Vista Harden Ranch

Allegation investigated: Staff is mismanaging resident's medications.

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to investigate the above allegations. LPA met with facility Administrator Maria Perez, and explained the purpose of today's visit. Licensing Program Analyst (LPA) conducted an interview with the reporting party, who is the resident’s physician. The physician stated that during a recent appointment, facility staff transported the resident with a medication list that included medications the resident was no longer prescribed, which had been discontinued. The physician expressed concern that the medication list was inaccurate and did not reflect current physician orders. Unsubstantiated The physician stated that due to the resident’s diagnosis, the resident was unable to reliably confirm their medications, and clarification was later obtained from the resident’s daughter the following day. The physician reported that he contacted the facility to notify staff of the discrepancies and to provide education regarding the importance of bringing the Medication Administration Record (MAR), as it more accurately reflects current medication administration. The physician stated that although the medication list was inaccurate, he did not observe any harm to the resident and was unsure whether the resident had actually been administered any incorrect medications. Based on information obtained, there is insufficient evidence to support that facility staff mismanaged the resident’s medications. 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 unsubstantiated. Exit interview conducted with facility Administrator Maria Perez, and copy of report providedthe state’s words, verbatim · CDSS document, Apr 30, 2026 · control 24-AS-20260409140057

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to conduct a Case Management. LPA met with facility Executive Director, Maria Perez, and explained the purpose of today's visit. Facility reported on March 2, 2026 at approximately 04:10 p.m. staff 1 reported to facility Executive Director they witnessed staff 2 slap resident across the face. An assessment of Resident 1 was completed immediately. Staff 2 was was suspended and removed from direct care duties pending the outcome of an investigation. LPA collected copies of Staff 2's Personnel file. Exit interview conducted with facility Executive Director, Maria Perez, and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 11, 2026

Allegation investigated: Staff did not prevent outbreak of scabies. Staff did not prevent outbreak of covid. Staff falsifying documents. Staff not wearing PPE or gloves when assisting residents with scabies. Staff does not provide assistance to residents in a timely manner resulting in falls sustaining injury(ies).

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to investigate the above allegations. LPA met with facility Administrator Maria Perez, and explained the purpose of today's visit. Regarding the allegation Staff did not prevent outbreak of scabies. LPA spoke with local county Health department who stated the facility is following required infection control guidlines. 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 unsubstantiated. Unsubstantiated Regarding the allegation Staff did not prevent outbreak of covid. LPA spoke with local county Health department who stated the facility is following required infection control guidelines. 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 unsubstantiated. Regarding the allegation Staff falsifying documents. The facility did report and document outbreak of skin rash. 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 unsubstantiated. Regarding the allegation Staff not wearing PPE or gloves when assisting residents with scabies. LPA interviewed facility staff and local health department. Interviews revealed contradicting statements on when and if gloves were needed for specific residents. 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 unsubstantiated. Regarding the allegation staff does not provide assistance to residents in a timely manner resulting in falls sustaining injury(ies). LPA reviewed records documenting some residents did have lengthy wait times when pushing pendant, however it is not clear if the waits resulted in falls with injury. 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 unsubstantiated. No deficiencies cited Per title 22 regulations. A copy of this report along with appeals rights provided.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 24-AS-20250909115322

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator Maria Perez, Continual Administrator's Certification expired 12/15/2025. Administrator is listed on CCLD Administrators certification pending applications. There are currently 73 residents who reside at this home and there is 5 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 114.6 degrees. Toxins and cleaning supplies are locked and inaccessible. LPA's reviewed a sample of staff and resident files. LPA 's reviewed facility Plan of Operation, Infection control plan, and Emergency Disaster Plan. The facilities staff files including training are not readily accessible for review. Resident 1's hospice binder did not include required training and updated hospice care plan. The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Administrator, Maria Perez and copy of report left at facilitythe state’s words, verbatim · CDSS document, Jan 29, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst's (LPA)'s Shawna Doucette and Sarah Hurt at the facility unannounced to conduct a Case Management visit. LPA's met with facility Administrator Maria Perez and explained the purpose of today's visit. During the course of complaint investigation 24-AS-20250909115322, LPA's reviewed records documenting facility signal system response times. On 08/01/2025 resident in room 137 waited 57 minutes for facility staff to respond to signal system pull chord. On 08/01/2025 resident in room 107 waited 25 minutes for staff to respond to signal pendant push. The following deficiencies are being cited Per title 22 regulations. A copy of this report along with appeals rights provided.the state’s words, verbatim · CDSS document, Jan 29, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 13, 2026

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. The following requirement has not been met as evidenced by: LPA's reviewed records documenting staff taking as long as 57 minutes to respond to resident signal system, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: Administrator will provide plan to assist residents when signal for assistance, and submit to LPA by POC date of 02/13/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Executive Director, Maria Perez , Continual Administrator's Certification expires 12/05/2025. There are currently 67 residents who reside at this home and there is 6 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The facility has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 117 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA reviewed facilities Emergency Disaster Plan, and Infection Control Plan. LPA reviewed 7 resident files, and 7 staff files. LPA reviewed hospice care plans for 2 facility residents. No deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Executive Director, Maria Perez and copy of report left at facilitythe state’s words, verbatim · CDSS document, Feb 20, 2025

Allegation investigated: Due to neglect, resident sustained stage 4 pressure ulcers.

