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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603815
Report Date: 03/18/2025
Date Signed: 03/18/2025 02:30:26 PM

Document Has Been Signed on 03/18/2025 02:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SOLARIS 36FACILITY NUMBER:
374603815
ADMINISTRATOR/
DIRECTOR:		ARCA, LUCIAFACILITY TYPE:
740
ADDRESS:14536 GARDEN RDTELEPHONE:
(858) 842-4246
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 5DATE:
03/18/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Caregiver Jovina Franco and Administrator Jushua "Justin" MendozaTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite additional deficiencies which were identified during a separate complaint investigation. LPA was welcomed by and identified himself to Caregiver Jovina Franco. LPA then met with and discussed the purpose of the visit with Administrator Jushua "Justin" Mendoza, who arrived shortly after.

According to facility care and hospice records, and corroborated by staff and outside source interviews, Resident #1 (R1) had no pressure injuries or areas of open skin when they first moved into Solaris 36 in January 2020. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] R1 was initially under hospice care for lymphoma but they discharged from hospice services on 04/02/2020. Starting 04/03/2020, R1 was under the concurrent care of an outside home health (HH) agency.


In their individual interviews: Staff #1 (S1) said sometime in April 2020, a closed mass on R1’s sacrum had opened-up, become “darker and softer to the touch,” “bluish” or “purplish,” had foul odor, and wept “yellowish” discharge. Staff #2 (S2) said a “fist”-sized area on R1’s sacrum opened-up, went from “normal color” to “red,” wept blood and puss, and smelled badly. S2 could not remember approximately when this started. Manager Staff #3 (S3) said their direct reports summoned them to personally look at R1’s sacrum on 04/01/2020, which had opened-up with foul odor and discharge. S1 said that R1’s responsible person (RP) and their HH agency [where R1’s assigned physician (PCP) was based] were timely informed by S3 of the skin breakdown on R1’s sacrum. However, interview of S3 showed they did not personally notify those parties of the problem. Rather, S3 was under the impression that S1 had completed such communication to RP and HH/PCP.


[CONTINUED ON LIC 809-C, 1 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SOLARIS 36
FACILITY NUMBER: 374603815
VISIT DATE: 03/18/2025
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[CONTINUED FROM LIC 809]

According to HH records: 04/24/2020 was HH’s earliest documentation of a pressure injury on R1; a HH nurse wrote they observed a Stage 2 pressure injury to R1’s coccyx. By 04/26/2020, R1’s HH physician upgraded the coccyx to a Stage 3 pressure injury. On 04/27/2020, the HH nurse wrote R1 had “wounds [to] entire buttock and lower back” with “wound infection” and “very foul-smelling drainage,” “covered with necrotic tissue,” concluding, “[R1] has met all criteria for severe sepsis and requires immediate intervention.” R1 had “shallow breathing,” “rectal bleeding,” and was “very lethargic,” “difficult to arouse,” and only able to “moan when turned.” R1 had “petit seizures with involuntary twitching of all extremities,” “pale skin,” and “tachy heart rate.” HH records and interview of RP further showed: a HH nurse called RP on 04/27/2020, which was the RP’s first notification of pressure ulcers on R1’s body. It was the RP (who came to the facility), and not facility staff, who then called 911 to have R1 transported to a hospital Emergency Department (ED). S1, S2, and S3 confirmed that facility staff themselves did not call 911 or arrange emergency medical care for R1 [even after R1 exhibited signs of infection (e.g., change in color, foul odor, and discharge) and a life-threatening medical crisis].

Hospital records showed R1 arrived at the ED “very weak” and “awake but not oriented.” R1 was treated at the hospital for “toxic encephalopathy” (defined by the National Institutes of Health as “brain dysfunction caused by toxic exposure”). R1 had a Stage 4 pressure injury to their sacrum (requiring surgery) with the “abscess cavity covered by necrotic tissue,” a Stage 3 pressure injury to their right buttock with “necrotic tan-like skin,” a Stage 2 pressure injury on their left buttock, and unstageable pressure injuries to both heels. Records of the skilled nursing facility (SNF), where R1 went to recover after surgery, corroborated the severity of R1’s earlier-described skin injuries to their bottom. SNF records also showed R1 had a Stage 2 injury on their left heel and an undetermined stage pressure injury on their right heel.

Per their LIC602 Physician’s Report, their LIC603 Resident Appraisal, their Functional Capability Assessment, and their plan of care, R1 had required assistance from Solaris 36 staff with dressing. R1’s HH agency had also instructed facility staff to “float” R1’s heels above their mattress to prevent skin breakdown. When CCLD individually asked S1, S2, and S3 if they observed or were aware of skin breaking down on R1’s heels leading up to their 04/27/2020 hospitalization, each staff said no.

[CONTINUED ON LIC 809-C, 2 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SOLARIS 36
FACILITY NUMBER: 374603815
VISIT DATE: 03/18/2025
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[CONTINUED FROM LIC 809, 2 of 2]

Regulation CCR 87466 required Licensee to “regularly observe [R1] for changes in physical [and] mental functioning,” to document such changes in condition, and to ensure they were timely “brought to the attention of the resident’s physician and the resident’s responsible person.” The preponderance of evidence showed Licensee did not meet this requirement. Regulation CCR 87465 required Licensee to arrange timely medical care congruent to the needs of R1, including telephoning 9-1-1 if a “circumstance has resulted in an imminent threat to [R1’s] health including but not limited to, an apparent life-threatening medical crisis.” The preponderance of evidence showed Licensee did not meet this requirement.

Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Administrator Jushua "Justin" Mendoza, to whom a copy of this report, the LIC 809-D page, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/18/2025 02:30 PM - It Cannot Be Edited


Created By: Dang Nguyen On 03/18/2025 at 02:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SOLARIS 36
FACILITY NUMBER: 374603815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/18/2025
Section Cited
CCR
87465(g)

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87465 Incidental Medical and Dental Care: “(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis…” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, R1 no longer lives at the facility, resolving the immediate risk. Licensee agreed to use a third-party source to retrain all current direct care staff on the topics of: a) Recognizing and Responding to Medical Emergencies, and b) Regulations 87465 Incidental Medical and Dental Care and 87469 Advance Directives and Requests Regarding Resuscitative Measures. Licensee agreed to E-mail a copy of the training certificates and/or sign-in sheet to LPA, by 04/18/2025.
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Based on interviews and records reviewed, Licensee did not immediately telephone 9-1-1 in response to an apparent life-threatening medical crisis affecting 1 of 5 residents (R1), which posed an immediate health risk to persons in care.
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Type A
03/18/2025
Section Cited
CCR87466

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87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed for changes in physical, mental…functioning… When changes such as…deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, R1 no longer lives at the facility, resolving the immediate risk. Licensee agreed to use a third-party source to retain all current direct care staff on the topics of: a) performing head-to-toe observation of residents during personal care and b) timely documenting and reporting changes in condition to facility leadership, physician, and responsible party. Licensee agreed to E-mail a copy of the training certificates and/or sign-in sheet to LPA, by 04/18/2025.
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Based on interviews and records reviewed, Licensee did not ensure that 1 of 5 residents (R1) was regularly observed for changes in physical and mental functioning, and that their deterioration was timely brought to the attention of their physician and responsible person. This posed an immediate health risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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