445202713-6-24-2026-26-AS-CKAI-DW8U3M-20260722151345

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202713
Report Date: 06/24/2026
Date Signed: 06/24/2026 12:14:37 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/15/2026 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20260415123051

FACILITY NAME:	RACHELLE'S HOME I		FACILITY NUMBER:	445202713
ADMINISTRATOR:	RECINTO, RACHELLE		FACILITY TYPE:	740
ADDRESS:	99 AIRPORT BLVD		TELEPHONE:	(831) 319-4190
CITY:	FREEDOM	STATE: CA	ZIP CODE:	95019
CAPACITY:	12	CENSUS: 5	DATE:	06/24/2026
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Tyrone Vega		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident sustained a fracture due to staff neglect.
Staff did not seek medical attention to resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Assistant Administrator Tyrone Vega. On 04/15/2026, the department received a complaint with the above allegations. On 04/16/2026, the department conducted an initial complaint investigation. On 05/21/2026, LPA Marrufo conducted an additional complaint investigation visit.

Allegation: Resident sustained a fracture due to staff neglect.
When the department received the complaint, it was alleged that resident R1 sustained numerous falls at the facility, resulting in a femur fracture. On 04/21/2026, the department received a copy of R1’s hospital records. R1’s hospital records indicate R1 was admitted to the hospital on 04/08/2026 via ambulance for a chief complaint of vomiting, diarrhea, and acute respiratory failure with hypoxia. At the hospital, R1 was diagnosed with rhino virus and pneumonia. On 04/14/2026, R1 was discharged home to the facility with a final diagnosis of viral disease and pneumonia. R1’s hospital records contained no indication that R1 sustained a fracture. See LIC9099-C page for more information. Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 26-AS-20260415123051

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: RACHELLE'S HOME I	FACILITY NUMBER: 445202713
	VISIT DATE: 06/24/2026

NARRATIVE

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LPA Marrufo requested that S2 provide documentation from R1’s Hospice Agency indicating that the Hospice Agency had discontinued R1’s test strips. On 05/22/2026, LPA Marrufo received an email from S2 that included a Medication Order/Prescription Authorization Form for R1 from R1s Hospice Agency as an attachment. The Medication Order/Prescription Authorization Form stated, “Discontinue routine blood glucose checks and discontinue glucose test strips.” The Medication Order/Prescription Authorization Form is dated 05/21/2026.

S3 stated during interview that he/she has been working at the facility for three months. S2 stated R1 does not have any test strips and no staff monitor R1’s glucose levels.

On 05/22/2026, LPA Marrufo conducted a telephone interview with S4. S4 stated that he/she called R1’s Hospice Nurse last month to ask for test strips and R1’s Hospice Nurse told S4 that R1’s test strips were discontinued. S4 stated he/she remembers that R1’s test strips were discontinued since January 2026.

LPA Marrufo made attempted telephone call interviews with R1’s Hospice Nurse on 05/22/2026 and 06/24/2026 and left a voicemail requesting a return phone call. LPA Marrufo was not able to reach R1’s Hospice Nurse for an interview.

Based on information from interviews conducted with staff and records reviewed, although the allegation listed above 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 were cited under California Code of Regulations Title 22

This report was reviewed with Assistant Administrator Tyrone Vega and a copy of this report was provided.

Page 3 of 3.

END REPORT

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 26-AS-20260415123051

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: RACHELLE'S HOME I	FACILITY NUMBER: 445202713
	VISIT DATE: 06/24/2026

NARRATIVE

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On 04/16/2026, the department obtained a copy of R1’s Appraisal/Needs and Services (ANS) Plan. The Needs subsection of the Physical/Health section of R1’s ANS states, “[R1] requires support with mobility, strength, and overall physical health, including assistance with daily activities due to his decreased strength and diabetes.” The Objective/Plan subsection of the Physical/Health section of R1’s ANS states, “Provide regular assistance, mobility support, and health monitoring to maintain [R1’s] strength, safety, and overall physical well-being.” The Person(s) Responsible for Implementation subsection of the Physical/Health section of R1’s ANS states, “Staff, Management.”

During visit on 04/16/2026, LPA Marrufo obtained a copy of R1s Training Plan, dated 10/25/2023. The document states, “…the staff will be trained to identify symptoms of low and high blood sugar levels, actions to take should [he/she] experience hypoglycemia or hyperglycemia, and emergent conditions that warrant immediate Emergency Medical Assistance (911).” The document states, “Staff will also be able to: …Demonstrate through return demonstration the proper use of [R1’s] blood sugar monitor.”

On 05/21/2026, LPA Marrufo interviewed staff S1-S3. During interview, S1 stated the staff are supposed to monitor R1’s glucose levels in the morning, but the pharmacy has not delivered R1’s test strips to check his/her glucose levels. S1 stated the staff have been calling the pharmacy for more test strips.