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegations listed above . LPA met with facility Administrator, Maria Perez and explained the purpose of today's visit. Regaring the allegation Due to neglect, resident sustained stage 4 pressure ulcers. Resident 1's Progress Notes document on 07/14/2024 redness and open sore on bottom. Resident 1 was re assesed by the facility nurse on 07/14/2024. Resident 1's Progress Notes document they were to be admitted to home health .Resident 1 was seen by Home health staff on 07/17/2024 and sent to the local emergency room. Resident 1's was admitted to the emergency room on 07/17/2024 with a stage 4 sacrococcyged wound. Based on documents reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with Executive Director Maria Perez, and a copy of this report along with appeals rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Dec 5, 2024 · control 24-AS-20240725145545

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 6, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The following requirement has not been met as evidenced by: Based on records review, facility staff observed wound on resident 1 on 07/14/24, and resident 1 was admitted to hospital with stage 4 wound on 07/17/24, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: Executive Director will conduct training with facility staff on timely care and submit proof to LPA by POC date of 12/06/2024.

Allegation investigated: Facility staff did not seek medical attention for resident in a timely manner Facility staff is not adequately meeting resident care needs. Unlawful eviction.

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegations listed above . LPA met with facility Administrator, Joy Carter and explained the purpose of today's visit. Regarding the allegation Facility staff did not seek medical attention for resident in a timely manner. Resident 1 frequently refused assistance with incontinent care, and also refused to take prescribed medications. Resident 1 at times also refused to see a physician. 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 unsubstantiated. Unsubstantiated Regarding the allegation Facility staff is not adequately meeting resident care needs. Facility staff is not able to provide needed care for Resident 1, therefore they are residing at Skilled Nursing facility. Resident 1 frequently refuses care from facility staff. 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 unsubstantiated. Regarding the allegation Unlawful eviction. Resident 1 was not provided an eviction letter. The facility nurse assessed Resident 1 and it was decided their condition required a higher level of care. 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 unsubstantiated. Exit interview conducted with facility Administrator, Joy Carter and copy of this report along with appeals rights provided.the state’s words, verbatim · CDSS document, Nov 23, 2024 · control 24-AS-20240426114057

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 7, 2024

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility (4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by: Reporting Party provided photos of several medications throughout Resident 1's bedroom, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 23, 2024

Plan of correction: Facility Administrator agrees to conduct training with facility medication technicians on medication administration and submit to LPA by POC date of 12/07/2024.

Allegation investigated: Staff did not follow resident's physician's order regarding medications

On 01/24/24, Licensing Program Analysts (LPAs) L. Salazar and Sarah Hurt arrived to the facility unannounced to deliver findings on the above allegation. LPAs met with Joy Carter via telephone and stated the purpose of the visit. During the investigation, LPA S. Hurt observed Centrally Stored Medication Destruction (CSMDR) from 04/04/22, which shows the medication in question, was given per the physician's orders. LPA Hurt also observed the active medication list that was faxed from R1's physician on 03/30/22. Facility communication logs show the responsible party (RP) for R1, contacted Staff S1 on 08/17/22 for an update on resident's medication being discontinued. S1 informed RP the facility did not receive any changes for R1's medications to be changed. S1 advised RP to contact R1's physician and request the order of discontinuation be faxed to the facility if medication is discontinued. On 08/18/22, facility received discontinuation order from R1's physician. On 08/18/22, the medication was discontinued on 08/18/22. Based on the information received, we have found that the complaint is Unfounded, meaning that the allegation is false, could not have happened, and/or is without reasonable basis, therefore, we have dismissed the complaint. Exit interview conducted. A copy of this report was provided at the time of visit. Nothe state’s words, verbatim · CDSS document, Jan 24, 2024 · control 24-AS-20240110113508

Allegation investigated: Resident sustained unexplained injury in care.

