Good Shepherd of Danville
RCFE · Memory Care
A Residential Care Facility for the Elderly (RCFE) is a non-medical residential care home licensed by California CDSS under Health & Safety Code §1560. Residents receive help with daily living activities such as bathing, dressing, and medication management. An RCFE with a Memory Care designation is additionally required by California Title 22 (§87705 and §87706) to provide specialized staff training in dementia care, individualized care plans for residents with cognitive impairment, and appropriate supervision protocols — requirements that go beyond a standard RCFE license.
287 Verde Mesa · Danville, 94526
Quick facts
Quality snapshot
Updated April 25, 2026Compared to 182 California RCFE memory care facilities of similar size, over the last 36 months.
Source: California Department of Social Services, Community Care Licensing Division. View raw inspection records →
Quality grade· click to show how this was calculated
Severity13thWeighted citations per bed
Repeats100thRepeat deficiencies as share of total
Frequency41thDeficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Quality grade· click to show how this was calculated
Weighted citations per bed
Repeat deficiencies as share of total
Deficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Good Shepherd of Danville scores C. Better than 51% of comparable California RESIDENTIAL CARE ELDERLY facilities. Severity: bottom 13%. Repeats: top 0%. Frequency: 41th percentile.
Each metric is converted to a 0–100 percentile within the peer set (higher = better). The composite grade averages all four. Peer set: CA / rcfe_memory_care / small beds (182 facilities).
Citation severity over time
↓ improvingWeighted severity score per month · 24 months
Weighted score (24mo)
135
Last citation
Sep 25
Finding distribution
24 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility
California Title 22 requirements for this facility, with the specific regulation and a suggested question for each.Rules this facility has been cited for are shown first.
What dementia-care training must staff complete?Cited Aug 202422 CCR §87705 / HSC §1569.625
Because this facility markets dementia or Alzheimer's care, state law mandates higher training standards:
- 12 hours initial dementia training — 6 hours before a staff member works independently with residents, 6 more within the first 4 weeks.
- 8 hours annual dementia in-service — required every year thereafter.
- Administrator CE — the administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle.
Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour: Ask how dementia training records are kept — families may request documentation.
What must this facility report to the state — and how fast?Cited May 202522 CCR §87211 / WIC §15630
- ImmediateElopement, fire, epidemic outbreak, or poisoningImmediately
- 2 hoursAbuse with serious bodily injury2-hour phone report + 2-hour written report — to the California Department of Social Services (CDSS), Adult Protective Services, and law enforcement
- 24 hrsAbuse without serious bodily injuryWithin 24 hours
- Next dayDeath of a residentPhone by next working day; written within 7 days
- Next dayInjury requiring medical treatment beyond first aidPhone by next working day; written within 7 days
- WrittenBankruptcy, foreclosure, eviction, or utility shutoff noticeWritten notice to CDSS and residents — $100/day penalty (max $2,000) for failure
Your enforcement lever:Incidents that aren't reported on time are themselves a separate violation. If you believe a reportable event wasn't filed, you can submit a complaint directly to the California Department of Social Services (CDSS).
How many staff must be on duty overnight?22 CCR §87415
Based on 6 licensed beds:
One qualified staff member must be on call and physically on premises at all times overnight.
Violation pattern to watch for:A facility that documents a staff member as "on call" but with that person physically off-site — when the law requires on-premises presence — is in violation of this section.
Ask on tour: Ask the facility to walk you through their overnight staffing plan and confirm whether on-call staff are on premises or off-site.
What health conditions can this facility legally accept or refuse?22 CCR §87612–87615
Restricted — allowed with physician order + care plan
- Supplemental oxygen
- Insulin and injectable medications
- Indwelling or intermittent catheters
- Colostomy / ileostomy
- Stage 1 and Stage 2 pressure injuries
- Wound care (non-complex)
- Incontinence
- Contractures
Prohibited — facility must refuse or discharge
- Stage 3 or Stage 4 pressure injuries
- Feeding tubes (PEG, NG, or J-tube)
- Tracheostomies
- Active MRSA or communicable infections requiring isolation
- 24-hour skilled nursing needs
- Total ADL dependence with inability to communicate needs
A hospice waiver (HSC §1569.73) can allow continued care for residents on hospice who would otherwise fall into a prohibited category.
Ask on tour: Ask whether your loved one's specific care needs are restricted or prohibited, and what the facility's process is if needs change after admission.
