Todos Santos Assisted Living and Memory Care

Applicant and licensee fees are charged by statute

An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. provides ....after initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license. -This requirement is not met as evidenced by:-Based on review, the licensee did not comply with the section above in not paying the annual fee which was due on 11/26/25.

Conformance with applicable laws and regulations

The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)....(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: The administrator stating "but those are just physical plant thing, why would that prevent us from passing" when not being granted a new license and asked to make corrections.

Report specified resident events within seven days

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.This requirement is not met as evidenced by: The facility finding an Illegal substance in a residents room and not reporting it to licensing.

Maintain facility in clean, safe, sanitary condition

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include the provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: LPA observed the cabinet in the assisted living "Bistro" to be dirty.

Keep window screens clean and in repair

All window screens shall be clean and maintained in good repair. This requirement was not met as evidenced by: At least one windows in memory care was missing a screens and another was broken

87463 Reappraisals(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition…(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident.This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not updating reappraisals for R1 with the frequent falls which poses a potential health, safety or personal rights risk to persons in care.

Call 9-1-1 for imminent health threats

87465(g) 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 except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with section above by not activating 9-1-1 if an injury or other circumstance which poses a potential health and safety risk to the persons in care.

87468.2 (a)(19) Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not giving R1 and/or R1's representative copies of R1's records as requested which poses a potential health, safety or personal rights risk to persons in care.

Records available to licensing agency for inspection

87506(d) Resident Records(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not ensuring that complete and former resident records were maintained and available for review as required. Specifically, the financial records for R1 from the year 2022 were not available during the visit on 11/19/25 and 03/11/26. In which poses a potential health, safety or personal rights risk to persons in care.

Develop required incidental medical care plan

87465(a) Incidental Medical and Dental Care ServicesA plan for incidental medical and dental care shall be developed by each facility to ensure that residents receive necessary medical and dental services.This requirement is not met as evidenced by: Based on interviews, and record review the licensee did not comply with the section cited above in by to ensure that Resident (R1) received appropriate medical evaluation or follow-up after sustaining an open wound to their hand. This failure resulted in R1 not receiving timely medical assessment following an injury. This poses a potential health and safety risk to residents in care.

Right to sufficient care and qualified staff

87468.2(a)(4) Additional Personal Rights Residents in all residential care facilities for the elderly shall have the following personal rights: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply with the section cited above in by to ensure that Resident (R1)’s request for assistance through the call pendant system was responded to promptly. This resulted in R1 remaining on the floor after a fall and unable to get up for approximately 26 minutes until staff responded. This poses a potential health and safety risk to residents in care.

Report specified resident events within seven days

87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not reporting the fall incident with R1 to Licensing which poses a potential health, safety or personal rights risk to persons in care.

Assist PRN administration when symptoms unclear

(d)If the resident is unable to determine...all of the following requirements are met:This requirement is not met as evidence by: Based on observation and record review the facility did not comply with the section above by having an inaccurate MAR which poses a potential health and safety violation for residents in care.

Care and supervision as defined by statute and rules

(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement was not met as evidence by: Based on interviews and record reviews the Licensee did not comply with the section cited above in charging R1 for a higher level of services than they were in.

(a)(1) (B) The text of the admission agreement,... shall be: Written in clear, understandable, coherent, and unambiguous language, using words with common and everyday meanings, and shall be appropriately divided with each section appropriately titled. This requirement was not met as evidenced by: Based on interviews and record reviews the Licensee did not comply with the section cited above by the facility not having in their admissions agreement if residents are agreeing to pay for a shared or single room.

Obtain required California clearance or exemption

Criminal Record Clearance. All individuals subject to a criminal record review... Obtain a California clearance...as required by the Department... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not having one staff fingerprint cleared which poses an immediate health and safety risk to the persons in care.

Request a transfer of criminal record clearance

Criminal Record Clearance. All individuals subject to a criminal record review...Request a transfer of a criminal record clearance... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not having two staff associated to the facility which poses a potential health and safety risk to the persons in care.