During interview, S2 stated the staff used to measure R1’s glucose levels, but after R1’s updated Care Plan from September 2025, R1’s glucose levels no longer need to be measured. S2 stated R1’s Hospice Agency no longer provides the facility with test strips. During visit, LPA Marrufo obtained a copy of R1’s Blood Sugar Log Sheets from January, February, and April 2026. LPA Marrufo observed that some entry rows on the log stated, “No Strips” and some entry rows were blank. S2 stated he/she did not know why some entry rows were blank. S2 stated that although the staff no longer need to measure R1’s glucose and R1’s hospice agency no longer provides test strips, staff still write “No Strips” on the Blood Sugar Log Sheet to provide a record to Quality Assurance inspectors from San Andreas Regional Center (SARC). S2 stated that S4 has called R1’s Hospice Agency requesting more test strips, but R1’s Hospice Agency nurse stated R1 does not need test strips and is no longer eligible for test strips.

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SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 26-AS-20260415123051

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: RACHELLE'S HOME I	FACILITY NUMBER: 445202713
	VISIT DATE: 06/24/2026

NARRATIVE

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Allegation: Staff did not seek medical attention to resident in a timely manner

When the department received the complaint, it was alleged that staff observed R1’s health decline for several days without requesting care for R1.

On 04/08/2026, the facility submitted an Unusual Incident/Injury Report (IR) to the department. The IR stated that on 04/08/2026, R1 displayed unusual lethargy and physical distress, leading to a coordinated medical intervention between facility staff, hospice nursing, and emergency services. The IR states that at 7:10 AM, staff were assisting R1 with his/her morning routine and observed that R1 seemed “off” and was not acting like his/her usual self. Staff proceeded to transition R1 to the dinning area for his/her meal. At 7:48 AM, R1’s condition declined. R1 refused the remainder of his/her meal, complained of abdominal pain, and began vomiting. At 8:00 AM, facility staff contacted R1’s hospice agency to report the change in R1’s condition. The attending nurse advised staff to administer anti-vomit medication and confirmed that he/she was enroute to the facility. At 8:27 AM, the hospice nurse arrived and performed a clinical assessment. R1’s oxygen saturation levels were noted to be below 90%. The nurse contacted R1’s family member/Power of Attorney (POA) to discuss the clinical findings. R1’s POA requested that R1 be transported to the hospital for further evaluation. At 8:40 AM, ambulance arrived at the facility. At 9:05 AM, the ambulance transported R1 from the facility to the hospital.

On 05/07/2026, the department received copies of R1’s hospice agency records. R1’s hospice agency records indicate that on 04/03/2026 and 04/06/2026, R1 showed no signs or symptoms of infection during routine Skilled Nursing visits. On 04/08/2026, R1 required a Skilled Nursing visit due to vomiting and diarrhea. R1 denied pain but noted he/she was uncomfortable with shallow breathing. R1’s oxygen saturation was 90 and had a heart rate of 108. A staff noted R1 was more pale than usual. R1 was sent to the hospital for further evaluation.

Page 2 of 3.

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/15/2026 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20260415123051

FACILITY NAME:	RACHELLE'S HOME I		FACILITY NUMBER:	445202713
ADMINISTRATOR:	RECINTO, RACHELLE		FACILITY TYPE:	740
ADDRESS:	99 AIRPORT BLVD		TELEPHONE:	(831) 319-4190
CITY:	FREEDOM	STATE:CA	ZIP CODE:	95019
CAPACITY:	12	CENSUS: 5	DATE:	06/24/2026
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Tyrone Vega		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not ensure resident's medical care needs were being met.

INVESTIGATION FINDINGS:

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When the department received the complaint allegation, it was alleged that facility staff were not checking R1’s glucose levels even though R1 has diabetes.

On 05/21/2026, LPA Marrufo obtained a copy of R1’s Physician’s Report. R1’s Physician’s Report was signed by R1’s physician on 01/09/2026. The document states that R1 is not able to do the following: administer his/her own prescription medications, administer his/her own injections, perform his/her own glucose testing, and administer his/her own PRN medications.

See LIC9099-C page for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20260415123051

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: RACHELLE'S HOME I	FACILITY NUMBER: 445202713
	VISIT DATE: 06/24/2026

NARRATIVE

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During visit on 05/21/2026, LPA Marrufo interviewed staff S1-S3. S1 and S2 stated that they did not observe R1 experiencing any change in health condition prior to his/her hospitalization on 04/08/2026. S3 stated that he/she observed R1 having a cough two days before R1 was admitted into the hospital. S3 stated many of the residents and staff had also been coughing during that time.

On 05/22/2026, LPA Marrufo conducted a telephone interview with staff S4. During interview, S4 stated he/she did not observe any change in R1’s health condition during the two days before R1 was hospitalized other than observing that R1 had a cough.

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 allegations were false, could not have happened, and/or are without a reasonable basis.

This report was reviewed with Assistant Administrator Tyrone Vega and a copy of this report was provided.

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026

LIC9099 (FAS) - (06/04)

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