Rommel Abedoza, who was informed of the purpose of the visit. There were (10) residents residing at the facility and (4) staff working during the time of the visit. LPA verified all staff present during the time of the visit were finger print cleared and associated to the facility. LPA toured the facility and observed all facility utilities to be on and operating without issues. The food supply meets the 7-day non-perishables, and 2-day perishables regulatory requirement. LPA observed resident medications are filled. LPA observed residents in common areas and being assisted by staff members in their rooms. There were no immediate health or safety concerns at the time of the visit. No deficiencies are being cited during the time of the visit. An exit interview was conducted where a copy of this report was discussed with and provided to the staff.the state’s words, verbatim · CDSS document, May 18, 2026

Allegation investigated: Staff would not release residents paperwork to authorized representative.

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Staff, Rommel Abedoza who was informed of the purpose of the visit. LPA spoke with Administrator and Licensee, Zayden Chen over the phone during the time of the visit. During the visit, LPA conducted interviews, conducted a walk through, and conducted records review. "Staff would not release residents paperwork to authorized representative." It was alleged that records such as Resident #1 (R1)'s LIC602 and medications list were requested by an authorized representative for R1 and were not provided. LPA conducted an interview with the administrator who revealed R1 is conserved. The administrator revealed an outside agency was requesting LIC602 and medications list for R1 who was not their authorized representative. Records review for R1 confirmed who R1's conservator is and confirmed that the conservator on file was not the person requesting R1's records. Additional internet search was conducted for the individual requesting records and it was found that they are working under a referral agency for senior care. Therefore, based on interview and record review the allegation that R1's authorized representative was not granted records is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Feb 10, 2026 · control 18-AS-20260204160956

Allegation investigated: Staff do not ensure that resident's toileting needs are being met while in care.

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Staff, Karen Pangilinan and spoke with Licensee and Administrator over the phone were was informed of the purpose of the visit. During the visit, LPA conducted interviews, documented observations/conducted a walk through, and conducted records review. “Staff do not ensure that resident's toileting needs are being met while in care.” It was alleged Resident #1 (R1) is not being assisted to their walker to use the restroom and that R1 has to evacuate their bowels in bed. Unsubstantiated R1’s LIC602 Physician’s Report dated 08/18/2025 revealed R1 is non ambulatory and facility care plan dated 09/22/205 documented R1 needs assistance with transfers and turning and using a wheelchair. R1’s Home Health care plan dated 11/01/2025 revealed R1 has a pressure injury and physical limitations with ambulation. The home health care plan indicates R1 is up as tolerated, requires assistance with transfers from bed to chair, is partial weight bearing, and is provided with both a walker and a wheelchair. R1 was interviewed on 11/25/2025, who stated they previously used a walker, however they are no longer physically able to. R1 reported they use a wheelchair with staff assistance. R1 self reported due to pain and physical limitations of a pressure injury on their bottom, they are not able to turn and reposition in bed without staff assistance. R1 demonstrated difficulty repositioning and turning to LPA. R1 reported staff regularly change their diaper, however R1 also stated staff does not assist R1 out of bed when requested. LPA interviewed (3) facility staff 11/25/2025, who revealed R1 does not currently use a walker and uses a wheelchair with assistance. (3) of (3) staff reported R1 often declines being placed in their wheelchair and does not wish to get out of bed. During facility visit 01/08/2026 LPA observed R1 in their wheelchair and assisted to the dinning table by staff. All staff interviewed stated they provide in bed toileting when R1 refuses to get out of bed. All staff interviewed stated R1 is unable to turn in bed without assistance and R1 has a pressure injury on their coccyx. Interview with R1’s responsible party revealed R1 is bedbound, cannot ambulate with a walker, and R1 is primarily bedbound due to physical limitations and their pressure injury. Therefore, based on interviews and records review, the allegation that are not meeting R1’s toileting needs while in care is unsubstantiated. There is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 8, 2026 · control 18-AS-20251230090726

