Wesley House III

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Hilda Ortiz, caregiver. The purpose of the visit was to amend a report originally delivered to the facility on 01/26/2026. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Hilda Ortiz and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 18, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Janet Leon. During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured the facility bedrooms and observed each bedroom had working lights and available bedding and clothing storage areas. LPA tested the smoke and carbon monoxide detectors in the hallways and resident rooms and observed that they all functioned properly when tested. LPA toured two out of two resident bathrooms and observed each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks measured at 109 F and 110 F. LPA toured the outside area and observed the outdoor exits to be clear of obstructions.LPA reviewed six out of six resident records and five staff records and found them to be complete. LPA reviewed the first aid kit and found it to be complete. The last fire drill was conducted on 01/16/2026. LPA requests that the following records be updated and copies sent to the department by 02/17/2026: LIC500 Personnel Report LIC308 Designation of Administrative Responsibility LIC610 Emergency Disaster Plan No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Janet Leon and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 10, 2026

Allegation investigated: Staff did not provide adequate care and supervision to the residents

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Janet Leon, Administrator. On 10/14/2025, the department received a complaint with the above allegation. On 10/23/2025, LPA Marrufo conducted an initial complaint investigation visit. When the department received the complaint, witness W1 alleged to have visited the facility on 10/09/2025 to visit resident R1. W1 reported that W1 observed R1 to begin to stand up and show signs of confusion. W1 then called out for a staff to help, but received no response. W1 stated R1 began to walk away from W1 and R1 tripped, but W1 was able to stabilize R1 and present R1 with his/her walker. R1 then began to walk to the restroom. W1 then began to continue to call out to staff for assistance while walking throughout the house but received no response. See LIC9099-C page for more information. Page 1 of 3. Substantiated W1 observed two other residents by themselves. W1 then went to Wesley House II, which is next door to the facility and owned by the same licensee, and called for help. W1 states a staff then ran to the facility and assisted R1 in the restroom. During visit on 10/23/2025, LPA Marrufo obtained a copy of R1’s Physician’s Report. R1’s Physician’s Report states R1 requires standby assistance while toileting and R1 can ambulate with assistance. On 11/14/2025, LPA Marrufo conducted a telephone interview with staff S1. S1 stated that around either November or December of 2025, S1 was working a shift at Wesley House II. S1 stated S2 was working a shift at Wesley House III at the same time. S1 stated that at around 2:00 PM, S2 left Wesley House III to go to the bank without notifying S1 that S2 was leaving the facility. S1 stated to have gone to Wesley House III to check if S2 needed help but did not find S2. S1 observed S2 returning to Wesley House III. Then, S1 returned to Wesley House II. S1 also stated that there was another occasion when S2 left Wesley House III to pick up medications and S1 provided supervision to both Wesley House II and Wesley House III alone at the same time for about an hour. On 01/26/2026, LPA Marrufo conducted a telephone interview with S3. S3 stated that there have been times when S3 has been the only staff on duty for both Wesley House II and Wesley House III. S3 stated that the last time S3 had to provide supervision to both facilities alone was around two to three years ago. On 01/26/2026, LPA Marrufo conducted an interview with witness W2. W2 stated to have observed times when there are no staff present at Wesley House III. W2 stated the staff working in Wesley House III will leave the facility unsupervised to help the staff in Wesley House II move a resident who requires two staff. Page 2 of 3. **This report was amended on 02/18/2026 to add "An immediate civil penalty of $500 is being assessed for absence of supervision."** W2 stated to have been present at the facility and to have not observed any sounds of any facility staff at the facility. W2 stated to have later seen S2 in the facility. W2 stated that S2 told W2 that S2 had gone to the pharmacy to pick up medications for S2. W2 stated that he/she told S1 that S2 told W2 that S2 had left the facility to pick up medications for S2. Based on records review and interviews, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated. See 9099-D for deficiencies cited per the California Code of Regulations, Title 22. An immediate civil penalty of $500 is being assessed for absence of supervision. This report was reviewed with Hilda Ortiz and a copy of this report and appeal rights were provided. Page 3 of 3. END REPORTthe state’s words, verbatim · CDSS document, Jan 26, 2026 · control 26-AS-20251014102101