How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58
- 1Notice of DeficiencyWritten citation with a correction deadline. Facility must submit a Plan of Correction.
- 2Civil PenaltyStarts at $50/day for non-serious; $150/day for serious deficiencies — immediately, with no grace period. Repeats escalate to $150 first day + $50/day, then $1,000 first day + $100/day.
- 3Suspension of AdmissionsFacility cannot accept new residents until violations are corrected.
- 4Temporary Suspension or RevocationEmergency suspension for imminent danger; full revocation after administrative hearing.
- 5Exclusion OrderAdministrator and operator can be barred from all CDSS-licensed facilities — not just this one.
See how these rules have been applied to this specific facility:
View state inspection record and citationsState records
California Dept. of Social Services · Community Care Licensing- License number
- 079201257
- License type
- RESIDENTIAL CARE ELDERLY
- License status
- LICENSED
- License expires
- Not yet indexed
- Licensed beds
- 6
- Operator
- Senior Legacy Health Care Services, Inc
Inspections & citations
15
reports on file
24
total deficiencies
9
Type A (actual harm)
1
dementia-care citations
Other visitSeptember 5, 2025Type A4 deficiencies
Plain-language summary
On September 5, 2025, state inspectors conducted the facility's annual inspection and found several deficiencies: some resident records were incomplete, one staff member was providing care without required training and without supervision, a garage had been converted to staff living quarters without approval, and that same staff member was not properly registered with the facility. The facility was given until October 1, 2025 to submit updated documentation and correct these issues.
View full inspector notes
On 9/5/2025 at 8:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Isigani Silvestre and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory of which 1 may be bedridden in room 2 only. LPA toured facility with Isigani Silvestre including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 5 bedrooms are occupied by the residents and 0 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 108.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last purchased on 3/28/2025. Emergency Disaster Plan was last posted on 3/1/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 6/15/2025. At 8:50 am, LPA reviewed 4 residents records. At 9:40 am/pm, LPA reviewed 2 staff records and 2 of 2 have current first aid training and 1 of 2 are associated to the facility. 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: Resident records were incomplete S2 not trained and was observed providing care unsupervised Garage was converted to staff living quarters and it was not been approved/cleared LPA observed that S2 is was not associated to the facility Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 10/01/2025: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Current Administrator’s Certificate All forms to update Administrator 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.
Regulation
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:
Inspector finding
Based on record review, the licensee did not comply with the section cited above in S2 not being associated which poses an immediate safety risk to persons in care. POC Due Date: 09/05/2025 Plan of Correction 1 2 3 4 S2 stopped working and agreed not to return until cleared. POC clear
Regulation
(a) Prior to construction or alterations, all facilities shall obtain a building permit.
Inspector finding
Based on observation and record review, the licensee did not comply with the section cited above by converting the garage without prior notice/ approval which poses a potential personal rights risk to persons in care. POC Due Date: 10/10/2025 Plan of Correction 1 2 3 4 By POC facility agrees to review the regulation and make updates as required and notify CCLD
Regulation
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:
Inspector finding
Based on record review, the licensee did not comply with the section cited above in S2 not being trained prior to providing unsupervised care which poses a potential personal rights risk to persons in care. POC Due Date: 09/26/2025 Plan of Correction 1 2 3 4 By POC facility agrees to train S2 prior to leaving them unsupervised and notify CCLD
Regulation
(b) Each resident's record shall contain at least the following information:
Inspector finding
Based on record review, the licensee did not comply with the section cited above in residents files being incomplete which poses a potential personal rights risk to persons in care. POC Due Date: 09/26/2025 Plan of Correction 1 2 3 4 By POC facility agrees to review all residents files and update them accordingly and notify CCLD
Other visitAugust 26, 2025Type A1 deficiency
Plain-language summary
On August 26, 2025, inspectors conducted a health and safety inspection following a priority complaint and found that hot water in the residents' bathroom measured 99.7 degrees Fahrenheit, below the required range of 105-120 degrees. All other safety measures checked out—food supplies were adequate, medications were locked up, smoke and carbon monoxide detectors were in place, the first-aid kit was complete, and fire extinguishers were full. The facility was cited for the hot water temperature violation and given a deadline to correct it.
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On 8/26/2025 at 3:30 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 1 complaint. LPAs met with Administrator, Isigani Silvestre Morgan and explained the purpose of the visit. LPA toured facility including but not limited to bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at degrees 99.7 F in residents shared bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked in kitchen cabinet. Smoke detectors and Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last purchased on 3/28/25. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. LPA cited for Hot water temperature not being in range 105-120 F. 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.