Licensing Program Analysts (LPA's) Sarah Hurt and Lisa Salazar conducted an unannounced facility visit deliver findings on the above allegations. LPA met with facility Administrator, Joy Carter over the phone and explained the purpose of today's visit. Regarding the allegation Resident sustained unexplained injury in care. Facility Resident 1 did sustain an unexplained injury at the facility on 08/14/23. The facility did seek medical care for Resident 1 in a timely manner. LPA reviewed Resident`R1's Physicians report that does not indicate R1 is in need of 1:1 staffing. 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 unsubstantiated. No deficincies cited Per 22 Regulations. Exit interview conducted with Administrator, Joy Carter, and a copy of this report left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 24, 2024 · control 24-AS-20230829083953

Allegation investigated: Staff did not ensure a safe and healthful environment for residents during an electrical outage Staff left resident on floor for an extended period of time Staff did not respond to residents pendent Staff do not safeguard residents personal belongings

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegations listed above. LPA met with facility Business Office Director, Maria Perez and explained the purpose of today's visit. Regarding the allegation Staff did not ensure a safe and healthful environment for residents during an electrical outage. The facility conducts Disaster drill trainings and has specific protocols on how to handle electrical outages including hourly checks on residents. LPA interviewed four facility residents and a majority agreed the facility staff does ensure a safe and healthful environment during electrical outages. 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 unsubstantiated. Continued.. Unsubstantiated Continued.. Regarding the allegation staff left resident on floor for an extended period of time. Resident 1 stated during the first power outage that occurred in July 2023 the facility staff did not conduct checks timely. Resident 1 stated they did fall, and was finally able to get up on their feet by themselves after being on the floor for hours. LPA Hurt interviewed facility staff 1 present during the power outage, who stated they clearly remember doing hourly checks during the power outage and observing Resident 1 in bed during checks. Staff 1 stated there was no alarm alerting caregivers Resident 1 pushed their pendant requesting assistance during the outage. Based on conflicting information provided it is not clear how long Resident 1 was on the floor during the power outage. 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 unsubstantiated. Regarding the allegation Staff did not respond to residents pendant. Facility residents’ pendants do work during power outages. Staff 2 stated the caregivers do get alerts if someone pushes their pendant during an outage, and there was no indication Resident 1 pushed their pendant to alert staff of a fall. Staff 1 stated a report was printed the day after the power outage and there was no record of Resident 1 pushing their pendant. 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 unsubstantiated. Regarding the allegation Staff do not safeguard residents personal belongings. Reporting party stated they are missing several personal items including expensive T-shirts and clothing. LPA Hurt reviewed Reporting Parties “Client/ Resident Personal Property and Valuables” LIC 621. Reporting Party did not list any specific expensive t-shirts on the form. 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 unsubstantiated. No deficiencies cited Per Title 22 Regulations. Exit interview conducted with Business Office Director, Maria Perez, and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 12, 2024 · control 24-AS-20230727085845

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA's) Sarah Hurt and Lisa Salazar conducted an unannounced visit today for the facility’s annual inspection. LPA's met with Business Office Manager, Maria Perez Continual Administrator's Certification for Joy Carter expires 01/11/2025. There are currently 73 residents who reside at this home and there is 11 residents on hospice at this time. LPA's inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The facility has a carbon monoxide detector. Water temperature was tested at 113 degrees. Toxins and cleaning supplies are locked and inaccessible. Facility dementia training records and updated and complete. LPA's ensured all facility staff is background cleared. LPA's observed the kitchen ice machine has black discoloration on the top inside. LPA's observed the facility soda machine inside the kitchen needs cleaning. LPA's observed first aid kits to be located throughout the facility, but not all are complete. LPA's reviewed facility records for 4 Memory care residents. Resident 1, Resident 2, Resident 3, and Resident 4 did not have current updated medical assessments. The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Office Manager, Maria Perez and copy of report left at facilitythe state’s words, verbatim · CDSS document, Dec 5, 2023

Allegation investigated: Staff did not provide proper notification of rate increase.

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint investigation. LPA met with facility Administrator, Joy Carter and explained the purpose of today's visit. Regarding the allegation. Staff did not provide proper notification of rate increase. The facility did send letters to residents and their responsible parties documenting a rate increase with an incorrect effective date, and incorrect rate increase amounts. The dates of the rate increase was corrected, and new letters sent out to residents and their responsible parties. However the amounts of the rate increase on the second letter was still incorrect. A third round of letters went out with the correct rate, and effective date. Continued.. Unfounded Continued.. The rate increases will go into effect beginning February 1, 2024 more than 60 days after the corrected letters were sent to residents and their responsible parties. The facility did admittedly send out incorrect letters in error but it was communicated to residents, and no resident paid any increased amount. Based on interviews, and records reviewed during this investigation we have found that the complaint was unfounded, meaning that the allegation is false, could not have happened and/or is without reasonable basis, therefore, we have dismissed the complaint. No deficiencies are being cited today Per Title 22 Regulations. Exit interview conducted with Administrator Joy Carter and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 28, 2023 · control 24-AS-20231122121138