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jan 27, 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. This requirement was not met as evidenced by: **Amended on 02/18/2026 to issue immediate civil penalty of $500** Based on interviews with two witnesses and two staff, there have been times when there were no staff present in the facility to provide the services necessary to meet resident needs, which poses an immediate safety risk to residents in care. **An immediate civil penalty of $500 is being assessed for lack of supervision**the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: Licensee agrees to submit a plan of correction by 01/27/2026 stating how the licensee will ensure that there is a sufficient number of staff at the facility at all times, including when residents from the neighboring facility, Wesley House II, need two staff to assist them with care.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Janet Leon. The purpose of the visit was to issue a deficiency citation to the facility for advertising dementia care services without having a facility dementia care plan in the facility program design. LPA Marrufo reviewed the facility file on 04/25/2025 and observed that the facility did not have a dementia care plan in its program design. The program design's "Prior to Admission" section states, "Will accept ambulatory and non-ambulatory, diet problems, diabetic, arthritis, and general aging.” The facility website states, "Accommodation: Secure Living Program - Dementia / Alzheimer's Care" During visit, LPA Marrufo obtained copies of Physician's Reports for residents R1-R4, whose Physician's Reports stated they had a diagnosis of dementia. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with Administrator Janet Leon and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(b) · Plan of correction due date: May 7, 2025

Plan of Operation 87208(b) A licensee who advertises or promotes dementia special care, programming, or environments shall include additional information in the plan of operation as specified in Section 87706, Advertising Dementia Special Care, Programming, and Environments. This requirement was not met as evidenced by: Licensee did not ensure that while the licensee advertised dementia care services on the facility website that there was also a Dementia Care Plan in the facility Plan of Operations, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 30, 2025

Plan of correction: Licensee agrees to submit a Dementia Care Plan to the department by Plan of Correction Date. **Deficiency Cleared During visit. Dementia Care Plan submitted to CCL on 04/29/2025**

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Janet Leon. During visit, LPA toured the kitchen and food storage areas. LPA observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA reviewed the first aid kit and observed it to be complete. LPA toured two out of two resident bathrooms. Each bathroom had working lights and available soap and paper towels. The bathroom sinks had water temperatures at 109 F and 111 F. LPA toured five out of five resident bedrooms. Each bedroom had available bedding and clothing storage areas. Each bedroom had working lights. LPA tested the smoke and carbon monoxide detectors in the facility and the detectors functioned properly when tested. LPA reviewed six out of six resident records, including Centrally Stored Medication and Destruction Records, and found them to be complete. LPA reviewed five staff records and found them to be complete. LPA reviewed the Emergency Disaster Drill Log, which indicated that the last emergency disaster drill was conducted on 11/05/2024. No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Janet Leon and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 14, 2025

