Yerba Buena Residential Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Noel Marayag, designee arrived later. Angelica Martinez Administrator Certificate 7000290740 expires 4/10/27. At approximately 9:15am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 113.1 in room #1 half bath, 116.3 degrees F in main bath, 105.9 degrees F in the back bath, all of which are within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 9/15/25. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted April 2026. At approximately 10:30am LPA conducted a review of six (6) resident records. All documentation present. However, physician's report for resident (R1) was not signed or dated by the physician. LPA advised to be sure to review the physician report signature pages to make sure they are signed. No deficiencies cited. Continued on 809C... Continued from 809... At approximately 11:00am LPA conducted review of five (5) staff records. Staff (S1) did not have a Health Screen on file; however S1 did have TB clearance on file. Staff S2 and S4 did not have required number of continuing annual training hours completed (deficiency cited, see 809D). Staff S2, S3, S4, and S5 did not have the required medication training completed (deficiency cited, see 809D). At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. Resident (R2) medication count off; prescription Lisinopril count of 100 was started on 4/2/26 but 16 pills remain (deficiency cited, see 809D). Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with designee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with designee and a copy of this report was given.the state’s words, verbatim · CDSS document, Jun 30, 2026

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Angelica Martinez. At approximately 9:35am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. LPA observed frozen milk. LPA discussed with Admin reason for freezing milk. LPA advised best practices not to freeze milk as it can cause the fat and protein to separate and affect the flavor and texture as well. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. Room #2 was found to have a soiled brief in an uncovered waste basket as well as urine present in an uncovered bedside commode (deficiencies cited, see 809D). Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents measured at 117.5 and 115.7 degrees F which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 9/23/24. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted November 2024. LPA advised to be sure to conduct disaster drills quarterly. Continued on 809C... Continued from 809... At approximately 10:30am LPA conducted a review of 6 resident records. Hospital beds, half rails, and postural support poles all observed in resident rooms, but doctor orders for these items missing for some residents. LPA observed written communications from Admin to various doctors requesting the orders, but executed orders not on file for some residents. At approximately 11:30am LPA conducted review of 5 staff records. Staff S1 and S2 had recently expired CPR, expired 6/26/25, however all other staff current. Staff S2, S3, S4 did not have required number of training hours completed (deficiency cited, see 809D). At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. LPA advised to be sure to keep all discontinuation papers on file for each resident. LPA observed pre-poured medications present in medication room for most residents (deficiency cited, see 809D). Angelica Martinez Administrator Certificate 7000290740 expires 4/10/27. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 9, 2025

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff hit resident in care

At approximately 1:00pm, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegation and met with caregiver. Angelica Martinez, Administrator contact by phone. Admin was not available to come to facility. Admin gave permission for caregiver to sign. Complaint alleges staff hit resident in care. Complainant states that facility Administrator pushed and hit resident (R1). During investigation, LPA reviewed R1’s chart notes dated between 1/1/2024 through 10/1/2024 and interviewed staff and residents. LPA’s review of R1’s chart notes indicate four [4] noted incidents of aggression and two [2] incidents of hitting staff. Three [3] out of three [3] staff interviewed report to LPA that resident has episodes of aggression and has lashed out and hit other residents and staff, including the facility Administrator. During investigation, LPA interviewed resident R2, R2 indicated that R1 has hit them and also has hit resident R3. Continued on 9099C... Unsubstantiated Continued from 9099... During investigation, LPA reviewed outside agency statement which reports that resident has history of being verbally and physically aggressive towards facility staff, a history of making false allegations, and that resident is noted to be an unreliable historian. So, 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 from 9099A... During investigation, LPA reviewed R1’s care plans. R1’s care plans indicate that the resident is independent and likes to go on walks and enjoys being outside. During investigation, Admin reported to LPA that she knows R1 likes to be outside and go on walks, it helps to de-escalate R1’s aggression, among other positive benefits. As a safety measure and precaution, Admin pro-actively purchased a GPS tracker for R1 to wear when going on walks so that if R1 is gone longer than 10 minutes, R1’s location can be quickly determined. Admin purchased this GPS with family of R1’s approval. During investigation, LPA reviewed the four [4] most recent physician’s reports and care plans for R1. Three [3] out of four [4] of the physician’s reports reviewed indicate that the resident can leave the facility unassisted, for short walks outside. However, the most recent physician’s report indicates a change in R1’s assessment of leaving the facility unassisted, the most recent physician’s report indicates that the resident cannot leave the facility unassisted. Admin advised LPA that Admin must have accidentally overlooked this change in the most recent physician’s report section that indicates that the resident cannot leave the facility unassisted. So, the caregiver allowed R1 to briefly be outside unsupervised, as the caregiver was not aware of the change in R1’s physician report. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099Dthe state’s words, verbatim · CDSS document, Oct 29, 2024 · control 21-AS-20241004090128

