Inspection visit

Follow-up on correctionsJune 3, 2025

TIERRASANTA VERNANEL CARE HOMELicense 3720048946 citations on this visit

6 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies which were identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Nelly Panao. Records and interviews showed: On 06/13/2021, Staff #1 (S1) directly witnessed Resident #1 (R1) sexually groping/molesting Resident #6 (R6). [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] Licensee did not personally witness, but was still later told by R6: On 07/30/2021, R1 touched R6 inappropriately. On 09/13/2021, R1 exposed their genitals to R6, without R6's consent. Thereafter, Resident #2 (R2) told Licensee that R1 entered their own bedroom and sexually groped/molested R2 on 09/18/2021, during which time R2 cried out for help for 20-30 minutes. The incidents did not result in physical injuries to either R6 or R2. Despite having constructive knowledge of the above incidents/allegations, Licensee did not report any of them to either CCLD, the Long Term Care Ombudsman (LTCO), or police within the required time frame of twenty-four hours, as required. Licensee also did not submit written incident reports for these same events to CCLD and the responsible persons for R1, R2, and R6, within seven (7) days of incident occurrence, as required. During CCLD’s subsequent complaint investigation: Licensee/S1 was made false/misleading statements to the Department about the extent of their knowledge of R1’s abuse against R6, as evidenced by discrepancies between their verbal statements to CCLD, verses S1’s earlier own dated and handwritten progress/care notes on R1 and R6. [CONTINUED ON LIC 809-D] [CONTINUED FROM LIC 809] Records review, confirmed by manager interview, showed: Licensee did not have on file a completed and signed written Pre-Placement Appraisal (or equivalent document) for R2 and Resident #5 (R5). While Licensee did have a Pre-Placement Appraisal document on file for R1, it was dated the same day of R1’s move-in to the facility. Staff interviews showed that R1 was not interviewed or assessed, and their responsible person was not meaningfully interviewed, prior to R1 physically arriving at the facility. Licensee was thus unaware at time of move-in that R1 was a registered sex offender (RSO) and the risk they would be inheriting. Per their LIC602 Physician’s Report, R1 was diagnosed with Dementia and tended to wander. R1’s physician determined that R1 was not safe to leave the facility unassisted. Care records showed: R1 moved in on 05/05/2020 and eloped from the facility later the same day during waking hours without staff seeing; police had to be called. Staff and resident interviews aligned to further show: During R1’s residency at the facility (which ended in February 2022), there were many subsequent occasions of R1 going into the facility’s outdoor yards at night without staff being aware, harassing multiple housemates by peering into their bedroom windows and unsuccessfully trying to enter their bedrooms using their side doors. A preponderance of evidence existed to show that facility staff did not provide consistent supervision/observation to R1, R2, and R6. Licensee also did not maintain staff alert devices on exterior doors (which was required when caring for persons with Dementia who are at risk for elopement, such as R1). Six (6) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). 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 809-D pages, 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 an other inspection of TIERRASANTA VERNANEL CARE HOME on June 3, 2025. 6 citations were issued: 6 Type B.

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

Yes, 6 citations were issued (0 Type A, 6 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 an 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 June 22, 2026. If you believe any information is inaccurate, report it here.

Follow-up on corrections·June 3, 2025