Regulation
(e) Water supplies... maintained as follows:(2) Faucets...temperature ...of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not as evidence by
Inspector finding
Based on observation the above requirement was not met by the shared bathrooms hot water measuring at 99.7 degrees F which poses an immedite health risk to residents in care.
Other visitAugust 12, 2025No deficiencies
Plain-language summary
On August 12, 2025, a state licensing analyst made an unannounced visit to deliver an amended report from a previous complaint investigation. No deficiencies were cited on this date.
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On 8/12/2025 at 8:30AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit to deliver an Amended Report for Complaint 15-AS-20240910163010. LPA met with Administrator,Isagani Silvestre and informed him the reason for visit. During visit, LPA delivered the amended report for complaint 15-AS-20240910163010. Caregiver Cynthia Candell approved to sign todays report due to Administrator needing to leave. No deficiencies are being cited on this date. Exit interview conducted and a copy of this report provided.
InspectionMay 28, 2025Type B3 deficiencies
Plain-language summary
During a May 28, 2025 inspection, an analyst observed a staff member yelling at a resident and heard the staff member say "that's not my job," and also found that the resident's care plan was not being followed. The facility was cited for staff speaking to residents inappropriately, failing to report incidents as required, and not following residents' care plans. The facility was notified that failure to correct these issues may result in civil penalties.
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On 05/28/2025 at 12:00 PM Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a Case Management visit while delivering findings for complaint 15-AS-20240910163010 . LPA met with Backup Administrator, Merdith Castro and explained the reason for the visit. Upon arrival to the facility LPA observed S1 yelling at R1 in their room and LPA heard S1 state "thats not my job". S1 stopped yelling at R1 once R1 started yelling back and LPA announced themself. LPA then interviewed R1. During the course of the case management LPA reviewed the care plan for R1, interviewed S1, S2, S3, R1, and R2. LPA observed R1s careplan and found that it is not being followed. LPA found that S1 has previously spoken to residents inappropriately and it has not been reported to CCLD. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: Staff talking to resident inappropriately Staff not reporting incidents as required Staff not following residents care plan The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided
Regulation
(a) Each licensee shall furnish... reports...to, the following:(1)A written report shall be submitted ...within seven days(D)Any incident which threatens the welfare,... of any resident. This requirement was not met as evidence by:
Inspector finding
Based on interviews, and record reviews, the facility did not comply with the section cited above by not reporting incidents to CCLD as required ehich posed a potential personal rights risk to persons in care.
Regulation
(a)Residents of residential care facilities for the elderly shall have all of the following rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by:
Inspector finding
Based on interviews, and observation, the staff did not comply with the section cited above by speaking inappropriately to residents which posed a potential personal rights risk to persons in care.
Regulation
(f) Basic services shall at a minimum include:(4)Personal assistance.. as indicated in the pre-admission appraisal, with ...bathing ... This requirement was not met as evidence by:
Inspector finding
Based on interviews, and record reviews, the facility did not comply with the section cited above by not providing resident with bathing as specified in their care plan which posed a potential personal rights risk to persons in care.
ComplaintMay 28, 2025· MixedType B4 deficiencies
Inspector: Alona Gomez
Plain-language summary
A complaint investigation found that staff failed to change a resident's diapers promptly or respond quickly to their calls for help, which caused a pressure injury to worsen over months—staff waited for the resident to request changes rather than checking proactively, and the resident sometimes waited hours sitting in soiled diapers. Investigators also found that staff questioned residents about their conversations with inspectors, violating privacy, and that staff raised their voices at the resident in ways that amounted to verbal abuse. The facility was assessed a $500 penalty, with additional penalties pending.