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 30, 2024

87411(a) 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 by licensee as evidenced by: elopement of R1, which poses an immediate potential health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Facility to submit LIC9098 self-certifying they have reviewed all of the most recent physician reports of residents and will ensure all staff are aware of the abilities and needs of all residents.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Christi Coppo and Jacky Macias arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Angelica Martinez, Administrator arrived later. At approximately 9:15 am LPAs and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Some food items were found to be expired or showing signs of expiration such as: Several heads of cauliflower found to have several brown and black spots, sandwich bag containing black avocado, bag of tomatoes with 3 tomatoes showing black spots and white rings, applesauce pouches with expiration date of 5/31/24, head of cabbage/lettuce in bag with brown liquefication, box of snack packs of jello with expiration of 5/17/24, and open items in refrigerator covered but not labeled with a date of opening.(deficiency cited, see 809D). Kitchen drawer with sharp knives locked. Sharps container containing sharps was left open on the kitchen floor and accessible to residents (deficiency cited, see 809D).Toxins stored in garage in secured cabinet. LPAs noticed 3 rat traps present in the garage. All bedrooms were equipped with lighting, night stand, and chest of drawers, however lamp in room 3 does not work. All bedrooms were clean. Bedroom #3 did not have electricity. Per LPA conversation with caregiver, the electricity has been out for 2-3 days. Per LPA conversation with Admin, they said they were not aware of any outage in room #3 (deficiency cited, see 809D) Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 105.5, 111, and 106.7 degrees F which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 9/15/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted 2/15/2024. Facility has a backup generator for use during a power outage. Continued on 809C... Continued from 809... At approximately 11:00am LPAs conducted review of 5 staff records. S1 did not have a Health Screen in file. Per LPA conversation with Admin, Health screen for S1 was not available (deficiency cited, see 809D). At approximately 12:00pm LPA conducted a review of 6 resident records. All required documentation present. Per R1's Physician's Report and Appraisal Needs and Services Plan, R1 is bedridden. However, facility license does not show non-ambulatory bedridden status. Facility to submit to CCL an updated LIC200 requesting updated license with non-ambulatory bedridden status. LPAs advised Admin to submit LIC200 to CCL no later than 10 business days from 6/14/2024. Per LPAs review of residents files, R1 and R2 require two person assists per Physician's Report and Appraisal Needs and Services Plan. However facility only has one NOC shift employee scheduled per NOC shift (deficiency cited, see 809D). At approximately 1:30pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a secured office. Per LPA conversation with Admin, medications are pre-poured (deficiency cited, see 809D). LPA advised Admin that medications can be prepared at the beginning of the day for the current day. Angelica Martinez Administrator Certificate 7000290740 expires 4/10/2025. All fees are current as of this time. LPAs and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report, LIC308- Designation of Responsibility, and current Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jun 14, 2024

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Office

An Informal Meeting with Licensing Program Manager, Bethany Moellers, Licensing Program Analyst (LPA), Farhaan Sarangi and Licensee/Administrator, Angelica Martinez was held for the purpose of discussing a document issued by Santa Rosa Fire Department that was determined to be modified. Licensee denied the verbiage that was added to the document and confirmed the shed located in the backyard of the facility is used for storage only. CCL will continue to collaborate with Santa Rosa Fire Department and Code Enforcement to resolve the issue. No citations issued during todays informal meeting.the state’s words, verbatim · CDSS document, Nov 15, 2023