Alamo Care Home

On 7/8/2025 at 8:00 AM, Licensing Program Analyst (LPA) A Gomez conducted a case management as a result of observations made during a visit on 6/19/2025. LPA met with Administrator, Levente Nagy and explained the purpose of the visit. Facility is licensed for 6 non-ambulatory. During todays visit LPA observed that the facility is not maintaining resident files. Administrator states that the facility maintains a MAR but that it is kept off site. LPA also observed that facility is storing R1's medication in a weekly med organizer and not keeping the medication for the week in their original container. When LPA requested to review the staff files administrator stated that they do not have the files available. While reviewing residents files for the last 3 months LPA observed that the facility was over capacity in June 2025. R3 moved into the facility when the facility was already at full capacity. R2 passed away 3 days after R3 moved in. LPA also found that the facility never sent in a death report for R2. When LPA asked administrator why there was not a death report sent in they stated that they did not know they needed to submit a report because R2 was on hospice. LPA found during the visit on 6/19/2025 that staff may be leaving residents at the facility unsupervised. On today's visit LPA spoke with administrator who confirmed that they have approved staff to leave the residents alone in the facility and advised the staff to take the call button alert system so that they would know if a resident required assistance. LPA found that staff are living in an are designated for office space and that a cosmetology related business is being ran out of the storage area Report continues on LIC809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: Medications are not being properly stored Staff are living in an designated office space and storage area is being utilized for an unrelated business where unknown individuals receive services. Facility is not following reporting requirements and did not report a death Residents records were not available upon demand Facility is not maintaining records for all staff** Facility is accepting residents beyond their approved capacity** Administrator is not qualified and is neglecting their responsibilities **Civil penalties in the amount of $1250 are being assessed for repeat violations** The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.

On 6/19/2025 at 8:00 AM, Licensing Program Analyst (LPA) A Gomez conducted a case management as a result of finding out that the facility does not have a facility phone for resident use. LPA met with Caregiver, Voichita Stoica (Gabriella) and explained the purpose of the visit. Licensee and Administrator were unavailable. Facility is licensed for 6 non-ambulatory On 6/17/2025 LPA contacted Licensee to inquire about facility documentation when they noticed that there was not a facility phone number available. LPA asked Licensee for facility phone number as to update the system information. Licensee stated that the facility does not have a designated phone. LPA inquired as to how residents have access to a phone. Licensee stated that residents must ask a staff to use their personal cell phone or have their own. Upon arrival to the facility for the case management LPA observed that staff where not answering the door. The front door was unlocked and when LPA entered they called out and there was no answer. LPA observed 4 residents unsupervised sitting in the dinning and kitchen area. LPA also observed a black kitchen knife in the kitchen on the counter. LPA walked throughout the facility and located S1 assisting a resident getting dressed and S2 mopping the bathroom floor. Through interview LPA also found that residents have been left unsupervised with no staff at the facility. Facility staff was unable to locate staff/resident files and lacked the tools to effectively assist residents in care. LPA also interviewed S1 and S2. Report Continues on LIC809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: Staff are not adequately trained * There is not a designated facility phone Residents are left unsupervised* Dangerous items are left out (Kitchen Knife) * Facility Does not have adequate/competent staffing* Facility Files not available upon request* Facility does not have an adequate substitute for Administrator when Administrator is away* ***Administrator was away during visit and was not answering the phone. LPA had staff sign off on todays report The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.

On 10/25/2024 LPA interviewed S1 who stated that they have given Liquid morphine to residents before including R1. S1 is not a medical professional. On 12/27/2024 LPA interviewed the Licensee who stated that they have given Liquid morphine to residents before including R1. Licensee is not a medical professional. On 12/27/2024 LPA also had a discussion with the Licensee regarding refunds and they admitted that they did not give the complete refund as required to R1s POA because they were unaware of the amount they were supposed to give. Based on interviews and record reviews the allegations “Licensee did not issue resident’s authorized representative a timely refund for the correct amount.” and “Staff did not dispense medication to resident as prescribed.” Are substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D Exit interview conducted and a copy of report provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On all visits LPA observed that the facility was fully stocked with good quality food and of appropriate quantities. LPA was unable to get proof of inadequate food service from any witnesses. Therefore the allegation “Staff did not provide residents with adequate food service.” Is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of report provided.

On 1/30/2025 at 3:00 PM, Licensing Program Analysts (LPAs) A Gomez conducted a case managment visit while at the facility for complaint 15-AS-20250124160912. LPA met with Caregiver, Voichita Stoica (Gabriella) and explained the purpose of the visit. Licensee and Administrator were unavailable. Licensee confirmed via phone that caregiver can sign the report. Facility is licensed for 6 non-ambulatory While conducting the investigation for complaint 15-AS-20250124160912 LPA observed that the facility is over capacity. Facility is licensed for 6 residents and currently has 7. Facility is using an approved staff bedroom as a resident room. LPA is assesing an immediate $500 civil penalty for violation of 87202(a) Fire Clearance. ***A Civil Penalty of $500 is being assessed*** The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.

On 7/05/2024 at approximately 12:30PM, while at the facility on an unrelated complaint investigation LPA A Gomez conducted a case management visit. LPA A Gomez observed a black kitchen knife, and 3 pairs of scissors in the kitchen unsecured. 1 type A deficiency is being issued. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.