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pg 2 On the allegations Staff not changing residents in timely manner, Staff neglecting resident resulting in pressure injuries, and Staff not responding to resident calling for help in a timely manner the following information was gathered: On 9/19/2024 a subpoena was served to Ace Home Health for R1’s medical records. The records revealed that between 1/23/2024 and 9/18/2024 R1 experienced worsening pressure injuries from lack of care and infrequent diaper changes by the facility staff. A care plan dated 10/31/2023 also stated that R1 is to have a call button and requires assistance with Activities of Daily Living (ADL’s). On 7/15/2024 W1 documented “R1 is left in soiled adult diapers during the night leading to severe excoriation of the skin and worsening of pressure injuries. Staff do not consistently respond to R1’s calls for assistance in a timely manner.” W1 also documented that they previously provided detailed instructions for staff to reposition R1 every 1-2 hours and promptly change R1’s diapers after incontinence; however, staff failed to consistently follow these instructions. W1 stated “I have repeatedly told the facility staff that R1 cannot sit in a wet diaper. It exacerbates R1’s skin injuries. They (staff) tell R1 that they will “get to it” but R1 ends up sitting in their waste for hours. R1 skin was bloody and raw on multiple occasions. W1 further explained that R1’s sacral pressure injury progressed to a stage 3 due to prolonged moisture exposure. W1 also noted that R1’s condition improves when wound care staff intervene, but the facility staff revert to neglectful care shortly after. R1 stated in interviews that sometimes they ring their call bell, and no staff come for hours. R1 states that once they had to wait so long that they started crying from sitting in their own waste. R1 states that staff tell them to “stop yelling because they are not an animal” R1 reported delays in assistance occurring particularly during night shifts and further described the pain they experience from sitting in their waste. Report Continues on LIC9099-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 pg 3 S1 stated that they estimate that R1’s diapers are changed about 12-18 times a day, but that staff relies on R1 to tell staff when they need to be changed, and that staff do not proactively check on R1. S1 admitted that there could be delays stating “Sometimes we(staff) are busy with other residents so there might be a delay, but we(staff) eventually get to R1.” S1 confirmed that staff were aware of R1’s need for frequent diaper changes. In the interview with S2 they denied being informed of delays in R1 being changed and the fact that R1 had pressure injuries. However, when S2 was presented with documentation of R1’s notes detailing the instructions for R1 from the wound care they stated that, “This should have not happened if proper care was provided” S2 also denied knowing of the notes left for R1’s pressure injuries S3, S4, and S5 all had similar account when it came to the frequency of changing R1 stating that they are changed on average 10 times a day but did wait for R1 to request being changed. Staff also all alluded to R1 “requiring a lot of attention” and that they were not always able to assist immediately. Based on the interviews, medical records, wound care notes and photos it was found that delays in providing incontinence care directly contributed to the progression of R1’s pressure injuries. While staff claimed to respond “eventually” the lack of proactive care and reliance on R1 to request assistance demonstrates systemic neglect. The facility failed to ensure adequate staffing or adherence to care instructions, resulting in preventable harm to R1. Therefore, the allegations of Staff not changing residents in timely manner, Staff neglecting resident resulting in pressure injuries, and Staff not responding to resident calling for help in a timely manner are Substantiated . Report Continues on LIC9099-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 pg 4 Amended On the allegation "Facility does not provide privacy to residents in care" during the course of the investigation it was found during interviews when CCLD comes to visit the staff will question the residents as to what they talked about with LPA's or Investigators. It was observed during the investigation that staff went to question R1 after speaking with the Investigator and that the Investigator had to advice staff that all interviews are confidential. Based on interviews and observations the allegation "Facility does not provide privacy to residents in care" is Substantiated . On the allegation of “Staff verbally abusing resident” 3/19/2025 LPA interviewed staff S2 and S6 on 3/19/202 that stated that they do not use profanity, call residents’ names, or yell at residents. S2 admitted to sometimes raising their voice when residents are yelling at them and making accusations that they deemed untrue. S2 emphasized that they do not yell at clients but that when clients are upset their tone elevates when trying to reason with residents. Therefore the allegation “Staff verbally abusing resident” is substantiated . ****A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.**** The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22. Substantiated findings will be reviewed for possible enhanced civil penalty assessment. Exit interview conducted and a copy of this report provided. ***Caregiver, Cynthia Caudill was approved by administrator to sign todays amended report*** 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 the allegations Staff physically abuses residents in care, and Staff does not allow residents access to phone interviews and observations were conducted. Throughout the course of the investigation it was found that the facility has a phone that is available to residents and that it is operational with service. It was observed on 3/19/2025 that the primary phone is located in the kitchen on the table and is cordless allowing residents to take the phone throughout the facility. During the investigation the LPA did not observe any residents with bruises or scratches. LPA interviewed staff and did not find any inclination of physical abuse. LPA was unable to interview additional residents due to their cognitive abilities. Based on interviews and observations the above allegations are 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
Regulation
(b)In addition … the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry … from incontinence This requirement was not met as evidence by:
Inspector finding
Based on interviews and record review the facility did not comply with the section cited above by not keeping R1 clean and dry from incontinence which posed a potential health , and personal rights risk to persons in care.
