Virtud Care

Allegation investigated: - Staff are overmedicating residents - Residents in care sustained unexplained bruises - Residents are showed with cold water - Staff handled residents in a rough manner - Staff yelled at a resident in care - Staff took away resident's personal cell phone

On this day, Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted by facility staff, granted entry, and informed them of the purpose of the visit. Administrator (AD) Geisel Sanchez arrived shortly to assist with the visit. The Department received a complaint on March 5, 2024. During the investigation, LPA Tea conducted interviews with facility staff, residents, and a witness, and reviewed facility records, resident documentation, and other relevant information. It was alleged that staff are overmedicating residents. Three staff members and one witness denied the allegation. Staff stated that medications are administered strictly in accordance with physician orders and that they are trained to follow those orders at all times. One resident interviewed did not support the (Complaint investigation continued on LIC9099C) Unsubstantiated allegation. The witness also indicated that the facility follows proper medication procedures. AD Sanchez reported that nurses regularly visit the facility and that any medication changes are made promptly with physician authorization. It was alleged that residents sustained unexplained bruising. Three staff members and the witness stated that some residents bruise easily due to fragile skin and medical conditions, including the use of blood thinners such as aspirin. Staff reported that they handle residents gently during care. The witness confirmed that one resident bruises easily. AD Sanchez stated she routinely monitors residents for bruising. It was also reported that one resident recently returned from the hospital with bruising caused by blood draw attempts. One resident interviewed denied experiencing unexplained bruising. It was alleged that residents are showered with cold water. Three staff members and the witness denied the allegation. Staff stated that residents are provided with warm showers and that hospice aides or home health nurses often assist with bathing while ensuring appropriate water temperature. Residents interviewed confirmed they have not received cold showers. AD Sanchez stated that staff prioritize resident comfort and use towel warmers to provide warm towels after bathing. It was alleged that staff handle residents in a rough manner. Three staff members and the witness denied the allegation and stated that care is provided in a gentle manner. The witness confirmed that staff treat residents with care and respect. AD Sanchez stated she maintains a zero-tolerance policy for rough handling. Three out of three residents interviewed confirmed they have not been handled roughly. It was alleged that staff yelled at residents. Three staff members and the witness denied the allegation. Staff explained that they may occasionally raise their voices due to residents’ hearing impairments but do not yell. The witness stated that staff demonstrate patience when interacting with residents. AD Sanchez reported that staff are trained to communicate respectfully and have not observed staff yelling. Residents interviewed confirmed that staff do not yell at them. One resident identified in the complaint as having been yelled at by Staff 1 (S1) stated that staff are very nice and do not yell. S1 also stated that they have never yelled at residents and expressed that they care deeply for the residents, describing them as their “babies.” It was alleged that staff took a resident’s personal cell phone. Three staff members and the witness denied (Complaint investigation continued on LIC9099C) the allegation. Staff stated that the facility advises residents’ families not to keep valuables exceeding $25 at the facility and noted that many residents are not fully alert or cognitively able to use cell phones. The witness confirmed that no resident’s phone was taken. AD Sanchez stated that residents typically do not have personal phones and reported that, in one instance, a family member removed a resident’s phone due to declining health. Although the complaint alleged that S1 took a resident’s phone, there is no evidence to support this claim. S1 reported that the resident frequently misplaced their phone due to forgetfulness. At one point, the resident’s grandson located the phone in the resident’s walker during a visit. After that, the family removed the phone due to the resident’s declining health and cognitive condition. Based on LPA Tea’s observations, interviews conducted, and records reviewed, the above allegations are determined to be UNSUBSTANTIATED, meaning that although the allegations may have occurred or may be valid, there is not a preponderance of evidence to prove that the alleged violations occurred. No deficiencies were cited at this time. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 22-AS-20240305154314

Allegation investigated: Facility is operating under unsanitary conditions. Facility is not in good repair.

