NARRATIVE |
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | LPA Monter interviewed staff S1 and S2. Both staff interviewed stated staff cleans the home everyday. S1 stated he/she cleans the facility everyday. S1 stated he/she washes the residents bedsheets and blankets 2x a month. S2 stated he/she hasn’t seen any issues with cleanliness in the home.
LPA Monter interviewed ADM Eduardo Carrana. ADM stated the facility staff is supposed to clean every day. ADM stated he has noticed the facility as clean. ADM stated there hasn’t been a time when he has seen the facility as dirty. ADM stated the staff change the residents bed sheets 3 times a week.
LPA Monter interviewed witness W1. W1 stated he/she hasn’t seen any issues at the home when it comes to cleaning. W1 stated the staff does keep the house clean.
On October 10, 2025, LPA toured the facility inside and out. While touring the backyard of the facility, LPA noted pieces of a sink ceramic in the backyard. LPA also noted a large amount of cigarettes, in the side of the home and the backyard. LPA noted directly across from the dinning room, family living room and kitchen: alongside the side of the home, there is garbage pilled up including cans and bottles.
While touring resident bedroom 1, 3 & 4, LPA noted along side all the furniture, at the floor level, was a layer of dirt/grime. LPA noted that bedrooms had a linger smell. LPA noted resident R1's mattress has holes in it.
While touring the facility bathroom, LPA noted the walls in the bathroom had stains, new the light switch and door knob. LPA also noted the shower base and lower section of the shower had grime and water damage. LPA observed the shower chair also had a layer of grime. Bathroom Mirror also had grime.
While inspecting the facility fridge, LPA noted the front of the fridge had a grime in the front facing doors. LPA observed at the bottom of the freezer additional grime and a red like substance.
Throughout the tour of the facility LPA noted in several corners of the facility, cobwebs in the following but not limited to areas: family living room, kitchen.
Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Page 2 Out of 4 |
NARRATIVE |
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | Resident was not accorded dignity in his/her personal relationships with staff
On October 6, 2025 the Department received a complaint alleging Resident was not accorded dignity in his/her personal relationships with staff
On October 10, 2025, LPA Monter conducted the initial complaint investigation visit. LPA interviewed residents R1-R5. R1 stated staff S1 speaks to him/her an inappropriate manner. R1 stated S1 tells him/her to clean up his/her mess. R1 stated S1 has threatened to lock the fridge.
Residents R2-R4 stated they haven’t heard the facility staff make inappropriate comments / threats/ mean statements towards the residents. Resident R5 declined to be interviewed.
LPA interviewed staff S1 and S2. Both staff interviewed denied staff ever making inappropriate comments / threats/ mean statements towards the residents.
LPA interviewed ADM Eduardo Carrana. ADM stated facility staff treat the residents with respect. ADM stated he hasn’t heard his staff expressing any negative comments or threats towards residents.
The Department reviewed R1’s progress notes, written by staff S1, dated October 4, 2025. The progress note stated, “ at around 7:00pm, I went to the room of R1 and told him/her that I will lock fridge at 10:00pm, but he/she is mad at me. Keep calm, I will not locked the fridge.”
On October 16, 2025, LPA Monter interviewed Staff S1. S1 confirmed he/she was the staff who filed out the progress notes. S1 confirmed he/she did tell R1, that he/she will, "lock the fridge at 10:00pm because R1 is being messy."
Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.
Page 4 Out of 4. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
10/17/2025
Section Cited
CCR
80087(a) | 1
2
3
4
5
6
7 | 80087 Buildings and Grounds (a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement was not met as evidence by: | 1
2
3
4
5
6
7 | ADM stated he will submit a written plan of action on how he will ensure the facility will address the rats in the home and the other physical plant issues noted on the 9099 & 9099-C, to ensure the facility remains clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. |
 | 8
9
10
11
12
13
14 | Based on interviews conducted, S1, W1 and ADM stated the facility has rats in the home. LPA also observed other physical plant issues noted in 9099 & 9099-C. This poses/posed an Immediate health, safety or personal rights risk to persons in care. | 8
9
10
11
12
13
14 | ADM stated he will submit the plan of action to LPA by POC due date, October 17, 2025. |
Type A
10/17/2025
Section Cited
CCR
80072(a)(1) | 1
2
3
4
5
6
7 | 80072 Personal Rights (a) (1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement was not met as evidence by: | 1
2
3
4
5
6
7 | ADM stated he will conduct a personal rights training with staff. ADM stated he will send documentation showing the training has taken place and will include: the name of the trainer, the name of the staff who attended the training, who long the training took place, materials used, and a signature of the staff who attended. |
| 8
9
10
11
12
13
14 | Based on interviews conducted, Staff S1 stated he/she threatened R1 to lock the fridge, because R1 was being messy. This poses/posed an Immediate health, safety or personal rights risk to persons in care. | 8
9
10
11
12
13
14 | ADM stated he will submit the written plan of action to LPA by POC due date, October 17, 2025. |