Carnelian Villas

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Case Management – Health Checks Inspection. LPA met with Staff #1 (S1) Richard Robles and discussed the purpose of the inspection. Administrator (AD) Cherie Wood arrived at the facility at around 9:45AM, about two hours after AD was called to the facility. AD stated they live about one to two hours away, depending on traffic, and Licensee (LE) Jing Struve lives about an hour away. Per AD, S1 is in charge when AD is not present at the facility, AD comes to the facility three or four times a week, and LE comes to the facility once or twice a month. AD stated they are the administrator for only one other facility in Los Angeles County Per S1, AD comes to the facility twice or three times a week, LE comes to the facility once or twice a month, and S1 is in charge when AD and LE are not here. LPA found S1 to be knowledgeable and competent to oversee the facility and assist LPA during the inspection before AD arrived and S1 was also highly knowledgeable about the conditions and needs of the residents. LPA reviewed the facility’s infection control policies, emergency disaster plan, and fire drills, and noted the facility does not have an infection control plan. LPA reviewed and obtained a copy of the resident roster, staff roster, staff schedule, and liability insurance. LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 8-bedroom, 10-bathroom, one-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA observed 2 staff and 6 residents present at the facility in addition to AD. Resident Bedrooms: the 6 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the 2 staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. 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 Water temperature: tested between 110 and 116 degrees F in the 7 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are not yet due. LPA reviewed 6 resident files and 5 staff files, interviewed 6 residents and 3 staff, and inspected medications for 6 residents. Facility does not handle resident money. During the inspection, LPA hand-delivered the Noncompliance Conference letter dated July 15, 2025, to AD scheduling a Noncompliance Conference to be held in-person at the Orange County Regional Office on Tuesday, July 29, 2025, at 10:00 AM. During the inspection, LPA and AD observed the following: based on observation, the licensee is not following its fire clearance by placing a latch on the very top of the front door which LPA observed Staff #2 (S2) was unable to unlatch for almost 2 minutes while trying to open the door to allow LPA entry and which AD stated was installed to address Resident #1’s (R1) wandering; based on documents and admission, the facility does not have an infection control plan; based on documents and admission, the licensee has not been conducting quarterly emergency disaster drills as there is only one partially completed disaster drill log for 2025; based on documents and observations, the licensee did not ensure Resident #3 (R3) received assistance with medications when they did not receive their evening Donepezil 10MG once this month; and based on documents and admission, the licensee does not have Staff #4’s (S4) personnel file present at the facility or otherwise accessible during the inspection Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

Licensing Program Analyst LPA Samer Haddadin conducted an announced visit for the purpose of completing an annual inspection. LPA was greeted and granted entry by staff member, Richard Robles. Administrator (AD) Cherrie Wood arrived shortly after. The facility is a single level home and licensed for six non-ambulatory of which 4 may be bedridden with a hospice waiver for 4. At the time of visit, resident had 5 residents in care. This facility is a Residential Care Facility for the Elderly. The facility had 7 bedrooms and 8 restrooms in which 6 are used for resident and 1 bedroom and bathroom for staff members. LPA toured the interior and exterior portions of the facility. Resident rooms were provided with furniture, chair, clean linen, adequate storage space, and kept free of tripping hazards. LPA observed over-the-counter medication in resident’s bedroom located in top drawer of nightstand. Hard wired smoke detectors, carbon monoxide and audible exit alarms were tested to be operational. LPA observed six screwdrivers, plier and a pair of scissors in the kitchen drawer and were not secured. LPA observed knifes and sharp were not locked nor secured due to a broken locked. Also, chemicals were found under the kitchen cabinet sink unlocked accessible to residents in care. LPA toured the outside exterior and observed shaded area for residents. LPA noticed both emergency exits doors were obstructed by a trash can and a brick from the opposite side. LPA tried to exit from one and could not. Bathrooms were observed not to be in good repair as three out of the 8-bathroom sinks were clogged and one bathroom did not have access to hot water due to thick rust on handle. Hot water was measured at 116.6 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. LPA checked fire extinguisher and it was in the green and was last purchased in December of 20204. (..CONTINUE 809C....) 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 LPAs reviewed two clients’ files and no medication discrepancies were observed. LPAs reviewed two staff files with no discrepancies. All files of staff and residents contained all required documentation. LPA did not observe that the emergency drill was last conducted on April 11, 2024 and not current Based on this on this visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of appeal rights and this report was provided to AD.

Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff and stated the purpose of this visit. Administrator Cherie Wood was unable to make the inspection. The facility is a single-level structure licensed for six non-ambulatory with a hospice waiver for four. Four may be bedridden. This facility offers Residential Care for the Elderly/Dementia. At about 11:15 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 5 residents in care and a staff member on duty. LPA toured the interior and exterior portions of the facility. There were 6 resident rooms. The facility also had a staff room which is inaccessible to residents. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 115.5 degrees Fahrenheit. Fire alarms and carbon monoxide alarms were tested to be operational. For the exterior portion, furniture was in good repair; and grounds were free of tripping hazards. LPA did notice a ladder and some chairs that needed to be repair. LPA also noticed two bed frames. Staff stated they will be picked up today. Facility offers a 2-car garage which is used for storage with an operational washer/dryer and 2 refrigerators. LPA noticed medications in one of the refrigerators. LPA was informed that one of the refrigerators was not working. LPA informed staff that non-operational refrigerator needs to be discarded. Kitchen was in good repair. LPA noticed no locks for the medications. Staff could not find the lock. LPA made them aware of citation. LPA noticed locks for disinfectants and sharps needed to be replaced. 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 LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. For this visit, one deficiency was noted in areas observed. One advisory was issued today. LPA Tapia conducted an exit interview with staff and copy of this report along with appeal rights were explained and left at the facility.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the following incidents self-reported by the Licensee: physical abuse of residents by facility staff, neglect/lack of care and supervision resulting in residents sustaining injuries, not providing timely medical treatment, and not properly reporting incidents. LPA met with Administrator Cherie Wood and explained the reason for today’s inspection. The investigation into the above allegations was conducted by Community Care Licensing Investigations Branch (IB) and revealed the following: During the course of the investigation, interviews were conducted with Administrator Wood, Licensee Jing Struve, facility staff, witnesses, and residents. Additionally, copies of bank statements, credit card statements, financial statements, medical records, and a police report were obtained and reviewed. Resident #1 (R1) and Resident #2 (R2) both reside at Carnelian Villas and reported on separate occasions physical abuse by former caregivers who are married identified as Staff #1 (S1) and Staff #2 (S2). S1 and S2 resided at the facility during their employment and managed the facility with little to no supervision by Licensee Struve and Administrator Wood. Caregiver S2 was never cleared to work at the facility and had an exclusion for physical abuse. On 01/29/21, Licensee Struve discovered bruising on R1’s hands and wrist and noticed a swollen black eye. Licensee Struve inquired to both caregivers about the multiple bruises R1 sustained and they informed her that R1 fell off the bed. Licensee Struve asked R1 about their injuries and they requested to be moved to another facility then after their move they reported being physically abused by caregiver S2. (Page 1) 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 03/08/21, Licensee Struve noticed bruising on R2’s wrist and asked them about the injuries and R2 informed her that the caregiver identified as S2 hit them several times on their wrist and on the back of their hand. Licensee Struve questioned caregivers S1 and S2 and they denied any misconduct with the residents. Licensee Struve terminated the caregivers on 03/08/21. Licensee Struve was made aware of the physical abuse in January after R1 disclosed their fear of the caregivers and after sustaining unexplainable bruises to their wrist, legs, forehead and a purple/bluish bruise to their left eyelid. However, Licensee Struve had R1 medically assessed two weeks later on 02/03/2021. Licensee Struve admitted that she was fearful of S1 and S2 and did not report the abuse and failed to protect the residents, she did not provide any timely medical attention to any of the injuries they sustained and failed to report the abuse to law enforcement immediately or to Licensing. There is admission and enough information to the support the findings, therefore, this case is substantiated. Based on the observations made during this investigation, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties in the amount of $500 are being assessed because a staff member worked over 5 days without a clearance transfer. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. (Page 2)