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Inspection visit

Complaint

TIERRASANTA VERNANEL CARE HOMELicense 3720048942 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

[CONTINUED FROM LIC 9099] Staff interviews aligned to show: During the complaint allegation time frame, Staff #1 (S1) was the primary caregiver at the facility. Staff #2 (S2) was the only other caregiver, but they worked far fewer hours. They also showed that R1, who had lived at the facility since mid-2020, was diagnosed with Dementia and tended to wander around the facility and its outside yards, sometimes naked, requiring staff redirection. R1 would also open housemates’ bedroom doors and stare at them. R1’s LIC602 Physician’s Report confirmed their dementia and wandering diagnoses. Interviews of staff, corroborated by police records and California’s Megan’s Law database, showed R1 was also a Registered Sex Offender (RSO). Meanwhile, R2, who moved into the facility on the evening of 09/17/2021, was vision-impaired but retained 10% eyesight in their right eye. R2 was diagnosed with major depressive disorder with psychotic features. However, per their LIC602 Physician’s Report, their doctor determined that R2 was not confused/disoriented, was able to follow instructions, and was able to communicate their needs. LPA met R2, determining that they were alert, oriented, and coherent enough to be qualified as a reliable historian. Per interview of R2: Around 6:00 AM or 7:00 AM on 09/18/2021 (which was their first morning living at the facility), they were sitting on the edge of their bed when R1 entered their bedroom and sat beside them. R1 solicited R2 for sex, which R2 refused. R1 then repeatedly touched R2 between their legs and squeezed R2’s breasts. R2 cried out for help. This went on for 20-30 minutes before an unknown person came to the room and redirected R1 away. R2 said there was a separate day during February 2022 when R1 tried to force their way into R2’s bedroom. Resident #3 (R3), who was visiting with R2 at the time, used their body weight to hold the door closed, until R1 gave up and walked away. Interview of R3 corroborated that second event. LPA did not interview R1. R1 had moved out by the time the complaint was filed with CCLD. Subsequent SDPD records showed their police officers tried interviewing R1, but quickly concluded R1 was too disoriented/confused to be a reliable historian. [CONTINUED ON LIC 9099-C, 2 of 4] [CONTINUED FROM LIC 9099-C, 1 of 4] In their own interviews, neither S1 nor S2 heard/witnessed any part of the 09/18/2021 incident between R1 and R2. S1 and S2 each denied being the person who redirected R1 away from R2. S1 said R2 told them about the incident shortly after, but S1 did not believe it really occurred, because they knew R2 to be nearly blind and to sometimes experience hallucinations. S1’s description of the incident from R2 closely matched what R2 told LPA. S1 did not report the alleged incident to either R1’s responsible person (RP) or R2’s RP, or to CCLD, the Long-Term Care Ombudsman (LTCO), or SDPD, as required. [Not meeting reporting requirements will be addressed in a separate case management visit report.] At the time of the incident, the other residents in care were Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5). LPA met each, determining that R3 and R4 were alert, oriented, and coherent enough to be reliable historians, while R5’s cognition was less strong. Per their interviews, these residents did not personally hear/witness the 09/18/2021 incident between R1 and R2. They denied themselves being physically/sexually abused by R1. However, R3 stated that R1 often prowled the facility’s yards at night, and on “half a dozen” nights tried unsuccessfully to open the side door which led from the outside directly into R3’s bedroom, being deterred when R3 yelled at them. R4 said R1 made vulgar sexual comments towards them personally. R4 confirmed that R1 on multiple nights tried unsuccessfully to enter their own bedroom from the outside using their side door. R4 said they made S1 aware of this troubling behavior. R4 also corroborated the day that R1 tried to force their way into R2’s bedroom and R4 stopped them. S1 told LPA they knew R1’s behaviors made multiple other residents uncomfortable, but S1 did not issue a 30-day eviction notice for R1 or inform their RP of their housemates' allegations against R1. Interviews of S1 and residents, corroborated by police records, showed: Multiple residents directly approached R1’s RP to inform them of their individual fears/concerns regarding R1. This was also how R1’s RP became aware of the 09/18/2021 incident between R1 and R2. Upon receiving this information, R1’s RP notified SDPD, who on 02/11/2022 visited the facility to open an investigation. Police wrote that R2 and R4 lived in “extreme fear” of R1, with R2 having to barricade