Carnelian Villas

Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that the Reappraisals on file for Resident #4 (R4) and Resident #5 (R5) were outdated.

1569.695(c) … (c) A facility shall conduct a drill at least quarterly for each shift... This requirement was not met as evidenced by: Based on documents and admission, the licensee has not been conducting quarterly emergency disaster drills as there is only one partially completed disaster drill log for 2025, which poses a potential safety risk to persons in care.

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department... This requirement was not met as evidenced by: Based on observation, the licensee is not following its fire clearance by placing a latch on the very top of the front door which LPA observed S2 was unable to unlatch for almost 2 minutes while trying to open the door to allow LPA entry and which AD stated was installed to address R1’s wandering, which poses an immediate safety risk to persons in care.

87208 Plan of Operation (a) …The plan and related materials shall contain the following: … (12) The Infection Control Plan pursuant to Section 87470.. This requirement was not met as evidenced by: Based on documents and admission, the facility does not have an infection control plan, which poses a potential health risk to persons in care.

87412 Personnel Records … (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement was not met as evidenced by: Based on documents and admission, the licensee does not have S4’s personnel file present at the facility or otherwise accessible during the inspection, which poses a potential safety risk to persons in care.

87465 Incidental Medical and Dental Care (a) … (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on documents and observations, the licensee did not ensure R3 received assistance with medications when they did not receive their evening Donepezil 10MG once this month, which poses a potential health risk to persons in care.

Based on observation the licensee did not comply with the section cited above in leaving medication in resident's room which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by not maintaining the three cloged restroom sinks which poses a potential health, safety or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above in leavining chemeclas under sink unsecured and unlocked which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above in sharpes unlocked and screw drivers in kitchn un secured which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above in 2 out of 2 counts which poses an immediate health, safety or personal rights risk to persons in care.

87468.2 … Personal Rights … (a) … residents … shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in … personal care and assistance, visits, communications…, and meetings... This requirement is not being met as evidenced by: Based on interviews, the licensee did not ensure R2’s privacy during visits and meetings and allowed S1 and S2 to always be present to intimidate and prevent R2 from reporting their abuse earlier, which poses an immediate health, safety, and personal rights risk to persons in care.

(a) … (3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement is not being met as evidenced by: Based on interviews and records, the licensee intentionally did not comply with the Department’s order excluding S2 by knowingly hiring S2 and allowing S2 to provide care for months, which poses an immediate health, safety, and personal rights risk to persons in care.

87468.2 … Personal Rights … (a) … residents … shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not being met as evidenced by: Based on interviews and records, the licensee did not prevent S1 and S2 from physically abusing R1 and R2, which poses an immediate health, safety, and personal rights risk to persons in care.

87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury … shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours... This requirement is not being met as evidenced by: Based on interviews and documents, the licensee suspected physical abuse by S1 and S2 as early as 01/2021 but did not report the abuse until the report to licensing on 04/01/2021, which poses an immediate health, safety, and personal rights risk to persons in care.

87464 Basic Services (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 is not being met as evidenced by: Based on interviews and records, the licensee noted R1’s injuries on 01/19/2021 but did not seek immediate medical attention for R1’s bruised forehead and eye, which poses an immediate health, safety, and personal rights risk to persons in care.

87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review ... shall prior to working ... (1) Obtain a California clearance or a criminal record exemption... This requirement was not met as evidenced by: Based on records, the licensee did not ensure S2 was background cleared prior to working at the facility and allowed S2 to work for months without a clearance, which poses an immediate health, safety, and personal rights risk to persons in care.

87405 Administrator ... Duties. (a) .... The administrator … shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility .... there shall be coverage by a designated substitute … responsible and accountable for management and administration … This requirement is not being met as evidenced by: Based on interviews, the licensee and administrator were afraid of S1 and S2, did not supervise the care provided by S1 and S2, and did not properly manage the facility, which poses an immediate health, safety, and personal rights risk to persons in care.