Inspection visit

Follow-up on correctionsJuly 28, 2025

ADULT CARE OC SATURNALicense 3060059345 citations on this visit

5 citations recorded

Inspector’s narrative

What the inspector wrote

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of citing deficiencies observed during the investigation of complaint 22-AS-20230628144300 and not related to the allegations investigated. There are six residents in care at the time of the present visit. LPA conducted a tour of the physical plant and requested resident records for all six residents in care. Per the review of records, one resident has been assessed to be bedridden, however the facility only has a fire clearance for six non-ambulatory residents. Type A citation issued and immediate civil penalty assessed. During the investigation of the complaint mentioned above, staff member May Kwok was referred to on multiple occasions as the acting administrator (AA) for the facility. A review of background clearance and staff associations in Guardian demonstrates that AA Kwok criminal record clearance was not associated with the facility’. Type A citation and civil penalty assessed. During the investigation, the death of a resident 1 dated December 24, 2022, and a fall incident resulting in fracture and hip replacement of resident 2 dated October 6, 2022, failed to be reported to licensing staff as required by regulations. Type B deficiency cited. Additionally, it was confirmed that facility staff failed to implement adequate fall prevention planning and measures while providing care for facility resident R2. Type A citation issued. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 Finally, it was confirmed that AA had obtained power of attorney over the affairs of facility resident R2, which title 22 regulations clearly forbid. Type A citation issued. Based on today’s visit, four type A deficiencies, one type B deficiency and two immediate civil penalties are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with a facility representative and a copy of this report along with appeal rights were provided.

Citations

8 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87211(a)(1)Type B
Per CCR 87211(a)(1) "A written report shall be submitted to the licensing agency (...) within seven days of the occurrence of any of the events specified in (A) through (D) below. (...) (A) Death of any resident from any cause regardless of where the death occurred"” This requirement is not met as evidenced by:No death or incident reports corresponding to the incidents evidenced during the investigation were found to have been submitted to the Department.
87355(e)(3)Type A
CCR 87355(e)(3) on Criminal Record Clearance “All individuals subject to a criminal record review (....) shall prior to working (...) in a licensed facility: (…) (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)”. This requirement is not met as evidenced by:Per a review of the Guardian background clearance system, AA May Kwok was never associated to the present licensed facility. This constitutes an immediate risk to the health, safety and personal rights of individuals in care. Civil penalty assessed.
87466Type A
Per CCR 87466: “The licensee shall ensure that residents are regularly observed for changes in physical (..) functioning and that appropriate assistance is provided when such observation reveals unmet needs.” This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, resident R2 had been identified as a fall risk, with multiple occurrences of fall prior and on October 6, 2022. The lack of adequate precautions resulted in the resident becoming injured and requiring surgery. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.
87606(c)Type A
Per CCR 87606(c): "To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance." This requirement is not met as evidenced by: Based on facility observation and records review, resident R3 is assessed as bedridden, however the current fire clearance for the facility does not include any provision for bedridden residents. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.
87465(g)Type A
CCR 87465 (g) “Incidental Medical and Dental Care. 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 appropriate to the conditions and needs of residents.” This requirement is not met as evidenced by: Based on the evidence gathered, despite the repeated pain complaints, it was confirmed that facility staff did not obtain adequate medical attention for the residents’ needs which constitutes an immediate risk to the health, safety and personal rights of individuals in care.
87468.2(a)(8)Type A
Per CCR87468.2(a)(8): "(...)residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, (...). This requirement is not met as evidenced by: Based on evidence reviewed, after activing administrator May Kwok obtained attorney-in-fact status access to two residents’ bank accounts, multiple payments were evidenced to have been made from those accounts for unrelated business and personal expenses. This constitutes an immediate risk to the health, safety and personal rights of individuals in care. Immediate Civil Penalty Assessed.
87507(g)(3)(C)Type A
CCR 87507(g)(3)(C) regarding Admission Agreements: “Admission agreements shall specify the following: (C)Any fee that is charged prior to or after admission, shall be clearly specified.This requirement is not met as evidenced by: Based on evidence reviewed, facility staff obtained payments in excess of the actual amounts due for R1 and R2 totaling $97,038 of overpayments. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.
87217(d)(2)Type A
CCR 87217(d)(2) “Except as provided in approved continuing care agreements, no licensee or employee of a facility shall: accept any general or special power of attorney for any such person”This requirement is not being met as evidenced by: Based on record review and interview, Licensee failed to ensure an employee of the facility was not designated as a power of attorney for R1. This poses an immediate health and safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the July 28, 2025 inspection of ADULT CARE OC SATURNA?

This was a other inspection of ADULT CARE OC SATURNA on July 28, 2025. 5 citations were issued: 4 Type A (serious) and 1 Type B.

Were any citations issued to ADULT CARE OC SATURNA on July 28, 2025?

Yes, 5 citations were issued (4 Type A, 1 Type B). The first citation was for: "Per CCR 87211(a)(1) "A written report shall be submitted to the licensing agency (...) within seven days of the occurren..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

Follow-up on corrections·July 28, 2025