Regulation
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by:
Inspector finding
Based on interviews the facility did not comply with the section cited above by not having adequete staff to respond to residents needs in a timely manner which posed a potential health, and personal rights risk to persons in care.
Regulation
(a)In addition … residents …shall have all of the following personal rights:(1)To have …personal privacy in… communications…and meetings of resident and family groups. This requirement was not met as evidence by:
Inspector finding
Based on interviews and observation the facility did not comply with the section cited above by not providing privacy to residents which posed a potential personal rights risk to persons in care.
Regulation
(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, … This requirement was not met as evidence by:
Inspector finding
Based on interviews the facility did not comply with the section cited above by speaking inappropriately to residents which posed a potential personal rights risk to persons in care.
ComplaintNovember 6, 2024· UnsubstantiatedNo deficiencies
Inspector: Gregory Clark
Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.
Plain-language summary
A complaint was investigated that alleged staff were not keeping the facility clean, sanitary, free of trash, or free of rodents. The inspector found the facility to be neat, clean, and free of rodents and odors, with trash properly stored in bins. The complaint was not substantiated.
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Upon inspection LPA observed the facility to be neat, clean, tidy, and free of rodents and odors. Trash bins are located behind the fence along the side of the facility. LPA did not observe any exposed waste or feces, the trash was neatly stored in the bins. There was no excess waste observed. This agency has investigated the complaint alleging staff do not keep the facility clean, sanitary or free of trash and staff do not keep the facility free of rodents. We have found that the complaint was unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.
InspectionSeptember 12, 2024No deficiencies
Inspector: Alona Gomez
Plain-language summary
A health and safety inspection was conducted on September 12, 2024, and no violations were found. The inspector checked the facility's hot water temperature, food supplies, medication storage, smoke and carbon monoxide detectors, fire extinguisher, first-aid kit, and passageways—all met requirements. The facility was also confirmed to be free of hazards like accessible bodies of water or obstructed walkways.
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On 9/12/2024 at 4:30 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Caregiver, Rommel Dimzon and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 110.5 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies on a weekly basis. Resident's medications were kept locked in the med room. Smoke detectors were observed. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last purchased on 4/8/2024. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Other visitSeptember 12, 2024Type A1 deficiency
Inspector: Alona Gomez
Plain-language summary
A follow-up inspection on September 12, 2024, found that the facility had not corrected a violation from its August inspection: a resident in room 5 was still listed as bedridden when the facility is only licensed to care for one bedridden resident, and that resident should be in room 2. The facility was assessed a $700 civil penalty for failing to correct this issue by the required deadline and will face ongoing penalties until the violation is resolved.
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On 9/12/2024, at 4:45PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Administrator, Merdith Castro, and explained the purpose of the visit. LPA conducted an annual inspection on 8/28/2024 and cited for the following deficiencies that has not been corrected. 87202(a)(2)- LPA observed resident in room 5 is still designated as bedridden and is not on hospice. Only room 2 is cleared for bedridden and facility is only cleared for 1 bedridden resident. ***Civil Penalty 100 day X 7 days= $700 Civil Penalties in the total amount of $700.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiencies are corrected. Exit interview conducted. A copy of this report, LIC421FC, and appeal rights provided.
Regulation
(a) All facilities shall maintain a fire clearance approved by the city, county, ..., or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
Inspector finding
Based on observation and record review, the licensee did not comply with the section cited above in having two bedridden residents and one of the residents is in room 5 that is not cleared for bedridden which poses an immediate health, safety risk to persons in care.
Other visitAugust 28, 2024Type A7 deficiencies
Inspector: Alona Gomez
Plain-language summary
This was an unannounced annual inspection on August 28, 2024, which found several safety issues: an unlocked medicine cabinet and unlocked drawer containing knives and scissors, a cleaning chemical left in a bathroom, an unsupervised staff member who was not authorized to work at the facility, one bedridden resident placed in a room not approved for bedridden care, and missing emergency disaster plan and drill records. The facility corrected the unlocked storage and removed the chemical during the visit, but was assessed $600 in civil penalties and required to submit missing documentation by September 10, 2024.