Facility personnel sufficiency and competence

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....This requirement is not met as evidenced by: The facility not having enough staff at that time to preform all resident ADL's

Provide assistance for residents medical needs

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... by compliance with the following:(2)The licensee shall provide assistance in meeting necessary medical and dental needs...This requirement is not met as evidenced by: The facility staff did not call for refill in timely manner which resulted in residents missing medication dosages. This poses an immediate health risk to resident in care.

Based on interview, the licensee did not comply with the section cited above by not conducting disaster drills quarterly which poses a potential health and safety risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above by having unlocked paints and detergents in the laundry room which poses an immediate health and safety risk to persons in care.

Food storage temperature control requirements

Based on observation, the licensee did not comply with the section cited above by having freezer temperature at 16 degrees F which poses a potential health and safety risk to persons in care.

Assist residents with self-administered medication

87565 Incidental Medical and Dental Care.(a) A plan for incidental medical shall be developed by each facility......(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidence by: -Based on review of records and interview, the licensee did not comply with the section above by not obtaining medication refills in a timely manner for R1 and order for one of R2's medications which pose an immediate health and personal rights risks the persons in care. This is a repeat violation.

Notice to quit must state specific reasons and details

The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidenced by: The facility refusing to take a resident back after they eloped and addmitted to a hsopital.

Maintain facility in clean, safe, sanitary condition

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include the provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: The facility not clean a residents room after rodent droppings were found.

Right to sufficient care and qualified staff

(a) In addition...the elderly shall have all of the following personal rights:(4) To care, supervision... that meet their individual needs ...This requirement was not met as evidence by: Based on interviews the facility did not meet the requirement above by not having enough staff which lead to two residents in memory care eloping from the facility which posed an immediate safety risk to residents in care.

Assist residents with self-administered medication

Incidental Medical and Dental Care. A plan for incidental medical...shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: Based on records review and interviews, licensee did not comply with the section cited above by given a resident the incorrect medication.

Maintain facility in clean, safe, sanitary condition

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include the provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement was not met as evidenced by: LPA observed dirty dishes in the cabinet in the memory care rec room, as well as dirt on the walls and cabinets.

Keep window screens clean and in repair

All window screens shall be clean and maintained in good repair.This requirement was not met as evidenced by: four windows in memory care were missing screens and at least two more had rips in their screens.

Surfaces such as floors,... shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. This requirement was not met as evidenced by: The facility being informed on 7/7/25 that urine was found in the courtyard and not cleaning/sanitizing it until after 7/19/25.

Right to sufficient care and qualified staff

(a) In addition...the elderly shall have all of the following personal rights:(4) To care, supervision... that meet their individual needs ...This requirement was not met as evidence by: Based on interviews the facility did not meet the requirement above by not having enough staff which lead to multiple elopements by of residents in memory care which posed an immediate safety risk to residents in care.

The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: Outdoor activity areas that are easily accessible to residents, protected from traffic, and have adequate shady areas. This requirement was not met as evidenced by: the memory care patio being locked from the inside not allowing access to residents in care.

Assist residents with self-administered medication

Incidental Medical and Dental Care. A plan for incidental medical...shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not obtaining medication refills in a timely manner which poses a potential health and safety risk to the persons in care.

Safe, healthful, comfortable accommodations

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on observation and interviews there was not adequate staffing to meet residents needs.

Fingerprints and criminal records of individuals in contact with clients...record exemption from the State Department of Social Services before his or her initial presence in a residential care facility for the elderly.

Dignity in personal relationships

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. Based on LPAs interview licensee did not comply with the section above by the facility staff yelling at

Maintain facility in clean, safe, sanitary condition

The facility shall be clean, safe, sanitary and in good repair at all times...This requirement in not met as evidenced by: Based on LPAs interview licensee did not comply with the section above in facility not being kept clean in the memory care uint, which poses a potential health and safety risk to persons in care.

Provide resident hot water for personal care

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.-This requirement is not met as evidenced by: -Based on observation, the licensee did not ccomply with the section cited above. LPA observed dried spilled food on the dining chair which poses potential health and personal rights risks to persons in care.