Allegation investigated: Neglect/Lack of Care and Supervision resulted in hospitalization

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit in order to deliver findings for the above allegation. LPA met with Staff, Rommel Abedoza who was informed of the purpose of the visit. LPA spoke with the current administrator, Lynn Drummond and Licensee Zayden chen over the phone who were informed of the purpose of the visit. The investigation consisted of interviews and records review. It was alleged “Neglect/Lack of Care and Supervision resulted in hospitalization” of Resident #1 (R1). It was alleged R1 developed an open wound with maggots due to neglect by facility staff. Substantiated Medical records for R1 dated 07/16/2024 revealed diagnosis of “pink skin with crawling maggots” between the toes, MRSA, Cellulitis, and non-pressure arterial ulcers on the toes of both feet. The medical records revealed R1 was admitted to the hospital on 07/16/2024. Pre-placement appraisal for R1 dated 02/19/2024 documented a history of MRSA, Cellulitis, and a Stage 2 ulcer on R1’s right foot. A review of R1’s Home Health Care Plan dated 06/06/2024 revealed, R1 was admitted to home health services for treatment of Cellulitis to the lower extremities on 06/07/2024. Home Health services were discontinued on 06/28/2024 and home health notes read, “Bilateral wounds and weeping resolved without complications.” A review of R1’s resident file revealed there was no documented care plan created or maintained by the facility for R1’s care. Interviews with three (3) facility staff revealed they were instructed by home health to continue wrapping R1’s legs with gauze following R1’s discharge from home health services. Staff interviews revealed the gauze was changed every two to three days. R1’s physician was interviewed and reported facility staff were instructed to change R1’s gauze daily and to monitor R1’s lower extremities closely. R1’s Physician’s Report dated 02/16/2024 was reviewed. It revealed R1 was unable to bathe themselves and R1 required assistance with grooming of their lower body by a caregiver. Interviews with six (6) facility staff revealed R1 did not take showers and instead used washcloths for personal hygiene. Staff indicated they would hand the washcloth to R1 who then used the washcloth independently. Of the staff interviews, (3) of (6) staff reported R1 washed their own feet. When staff were asked about assisting R1 with putting on socks and shoes, staff reported they assisted R1 with this task because R1 was not able to bend down far enough to put on their own socks and shoes. On 07/11/2024, Staff #1 (S1) reported assisting R1 with bathing and stated they did not observe any sores on R1’s feet. On 07/12/2024 Staff #2 (S2) reported they washed R1’s feet and observed an open sore on the second toe of R1’s left foot. S2 stated they reported this sore to the administrator, however an interview with the administrator revealed they did not recall being notified of any sores. No documentation or evidence of follow-up or medical intervention for the sore was provided by the facility. On 07/16/2024, S1 reported seeing flies around R1’s feet, and upon removing the gauze, S1 observed maggots on R1’s feet. Emergency services were contacted, and R1 was transported to the hospital. Hospital photographs taken on 07/16/2024 revealed both of R1’s feet were red, swollen, with yellow and black buildup between and under the toes, flaking skin, and discoloration of the toenails. Based on interviews and review of records and documentation, the preponderance of evidence standard has been met. Therefore, the allegation is substantiated. A violation of California Code of Regulations (Title 22, Division 6, Chapter 8) is cited on the attached LIC 9099-D. An immediate civil penalty in the amount of $500 is being assessed. In accordance with Health and Safety (H&S) Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident is pending and under review by the Department. An exit interview was conducted, and this report, along with LIC 9099-D, LIC 421IM (civil penalty), and appeal rights were provided to the facility representative. A plan of correction was discussed and documented with licensee Zayden Chen and Lynn Drummondthe state’s words, verbatim · CDSS document, Sep 25, 2025 · control 18-AS-20240717163615