Allegation investigated: Staff violated resident's personal rights

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Janet Leon, Administrator. On 09/26/2023, the facility received a complaint with the above allegation. On 10/05/2023, the Department conducted an initial complaint investigation visit and conducted an additional visit on 12/07/2023. LPA Marrufo interviewed facility staff and Administrator, resident R1's Family Members F1 and F2, and R1's Hospice Nurse Case Manager N1. LPA Marrufo obtained copies of resident and facility records. Resident R1’s Admission Agreement was signed 08/09/2023 by resident’s Responsible Party. The Admission Agreement Visitation Policy states, “The facility is open for visiting from 10 AM to 4 PM. See LIC9099-C for more information. Page 1 of 2. Unsubstantiated Additional visiting hours before or after these hours will be accommodated with prior arrangements being made with the office.” R1’s Death Report was submitted to the Department on 08/16/2023 and states R1’s date and time of death as 08/14/2023 at 9:30 PM. The facility visitation log states that R1’s Family Members, F1 and F2, visited the facility on 08/14/2023 at 9:35 AM and at 3:30 PM. During interview, Reporting Party stated Administrator verbally agreed to allowing Resident’s family to visit from 5PM-7PM each day. During interview, Administrator stated to have communicated with Resident’s Responsible Person that facility visitation hours are from 10AM-4PM and family usually visits for 1-2 hours. Administrator stated Resident R1's family members would stay from 10 AM, then lunch, and come back from 1 PM to 6 PM. Administrator stated the family visits outside of normal visiting hours were interfering with the care of the resident. Administrator stated to have discussed the visiting hour policy with R1’s family members multiple times. Administrator stated during interview that on the day Resident passed on 08/14 at 9:30 PM, Administrator noticed at 6PM that Resident was visibly taking shorter breaths and notified Resident R1's family and hospice. Administrator stated to recall that F1 and F2 arrived at the facility after Administrator called F1 to notify F1 that R1 was near death. Administrator stated F1 and F2 arrived at the facility, but does not recall at what time exactly they arrived. Administrator states F1 and F2 both visited R1, but does not recall the duration that they visited R1. Administrator stated F1 and F2 told Administrator that they would be leaving to go to dinner, and F1 and F2 never returned that night. Administrator stated R1 passed away at 9:30 PM and hospice didn’t arrive and pronounce R1 deceased until 11:30 PM. Administrator stated F1 arrived at the facility sometime in the afternoon on 08/15/2023 to pick up R1’s belongings. Page 2 of 2. During interview, R1’s Family Member, F1, stated to have not been notified of R1’s passing until 11 PM on the night of R1’s passing. F1 stated that the hospice nurse notified F1 of R1’s passing. F1 stated to have not been present with R1 at the facility while R1 was passing. R1’s Family Member F2 stated to have not been notified prior to R1’s passing that R1 was near becoming deceased. F2 stated to believe to have visited R1 the day R1 deceased, and staff told F2 that F2 could not visit past 6 PM. F2 stated to have stopped visiting R1 at 6 PM the night of R1’s passing and R1 passed away later that night. During interview, Hospice Nurse N1 stated R1 moved into the facility on 08/09/2023 and was noted to be declining and transitioning to death on 08/10/2023. Hospice Nurse N1 stated to have arrived at the facility on 08/14/2023 at 11:15 PM and confirmed R1 was deceased. N1 stated to have then notified F1 that R1 had deceased. During interview, staff S1 stated to have worked the night shift on the night of R1’s passing and started working that night at 6 PM. S1 stated to not recall any of R1’s family members at the facility during the time of R1’s passing. Based on information from interviews conducted with staff, family members, and witnesses, and records reviewed, although the allegation listed above may have happened or are 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 under California Code of Regulations Title 22 This report was reviewed with Administrator Janet Leon and a copy of this report was provided. Page 3 of 3. END REPORT During interview, Administrator stated the staff turned the R1 and tried to keep R1 comfortable as much as possible. Administrator stated the hospice nurse verified with Administrator and staff that Resident was too brittle to sit on a commode or to be moved from the hoyer lift to the commode. Administrator stated the hoyer lift was never used. During interview, Hospice Nurse N1 stated R1 moved into the facility on 08/09/2023 and was noted to be declining and transitioning to death on 08/10/2023. N1 stated It is generally not recommended to take someone out of bed when they are in their stage of actively declining towards death for reasons of safety and comfort. R1’s Admission Agreement was signed on 08/08/2023 and R1 moved in to the facility on 08/09/2023. R1 passed away on 08/14/2023. During interview, R1’s Family Member F1 stated to have moved R1’s belongings out of the facility shortly after 12:00 AM on 08/15/2023. LPA Marrufo obtained a copy of R1’s Processing Fee Agreement, which was signed and dated on 08/08/2023 by R1, R1’s responsible party, and Administrator. The document states that the facility processing fee for R1 of $9,500 covers the administrative costs of admitting the resident into the facility and is non-refundable. LPA Marrufo obtained a copy of R1’s Cost of Care document, which states R1’s cost of care for the first 30 days of residency at the facility was $8,000 and was fully paid. LPA Marrufo obtained a copy of the check made from the facility to R1’s Family Member F1 on 09/04/2023 for $6,133.33. Administrator stated to have arrived at the check amount of $6133.33 by calculating the daily costs of care, which at $8,000 for 30 days comes out to $266.66 a day and counting from the initial day R1 moved into the facility, which was 08/09/2023 to the day R1’s belongings were moved out of the facility, which was 08/15/2023, which amounts to $1,866.66 and subtracted that amount from the $8,000 for 30 days of care, which amounts to $6,133.33, the amount of the check. Page 2 of 2. This agency has investigated the complaint allegations listed. Based on interviews and review of records, the Department has found that the complaint allegations are unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This report was reviewed with Administrator Janet Leon and a copy of this report was provided. Page 3 of 3. END REPORTthe state’s words, verbatim · CDSS document, Feb 27, 2024 · control 26-AS-20230926140323

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Janet Leon. During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed the facility kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least 7 days. LPA Marrufo toured 4 out of 4 resident bedrooms and observed each bedroom to have available bedding and clothing storage areas and functioning lights. LPA Marrufo tested the smoke and carbon monoxide detectors and they functioned properly when tested. LPA Marrufo toured 2 out of 2 resident bathrooms and observed each bathroom had water temperature at 105 F. Each bathroom had available soap and paper towels and working lights. LPA Marrufo toured the outside area and observed the exits to be clear of obstructions. LPA Marrufo toured the resident records and Centrally Stored Medication Logs and found them to be complete. LPA Marrufo reviewed staff records and found them to be complete. No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Janet Leon and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 26, 2024