On October 23, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purpose of conducting a subsequent complaint investigation visit into the above allegations. LPA announced self and stated the purpose of the visit to staff. Licensee (LI) Geisel Sanchez shortly arrived on site to assist with the investigation. On August 26, 2025, LPA initiated the complaint investigation. During the visit, LPA toured the facility accompanied by staff and obtained the following documentation: Resident/Staff Rosters, Personnel Record (LIC500), and fire drill training. The following was determined based on observations: Regarding the allegation, Facility is operating under unsanitary conditions, it was reported that mold was present in the restrooms and underneath the kitchen sink, and dog feces were not removed from the back yard. CONTINUE TO LIC809-C.... Substantiated During the tour of the facility on August 26, 2025 with LI, LPA observed a dead fish inside the dirty/cloudy fish tank, and on the cabinet floor under the kitchen sink and Resident (R1's) bathrooms as evidenced by photos attached. In the back yard, LPA observed dog feces in 5-6 different areas, three large garbage cans full of trash, and directly next to the trash cans, were two large full garbage bags filled with trash stored along the brick fence. Staff #1 (S1) stated they called the garbage company to schedule a pickup but could not provide a date. Based on observations and interview, it was determined that the facility had at least 7 days of overflowing trash which was corroborated by S1. Regarding the allegation, Facility is not in good repair, it was reported that there is water leaking in the cabinet below the kitchen sink and behind the sink in the main bathroom utilized by residents; and moisture in two walls in two out of six bedrooms. Reporting Party could not identify which bedrooms contained moisture in walls. During the initial visit, LPA observed water stains on the wall of the cabinet under the sink, but did not observe a leak at the time. LPA did not observe mold or moisture in either bathrooms or any of the bedrooms. However, LPA observed two out of two sinks in the bathrooms in which the water did not drain properly and quickly filled up to the top of the basin. One window screen in the Resident 1 (R1's) bathroom was missing and the window screen of Resident 2 (R2's) room was damaged with a 1 inch hole. The roof of the garage is made of wood planks and LPA observed water stains in multiple areas of wood. Water stains were also observed on a ½ built wall below the roof and on the full walls below it. The paint on walls below it were peeling and in need of repair. The damage in the garage was observed during inspection on both August 26, 2025 and October 23, 2025. Based on observations made during the investigation, the preponderance of evidence standard has been met, therefore the allegations, The facility is operating under unsanitary conditions and Facility is not in good repair are deemed SUBSTANTIATED. See the attached LIC9099-D. An exit interview was conducted with Licensee Geisel Sanchez, and a copy of this report, LIC9099-D, LIC811 and appeals rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 22-AS-20250819161759

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a-c) · Plan of correction due date: Oct 31, 2025

87303(a)The facility shall be clean, safe, sanitary and in good repair at all times..... (c) All window screens shall be clean and maintained in good repair. This is evidenced by: Based on observations, the licensee did not comply with the section cited above, which poses a potential risk to persons in care. LPA observed a dirty/cloudy fish tank, floor of the cabinets under the kitchen sink and R1's bathroom sink were dirty, a damaged window screen in R2's bedroom, roof and wall damage in garage, and animal feces in multiple areas in back yard.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: Licensee stated they will remove fish tank, clean under sinks and back yard, replace window screens and meet with landlord to make repairs to garage and submit proof to CCLD by POC due date. During visit on 10/23/25, LPA observed fish tank no longer present at facility, garage has been picked up, and window screen replaced.

Type of visit: Case Management - Other

On August 26, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted a case management deficiency visit unrelated to allegations of complaint #22-AS-20250819161759 During the complaint visit, LPA tested water temperature and observed the water temperature measure at 129.3 degrees F in the main bathroom used by residents. Licensee stated they plan to purchase new water heater. A deficiency was cited by Title 22 Division 8 Chapter 8. An exit interview was conducted, and a copy of this report, LIC809-D, and appeal rights was provided to Licensee Geisel Sanchez at exit.the state’s words, verbatim · CDSS document, Aug 26, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Aug 27, 2025

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal .... shall be maintained to automatically regulate the temperature of hot water used by residents...not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). Based on observation, the licensee did not comply with the section cited above in one out of two bathrooms, which poses an immediate health and safety risk to persons in care. LPA observed the water temperature measure at 129.3 degrees F in the main bathroom used by residents. Licensee stated they plan to purchase new water heater.the state’s words, verbatim · CDSS document, Aug 26, 2025

Plan of correction: Licensee made adjustments to hot water during visit. Licensee stated they will keep temperature logs for resident bathroom every two hours for the next 24 hours and submit logs and pictures to CCLD via email by 5pm on POC due date.