their bedroom door at night and R4 losing sleep. With R1’s impaired cognition, police officers deemed R1 a “danger to others” and that same day arranged for R1 to be transported to the hospital on a Welfare and Institutions Code 5150 psychiatric hold. From there, R1’s RP arranged for R1 to discharge elsewhere; R1 did not return to Tierrasanta Vernanel Care Home. [CONTINUED ON LIC 9099-C, 2 of 4] [CONTINUED FROM LIC 9099-C, 1 of 4] Per the police report: R1 was so disoriented to other persons that R1 previously made sexual comments towards their own RP and tried to grope them too. The statements S1, R2, R3, and R4 individually gave to SDPD were consistent with their later statements to CCLD. During questioning, S1 told LPA that former Resident #6 (R6), who had moved out prior to the complaint time frame, previously told a hospice agency staff that someone had come into their bedroom and touched their legs and chest. S1 stated they did not witness this incident and did not believe it really occurred, since they claimed R6 had Dementia and sometimes experienced hallucinations. S1 did not report the alleged incident to either R6’s responsible person (RP), CCLD, the Long-Term Care Ombudsman (LTCO), or SDPD, as required. S1 denied there being other instances of possible abuse between R1 and R6. CCLD subsequently reviewed a series of dated handwritten progress notes written by S1, which revealed: On 06/13/2021, S1 personally witnessed R1 inside R6’s bedroom, touching R6’s face and breast without their consent, requiring S1 to redirect R1 away from R6. There were also two successive incidents when R1 entered R6’s bedroom (unwitnessed by S1 but which R6 later reported to them): R6 said on 07/30/2021, R1 was touching them without their consent. R6 said on 09/13/2021, R1 removed R1's own pants and exposed their genitals to R6, who shoved R1 away from them. [False/Misleading Statements and Not Meeting Reporting Requirements will be addressed in a separate case management visit report.] LPA did not interview R6. They had already moved out by the time the complaint was filed with CCLD, and by the time LPA established contact with R6’s RP, he learned that R6 had since died. R6’s RP confirmed not being informed of allegations/instances of physical/sexual abuse against R6. R6’s RP also denied R6 having Dementia or hallucinations during the time they lived at the facility. Per R6's LIC602 Physician's report, R6 did not have either Mild Cognitive Impairment or Dementia. Their doctor also determined that R6 was not confused/disoriented, was able to communicate their needs, and was able to follow instructions. R4 told LPA that R1 stole $80 from their purse. R4 said they told S1 about this. S1 said they later checked R1’s pants pockets during laundry but never found money. R3 told LPA that R1 had taken their own belongings on several occasions, most of which resulted in them recovering the missing items. However, there was a bottle of mouthwash and two sweaters which R3 never got back. Records review and manager interview showed: Licensee did not maintain a written Theft and Loss Record for the facility, as required. [CONTINUED ON LIC 9099-C, 4 of 4] [CONTINUED FROM LIC 9099-C, 3 of 4] Licensee also did not maintain a written Personal Property Inventory for R1 through R6, as required. Licensee did not report these losses to the responsible persons for either R1 or R3, nor compensate/reimburse the residents for these losses. Based on records and interviews, a preponderance of evidence exists to prove the Licensee did not protect a resident (R2 and R6) from another resident’s (R1’s) sexual abuse, and that Licensee did not safeguard resident personal property. Both allegations are therefore Substantiated, and two (2) deficiencies were cited for them per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Licensee Nelly Panao, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099-A] Interviews of staff and residents, and SDPD records, generally aligned to show: On 02/02/2022, Resident #2 (R2) gave a packet of cookies to R3. R1, who was diagnosed with Dementia, claimed that the cookies belonged to themselves. This was the basis for an ensuing argument between R1 and R3, which took place in the facility’s dining room. R1 hit R3 with a cane, once on the shoulder, and once on the head. Staff #1 (S1) responded quickly to break up the altercation, separating R1 from R3 until police arrived. SDPD subsequently transported R1 to the hospital on a Welfare and Institutions Code 5150 hold. R3 said the hits were not hard and denied experiencing pain or injury. Based on records and interviews, a preponderance of evidence does not exist to support that Licensee did not protect R3 from being hit by R1. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Licensee Nelly Panao, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Citations

