Complaint·May 11, 2026

[CONTINUED FROM LIC 9099] R1’s first day at the facility was 04/13/2026; their last day at the facility was 04/29/2026. The Complainant said during April 2026, facility staff were giving R1 evening doses of both their routine Alprazolam (Xanax) and Quetiapine (Seroquel) medications at dinner time instead of closer to bedtime. Records and interviews aligned to show that during the complaint time period: Facility staff were typically giving R1 their prescribed Alprazolam (Xanax) doses within plus/minus one hour of 8:00 AM, 12:00 noon, and 5:00 PM, daily. Facility staff were typically giving R1 their prescribed Quetiapine (Seroquel) does within plus/minus one hour of 8:00 AM and 5:00 PM, daily. These times were being set/determined by the third-party pharmacy that was dispensing R1’s medications. Per official prescriptions and doctor’s orders, R1’s Alprazolam (Xanax) was written/instructed as “two times per day” (also known as bis in die or BID) and R1’s Quetiapine (Seroquel) was written/instructed as “three times per day” (also known as ter in die or TID). When medication orders are written with such verbiage, it allows residents/Licensees some flexibility in the specific times such doses can be taken. (At present, RCFE regulations and CCLD publications do not specifically address the minimum time gap required between BID and TID doses.) Starting 04/24/2026, facility staff began giving R1 their second/evening Quetiapine (Seroquel) dose within plus/minus one hour of 9:00 PM, in alignment with R1’s hospice agency around this date amending/reissuing the written prescription/order for this medication to read, “once in the morning and once at bedtime.” The timing of R1’s BID and TID pass times, in and of themselves, did not result in a regulatory violation. However, during review of R1’s MAR, LPA observed, and manager interview confirmed: Facility staff did not give R1 any dose of their Alprazolam (Xanax) until 04/18/2026, meaning R1 missed this medication entirely during their first five (5) days living at the facility. Facility medication technicians wrote that the reason these doses were missed was due to “no supply/waiting for refills,” meaning Licensee did not have said pills on hand to give to R1. There were also multiple other routine medications prescribed to R1 from time of move-in, which in practice were not given to R1 due to “no supply/waiting for refills,” with this problem extending even past 04/18/2026 for these latter medications. According to manager interview: Licensee expects its staff to continually have on-hand supplies of all prescribed medications for each resident, to include for new residents on/by their move-in date. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] R1 came to Stellar Care from a skilled nursing facility (SNF), and Licensee’s staff were supposed to coordinate with the SNF to ensure that R1 discharged with their medications physically accompanying them, until Licensee’s own contracted pharmacy could deliver the next cycle of refills for R1. Licensee’s internal written policy titled “Filling/Refilling Medications” further states that each shift is “responsible for maintaining supply of medications” and that if a medication refill is not received by “10 days out” before the last dose is expended, line staff are required to contact the pharmacy and then escalate the matter to the facility’s nurse and/or Assisted Living Director (ALD), as needed. Interviews showed that prior to CCLD’s involvement, facility management was unaware that R1 had missed multiple doses of their required routine medicines due to no supply. Based on records and interviews, a preponderance of evidence exists to show that Licensee did not give R1 medication as prescribed. The allegation is therefore Substantiated, and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Assisted Living Director Annelie Damasco, 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] The Complainant said that on 04/18/2026, facility caregiver Staff #1 (S1) turned/rotated R1 too quicky/roughly in bed while trying to change R1’s incontinence products; they did not allege any bruising or injury to R1. LPA interviewed S1 and all other witnesses to the 04/18/2026 incident [Person #1 (P1), Person #2 (P2), and Person #3 (P3)]. Interviews, corroborated by photographic and video evidence, unanimously showed: Leading up to the incident, R1 was in their wheelchair in the dining room for dinner, unable to stay awake, unable to be woken up, and unable to maintain upright sitting posture. S1 thus took R1 to their room to rest. S1 transferred R1 to their bed, then changed S1’s Depends while R1 was prone in bed. R1 was too weak to bear their own weight or assist with the transfer motion and too weak to even grab and hold the side rail of their bed. Although P1, P2, and P3 essentially said S1 moved too fast/quick during their transfer of R1 from wheelchair to bed, and during subsequent changing of R1’s depends, these persons also denied R1 sustaining any bruise, skin tear, or injury from S1. They also denied suspecting S1 of acting with any ill-intent during the incident. S1 themselves denied being too fast or rough with R1 during the incident. CCLD concluded that R1 was so non-responsive and deadweight during the 04/18/2026 incident that it was reasonable and appropriate in