Type of visit: Required - 1 Year

On July 2, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted and granted entry by Caregiver (CG) Sayra Ocampo. Administrator (AD) Geisel Sanchez arrived at the facility around 9:00am. The facility is licensed to operate for five (5) non-ambulatory and one 1 bedridden, with a hospice waiver for six (6) residents. The home consists of 6 resident bedrooms, 1 staff resting room, 1 office space, 2 bathrooms, living room, dining room, and kitchen. LPA Bentley toured inside and outside of the physical plant with AD Sanchez. There were no bodies of water or obstructions on the premises. A comfortable temperature of 74 degrees F was maintained in the facility. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The resident bedrooms were inspected and contained all the required elements. Bathrooms were found to be clean and operational. The water temperature measured at 79.8 degrees F in the main bathroom used by residents. The other bathroom used by staff, measured between 117.5 to 118.5 degrees F. A deficiency was cited for water temperature in bathroom used by residents in care. LPA Bentley observed the facility to be sanitary and appropriately furnished at the time of visit. CONTINUE TO LIC809-C Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not 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. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade and one exit gate on the right side of the facility is self-latching and operational. LPA observed a pad lock on gate which was removed during the visit. During the visit, LPA Bentley observed the smoke detectors and carbon monoxide detectors were operable. A working telephone (714-583-8441) remains available, and the facility has a device that can be used for video teleconference purposes. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has two (2) fire extinguishers that were charged, mounted in the kitchen and hallway, and serviced on October 10, 2024. Emergency safety drills was last conducted on March 17, 2025 and are conducted quarterly. First aid kit is maintained and contains all the necessary elements. Liability Insurance is effective 7/30/2023 and expired on 7/30/2024. Licensee stated they do not currently have liability insurance but has plans to obtain new policy in July 2025. LPA Bentley conducted an audit of four (4) resident files (R1-R4), four (4) staff files (S1-S4), and medication and medication administration records were reviewed. LPA Bentley conducted staff iand resident interviews. Administrator Geisel Sanchez has an administrator certificate that expires on February 12, 2026. Based on observations, deficiencies are being cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. An exit interview was conducted, a copy of this report, LIC809D and appeal rights were provided to Administrator Geisel Sanchez.the state’s words, verbatim · CDSS document, Jul 2, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by administrator, Geisel Sanchez and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for six and bed-ridden for one. Currently there are six residents, of which four are on hospice during today's visit. LPA Tea along with the Administrator toured the facility at 2:18 PM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 5 resident bedrooms, 1 staff resting room, 1 office room, 2 bathrooms, living room, dining room, and kitchen. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured around 109.5 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen cabinet. LPA also observed toxin substances to be locked and inaccessible to clients in care locked and secured in cabinets in the garage. The fire extinguishers throughout the facility were fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade and one exit gate on the right side of the facility is self-latching and operational. LPA observed emergency supplies, food and water in the garage. Facility provides activities based on resident interests. The residents watch television, listen to music, reading books and newspapers and completing puzzles. At the time of annual visit, residents were seen playing cards and doing puzzles. Continuation of annual inspection on LIC-809C LPA Tea reviewed six resident files and one staff file. There were discrepancies noted in the review of resident and staff files. Administrator certificate expired on February 12, 2024 however administrator has complied with all course work and is pending renewal at this time. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order but not properly documented. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Gloria Sanchez and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, 9102 and Appeal Rights.the state’s words, verbatim · CDSS document, Jul 16, 2024

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

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit in conjunction to a 10 day inspection visit for complaint control #22-AS-20240305154314. LPA Quiroz was greeted and granted entry into the facility by Licensee/Administrator (L/AD) Geisel Sanchez and explained the reason for the visit. During today's visit, LPA Quiroz along with (L/AD) Sanchez conducted a tour of the interior and exterior of facility premises. While conducting facility tour, LPA Quiroz observed 7 residents in care. (SEE LIC 809-D) The Facility is licensed to operate a Residential Care Facility for the Elderly, age range 60 and over. Fire Clearance for five (5) non-ambulatory residents and one (1) bedridden resident in room #1 and has a hospice waiver approved for six (6) residents. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. Civil penalty assessed during today's visit. (SEE LIC 421-IM) An exit interview was conducted with (L/AD) Sanchez, and a copy of this report, 809-D Page, Civil Penalty, and Appeal Rights were provided at exit.the state’s words, verbatim · CDSS document, Mar 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: Mar 8, 2024

87204(a)Limitations - Capacity and Ambulatory Status(a)A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons...This requirement is not being met as evidenced by: CONT During today's inspection visit, LPA Quiroz observed 7 residents in care. The facility iis licensed for a capacity of 6 residents Fire Clearance for five (5) non-ambulatory residents and one (1) bedridden resident in room #1 and has a hospice waiver approved for six (6) residents.the state’s words, verbatim · CDSS document, Mar 7, 2024

Plan of correction: (L/AD) Sanchez relocated R1 to Sister Facility VIRTUD CARE LLC II #306006211 at 12:00pm. Corrected during today's visit. Civil penalty assessed during today's visit. This poses an immediate risk for residents in care.