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Sep 26, 2025

87465 Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed...(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interview and record review the facility did not develop a plan to address R1's care needs or arrange for the timely medical attention of R1's feet. This poses an immediate. health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: The licensee and administrator agreed to submit proof of terminiation of previous Administrator, and submit the administrator's schedule and routine to ensure staff communication, proper notification,care and changes of condition for residents are reported timely by the POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility for an unrelated matter and documented deficiencies observed. LPA met with House Manager, Odette Derafera, who was informed of the purpose of the visit. During the visit, LPA conducted an interview and walk through of the facility. A health and safety check was conducted on the facility residents, the following violations were observed: During the walk through LPA observed (2) video monitors with audio with live feeds showing residents in their rooms. The use of video surveillance in residents rooms are not permitted, and the use of video with audio capabilities is not permitted. LPA also reviewed the current staff scheduled for the week, and identified staff present during the time of the visit. (1) staff was not associated to the facility. The deficiencies were cited and a plans of correction was created with the house manager. The criminal record clearance has a civil penalty of $100 per day per person for the maximum of (5) days. The facility is being cited a total of ($500) in civil penalties. An exit interview was conducted with the house manager, where this report, LIC811, deficiency pages, civil penalty pages, and appeal rights were reviewed and provided to them.the state’s words, verbatim · CDSS document, Jul 18, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Jul 25, 2024

(a) In addition...elderly shall have all of the following personal rights:(1)To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications...and meetings of resident and family groups. This requirment was not met as evidenced by: Based on observation and interview R1 and R2 have a video monitor with audio placed in their private rooms. This poses a potential saftey, health or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 18, 2024

Plan of correction: House manager agreed to removed the recording devices in the resident rooms, and conduct a training on the use of video cameras in the facility. Proof of this is due by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jul 19, 2024

(e) All individuals subject to a criminal record review...shall prior to working...(2)Request a transfer of a criminal record clearance...This requirement was evidenced by: Based on records review, it was found that S1 was not associated to the facility. This poses an immediate, health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 18, 2024

Plan of correction: The hosue manager agreed to send a transfer for S1 by the POC due date.

Type of visit: Required - 1 Year

***Please note this report has been amended*** Licensing Program Analyst (LPA) Javina George, made an unannounced visit for the purpose of conducting a 1 year required visit/annual inspection. LPA met with Caregiver Gerald Madla where LPA explained the purpose of the visit. The facility is licensed for a capacity for (10) residents, ages 60 and up, with an approved hospice waiver for (10). There are currently (4) residents receiving hospice services. On 4/18/2023 by Escondido Fire Department approved the home for (10) non-ambulatory residents. At the time of LPAs visit there were (3) staff and (9) residents present. All staff present have obtained proper fingerprint clearance, however Staff #1 is not associated to the facility. Deficiency cited. During today's visit LPA conducted a walk through of the interior and exterior of the facility. The facility is a single story home with (10) bedrooms and (3) bathrooms. The facility was observed to be clean, clutter and odor free. The exits and passageways are free from obstruction. The resident bedrooms were observed to had have the required furniture ( bed, chest of drawers, adequate lighting, chair). There are no pools or bodies of water, or known guns or ammunition on the premises. The facility smoke and carbon monoxide detectors were tested and were found to be operable. LPA conducted a review of facility records and observed for the facility to have no record of emergency disaster drills being conducted on a quarterly basis. Deficiency cited. The facility was observed to have a 2 day supply of perishable and a 7 day supply of non-perishable food items. The medications are stored in a locked cabinet inside the hallway, the facility utilizes Medication Administration Records (MAR) to assist with tracking the administering the resident's medications. The facility is to submit a copy of current liability insurance to the regional office. The annual fees for the facility have not been paid as of today's date and are due on or before 6/21/24. LPA will provide the PIN so that the fees can be paid electronically. Based on today's inspection a citation(s) will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of this report, 809D, LIC9098-Proof of Corrections form, LIC421BGand appeal rights were provided to Gerald Madla, Caregiver.the state’s words, verbatim · CDSS document, Jun 17, 2024