this instance for S1 to lift and immediately transfer R1 from their wheelchair to their bed (rather than have S1 on the edge of their bed first, before lifting and swinging their legs in.) It was furthermore reasonable and appropriate in this instance for S1 to physically prop/hold R1 up on their side (rather than rely on R1 to grab the side rail and support their own weight) as they changed R1’s Depends. Additionally, LPA interviewed multiple line staff and managers who were coworkers of S1; none of these persons had seen S1 ever handle R1 in a rough or overly-quick manner, on any day. The Complaint said there was a subsequent day (later identified as 04/25/2026) when S1 did not thoroughly clean R1 during incontinence care; the basis for them believing this was because R1 had a strong urine odor and because they didn’t see S1 use R1’s peri-area skin cleanser spray during the changing. LPA interviewed S1 and all other witnesses to the 04/25/2026 incident [P2 and Person #4 (P4)]. P2 and P4 said R1 had a strong urine smell on this date when S1 opened R1’s wet Depends to swap them out for a new/fresh pair. They said R1 did not have any odor/indication of a bowel movement inside their Depends. S1 denied smelling a strong urine odor during this incident but likewise confirmed that R1 did not have any odor/indication of a bowel movement inside their Depends. [CONTINUED ON LIC 9099-C, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] [Interviews and later records aligned to show that R1, who had a history of chronic urinary tract infections (UTIs) predating their move-in to Stellar Care, also had an active UTI on 04/25/2026. According to the Mayo Clinic, UTIs can be a common cause of strong, foul-smelling, or ammonia-like urine odor.] S1, P2, and P4 unanimously reported that while no peri-area skin cleanser spray was initially used during the incident, S1 did start out by thoroughly wiping the skin in R1’s peri-areas with wet wipes designed for incontinence care, before putting the new/fresh pair of Depends on R1. According to interview of R1’s assigned hospice agency registered nurse (RN) case manager: It was never an order/requirement from the hospice agency or R1's physician that facility staff use peri-area skin cleanser spray when changing R1’s Depends. The spray was provided by the hospice agency to facility staff simply as an optional tool. The RN further told LPA that use of wet wipes as a stand-alone cleaning tool for cleaning patients during Depends-changing was adequate/sufficient for good hygiene, and that they had no concerns about the frequency or quality of incontinence care that Stellar Care caregivers provided to R1 in practice. There was also nothing in R1’s LIC602 Physician’s Report, LIC603 Preplacement Appraisal, or LIC625 Appraisal/Needs and Services Plan that showed peri-area skin cleanser spray was ever required to be used on R1 during changing. Interview of R1’s responsible person (RP) and facility managers also showed that at the time that R1 moved into the facility, use of this spray was neither specifically requested/discussed by the RP, nor specifically promised by facility managers. Neither current RCFE regulation nor Licensee’s internal written policies mention peri-area skin cleanser spray being a specific requirement during changing of briefs/Depends, either. The Complainant said R1 was witnessed wearing no dentures in their mouth around dinner time on 04/18/2026, and that staff did not bring them over to R1 until family members said something to the staff. The Complainant admitted to LPA that they never inquired with the staff as to why the dentures were not put in R1’s mouth. Multiple care documents on R1, E-mailed correspondence, and interviews of staff and outside sources aligned to show: R1 had an upper denture which was already broken, prior to their move-in to the facility. From the outset, facility managers provided R1’s RP with a list of local dentists (to include a mobile dentist) and requested their help in contracting a dentist to have the denture repaired. By the date the complaint was filed, R1’s upper denture still had not been repaired or replaced. R1 was on a soft-texture diet and was still able to consume food when they chose to eat, even without this upper denture in their mouth. Per interview of R1’s assigned hospice RN, R1 had lost almost twenty pounds of body weight between February 2026 and 04/13/2026, the date R1 moved into the facility. [CONTINUED ON LIC 9099-C, 3 of 3] [CONTINUED FROM LIC 9099-C, 2 of 3] The RN told LPA that even if R1’s upper denture had not been broken, R1’s dramatic weight loss, since the denture was manufactured, could make it so that they still would not fit/seat well inside R1’s mouth. The RN further said it was reasonable/appropriate for facility staff to not put broken and/or ill-fitting dentures in R1’s mouth. Based on records and interviews, a preponderance of evidence does not exist to show that Licensee’s staff handled R1 in a rough manner, that Licensee did not thoroughly clean R1 during incontinence care, or that Licensee did not assist R1 with wearing their dentures. These allegations are therefore Unsubstantiated, and no deficiencies were cited for them. An exit interview was conducted with Assisted Living Director Annelie Damasco, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.