17 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.

  • 87218(a)Type B

    87218 Theft and Loss: “(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. This posed a potential personal rights risk to 6 of 6 residents (R1 through R6) in care.

  • 87468.2(a)(8)Type A

    Right to freedom from abuse and neglect

    87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from… mental, physical, or sexual abuse.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 2 of 6 residents (R2 and R6) were free from, mental, physical, or sexual abuse. This posed an immediate safety and personal rights risk to persons in care.

  • 87303(a)Type B

    Maintain facility in clean, safe, sanitary condition

    87303 Maintenance and Operation: “(a) The facility shall be clean…at all times.” This requirement was not met, as evidenced by: Based on interviews, Licensee did not ensure that the facility was clean at all times. This posed a potential health and personal rights risk for 3 of 3 residents [R1, Resident #2 (R3), and R3] in care.

  • 87307(a)(3)(C)Type B

    Clean linen quantity and hygiene supplies

    87307 Personal Accommodations and Services: “(a)(3) …The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads…” This requirement is not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 2 of 3 residents (R1 and R3) had clean linen. This posed a potential health and personal rights risk to persons in care.

  • 87625(b)(3)Type A

    Maintain cleanliness and prevent incontinence odors

    87625 Managed Incontinence: “(b) …the licensee shall be responsible for the following: “(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 1 of 3 residents (R1) who was incontinent was kept clean and dry and free of odors from incontinence. This posed an immediate health and personal rights risk to persons in care.

  • 87207Type B

    Prohibit false or misleading facility statements

    87207 False Claims: “No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility…” This requirement was not met, as evidenced by: Based on records and interviews, during a formal CCLD investigation, Licensee made a false or misleading statement regarding the extent of their knowledge of abuse against 1 of 6 residents (R6). This posed a potential safety and personal rights risk to persons in care.

  • 87211(a)(1)(D)Type B

    87211 Reporting Requirements: “(a)(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. (D) Any incident which threatens the welfare, safety or health of any resident…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not submit a written report to the licensing agency and the persons responsible regarding incidents which threatened the welfare and/or safety of 3 of 6 residents (R1, R2, and R6), within seven days of incident occurrence. This posed a potential safety and personal rights risk to persons in care.

  • 87211(c)Type B

    Report suspected non-serious physical abuse within 24 hours

    87211 Reporting Requirements: “(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not report suspected physical abuse affecting 2 of 6 residents (R2 and R6), but not resulting in serious bodily injury to either, to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours. This posed a potential safety and personal rights risk to persons in care.

  • 87457(c)Type B

    Complete admission suitability appraisal

    87457 Pre-Admission Appraisal: “(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria…” This requirement was not met, as evidenced by: Based on records and interviews, for 3 of 6 residents (R1, R2, and R5), Licensee did not meet/interview the resident and their responsible person to determine the resident’s suitability for admission, prior to admission. This posed a potential health, safety, and personal rights risk to persons in care.

  • 87466Type B

    Regular observation and documentation of resident changes

    87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that for 3 of 6 residents (R1, R2, and R6) were regularly observed. This posed a potential safety and personal rights risk to persons in care.

  • 87705(d)Type B

    Auditory exit monitoring for elopement risk

    87705 Care of Persons with Dementia: “(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement…” Based on records and interviews, 1 of 6 residents (R1) had Dementia and was at risk for elopement, but Licensee did not ensure the facility had an auditory device (or similar staff alert feature) on its exterior doors. This posed a potential safety risk to persons in care.

  • 87307(a)(3)(A)Type B

    Bed provision and bedding standards for residents

    87307 Personal Accommodations and Services: “(a)(3) …The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (A) A bed for each resident…Each bed shall be equipped with good springs, a clean and comfortable mattress…” This requirement is not met, as evidenced by: Based on LPA observation and interviews, Licensee did not ensure that 1 of 3 residents (R3) had a mattress that was both equipped with good springs and comfortable. This posed a potential personal rights risk to persons in care.

  • 87458(a)Type B

    Obtain baseline medical assessment before resident admission

    87458 Medical Assessment: “(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 3 residents (R1), Licensee did not obtain documentation of medical assessment prior to the person’s acceptance as a resident. This posed a potential health risk to persons in care.

  • 87464(f)(4)Type B

    Personal assistance and care for required daily activities

    87464 Basic Services: “(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident…such as…bathing…” This requirement was not met, as evidenced by: Based on records and interview, Licensee did not consistently provide 1 of 3 residents (R3) needed assistance with bathing. This posed a potential health and personal rights risk to persons in care.

  • 87467(a)Type B

    Admit resident care meeting requirements

    87467 Resident Participation in Decisionmaking: “(a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.” This requirement was not met, as evidenced by: Based on records and interviews, for 3 of 3 residents (R1, R2, and R3), Licensee did not prepare a jointly developed written record of care for the resident within two weeks of the resident’s admission. This posed a potential health, safety, and personal rights risk to persons in care.

    Read full inspector narrative
  • 87507(a)Type B

    Must complete individual written admission agreements

    87507 Admission Agreements: “(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not complete an individual written admission agreement with 1 of 3 residents (R1). This posed a potential personal rights risk to persons in care.

  • 87633(b)Type B

    Facility must keep complete hospice care plan on file

    87633 Hospice Care of Terminally Ill Residents: “(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not maintain at the facility a current and complete hospice care plan for 1 of 3 residents (R1) who was receiving hospice care. This posed a potential health risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the June 3, 2025 inspection of TIERRASANTA VERNANEL CARE HOME?

This was a complaint inspection of TIERRASANTA VERNANEL CARE HOME on June 3, 2025. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to TIERRASANTA VERNANEL CARE HOME on June 3, 2025?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "87218 Theft and Loss: “(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safet..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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