Inspection visit

ComplaintJune 3, 2025

TIERRASANTA VERNANEL CARE HOMELicense 3720048943 citations on this visit

3 citations recorded

Inspector’s narrative

What the inspector wrote

[CONTINUED FROM LIC 9099] Staff #1 (S1) was the primary caregiver at the facility during the complaint time frame, with Staff #2 (S2) serving as their back up. However, starting 04/14/2025, S1 ceased their direct care tasks, and S2 took over as the primary caregiver at the facility. Interviews of staff and outside sources, corroborated by hospice records, showed: R1 moved in on 03/28/2025 under the concurrent care of hospice. R1 spent all day in bed and was unable to turn/reposition themselves in bed. R1 was both incontinent of bowel and bladder and fully depended on staff to check/change their incontinence briefs. Per R1’s hospice nurses, R1 was supposed to have their briefs checked at least once every two (2) hours. S1 told CCLD that during the complaint timeframe, they typically checked/changed R1’s briefs five (5) times per day (i.e., around 8:00 AM, 10:00 AM/11:00 AM, 3:00 PM, 7:00 PM/8:00 PM, and 11:00 PM, respectively). However, interview of R1 showed they were only changed three (3) times per day (i.e., morning, midday, and evening). Interview of S2, who took over for S1 starting 04/14/2025, showed that they too were only checking/changing R1’ briefs three (3) times per day, prior to CCLD starting is complaint investigation. Several hospice personnel who regularly visited R1 at the facility described having at least one site visit during which they observed R1 wet/soiled upon arrival, having to change R1 themselves (instead of facility staff doing it). Multiple hospice personnel said they observed R1’s briefs saturated to the point that urine and/or feces escaped from R1’s brief and stained their bed. One medical professional saw dried feces stuck to R1’s thigh and hip. One non-medical visitor said that out of six (6) visits they made, R1’s brief had a urine and/or fecal odor during five (5) of those visits. S1 admitted to CCLD that they physically struggled to turn/move R1 in bed (which is needed to change R1’s briefs). S1 had also expressed the same to R1’s hospice agency. S2 also admitted to CCLD that they too struggled to move R1 in bed, and that R1 required the joint-assistance of two caregivers to have their brief changed in bed. This latter point was reiterated in the 30-day eviction notice which Licensee issued to R1 and their responsible person on 05/12/2025. [CONTINUED ON LIC 9099-C, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] Hospice records and interviews revealed multiple personnel had concerns regarding the condition of R1’s bed. One professional said they found R1’s bed “completely dirty” upon their arrival, across six (6) different site visits, and that they personally changed R1’s bed linens each time. They saw food both on R1’s body and on their bed. On one occasion, they saw R1 laying on top of a Scotch tape dispenser that had stuck to R1’s back. A second professional on a different day described seeing R1 laying on top of a large metal flashlight, a TV remote, colored pencils, and a pencil pouch. They saw multiple stains, including urine and fecal stains, on R1’s bed linen. A third professional on a different day described seeing R1 laying on top of a pack of pretzels that had “fully imprinted” into R1’s back. They added that very near R1’s body (but not directly under them) was also an Icebreakers mint container, phone chargers, and an empty bottle of hand sanitizer. The Mayo Clinic’s encyclopedic entry titled “Bedsores (Pressure Ulcers)” states, “Skin becomes more vulnerable with extended exposure to urine and stool,” and that “constant pressure on any part of the body can lessen the blood flow to tissues” which also contributes to skin breakdown. Review of hospital and hospice agency records showed: R1 moved into the facility with an existing Stage 2 pressure ulcer on their sacrum. However, per hospice nursing assessment, on 05/01/2025, R1’s sacral pressure ulcer worsened to Stage 3. Hospice records and interviews revealed multiple personnel had concerns regarding the cleanliness of R1’s bedroom: During a visit, one professional saw multiple pieces of trash and multiple opened/uneaten chocolates on R1’s bedroom floor; they clean up R1’s floor and threw away other expired food seen in R1’s bedroom. A second professional said that R1’s room was so cluttered with objects that it was difficult to walk through R1’s room or even set their workbag down. A third professional reiterated the clutter in R1’s room and said R1’s bedside table was “sticky” and R1’s furniture was dusty. One non-medical visitor said they and another visitor sometimes saw dust on R1’s furniture, which they personally wiped clean. They also threw away expired food seen in R1’s room. [CONTINUED ON LIC 9099, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] A separate outside source revealed: Resident #3’s (R3’s) bed linens were also not consistently clean; they saw stains on R3’s pillows, bedsheets, and mattress during the complaint timeframe. This person said R3’s bedroom floor was “very dirty,” and that they personally cleaned it as a result. They also said that the facility’s shared bathroom was not kept clean during the complaint timeframe, and that there was evidence of insects at the facility. During his 06/03/2025 site visit, LPA himself observed a few gnats flying in the dining room area. Based on records and interviews, a preponderance of evidence exists to show that Licensee did not meet R1’s incontinence care needs, that Licensee did not ensure resident had clean linen, and that Licensee did not maintain facility cleanliness. These allegations are therefore Substantiated, and three (3) deficiencies were cited for them per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D pages). Since one of the deficiencies contributed to the worsening of an injury to R1, an Immediate Civil Penalty of $500 was charged/assessed (refer to the LIC421-IM 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 pages, the LIC421-IM page, the LIC811 Confidential Names List, 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. 3 citations were issued: 1 Type A (serious) and 2 Type B.

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

Yes, 3 citations were issued (1 Type A, 2 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 CCLD View original report

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Data from CCLD public records. Last updated June 29, 2026. If you believe any information is inaccurate, report it here.

Complaint·June 3, 2025