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On 8/28/2024 at 9:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with On-Call Nurse, Merdith Castro and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory of which 1 may be bedridden in room 2 only. Facility currently has 2 bedridden residents at the facility that are not in hospice. LPA toured facility with Caregiver, Rommel Dimzon including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 112.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last purchased on 4/08/2024. Emergency Disaster Plan was not posted or available for review. First aid kit was observed to be complete. Emergency disaster drill was last conducted in February but facility does not have any record. At 1:00pm, LPA reviewed 6 of 6 residents records. At 2:20pm, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. 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: At 10:37AM LPA observed that medicine cabinet was unlocked and unsupervised. staff locked cabinet. At 10:77AM LPA observed that sharps drawer with knives and scissors was unlocked and unsupervised. staff locked cabinet. At 10:38AM LPA observed a bottle of Oil Eater on the clients bathroom counter. Staff removed solution. At 10:56AM LPA observed an individual who is not currently fingerprint cleared and has previously been marked "NOT ELIGIBLE" working at the facility unsupervised. Individual left facility. (Civil Penalty $100) At 1:13PM LPA observed R1 to be designated as BEDRIDDEN and in room 5. (Civil Penalty $500) At 3:20PM The facility did not have an Emergency Disaster plan available for review At 3:25PM The facility did not have disaster drill logs available for review but said they did a drill in February. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 9/10/2024: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Current Administrator’s Certificate ****Total Civil Penalties Assessed $600**** 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.
Regulation
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fi…
Inspector finding
Based on observation and record review, the licensee did not comply with the section cited above in having two bedridden residents and one of the residents is in room 5 that is not cleared for bedridden which poses an immediate health, safety risk to persons in care. POC Due Date: 09/05/2024 Plan of Correction 1 2 3 4 Administrator agrees to put resident on hospice or find new placment for resident.
Regulation
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
Inspector finding
Based on observatio, the licensee did not comply with the section cited above in having a cleaning solution out in residents bathrooms which poses an immediate health, and safety risk to persons in care. POC Due Date: 08/29/2024 Plan of Correction 1 2 3 4 Facility Locked away cleaner
Regulation
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
Inspector finding
Based on observation, the licensee did not comply with the section cited above in having knives unlocked which poses an immediate safety risk to persons in care. POC Due Date: 08/29/2024 Plan of Correction 1 2 3 4 Facility Locked cabinet.
Regulation
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:
Inspector finding
Based on record review, the licensee did not comply with the section cited above in not having an updated emergency disaster plan which poses a potential safety risk to persons in care. POC Due Date: 09/10/2024 Plan of Correction 1 2 3 4 Adinistrator agrees to review and update Emergency Disaster plan and email a copy to CCLD
Regulation
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill,…
Inspector finding
Based on record review, the licensee did not comply with the section cited above innot having done required disaster drills which poses a potential safety risk to persons in care. POC Due Date: 09/10/2024 Plan of Correction 1 2 3 4 Administrator agrees to conduct the required drills document and notify CCLD
Regulation
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in having medications cabinet unlocked which poses an immediate safety risk to persons in care. POC Due Date: 08/29/2024 Plan of Correction 1 2 3 4 Facility locked cabinet
Regulation
Criminal Record Clearance. All individuals subject to a criminal record review... Obtain a California clearance...as required by the Department...
Inspector finding
Based on record review, licensee did not comply with the section cited above by not having staff fingerprint cleared which poses an immediate health and safety risk to the persons in care. POC Due Date: 08/29/2024 Plan of Correction 1 2 3 4 Staff Left facility.
Other visitAugust 13, 2024No deficiencies
Inspector: Alona Gomez
Plain-language summary
On August 13, 2024, state regulators made an unannounced follow-up visit to check on the facility's response to a complaint investigation completed five days earlier. The inspector met with staff and reviewed the findings, which included correcting an earlier report that had incomplete information about who was present during the initial investigation. No violations were found during this follow-up visit.
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On 8/13/2024 at 3:14 PM Licensing Program analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit relating to the complaint investigation done on 8/8/2024. LPA met with Caregiver, Rommel Dimzon and explained the purpose of the visit. On 8/1/2024 LPA came to the facility to conduct an initial 10-day complaint investigation and deliver findings. LPA met with Administrator, Maria Arceo . At the time of the visit LPA did not put who they met with on the top of the report. LPA amended the incorrect report and provided the facility with a copy of the amended report. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
ComplaintAugust 1, 2024· SubstantiatedType B2 deficiencies
Inspector: Alona Gomez
Regulation
(a) Based on the individual's preadmission appraisal,... Postural supports may be used under the following conditions.(2) Postural supports shall... permits quick release by the resident. This regulation is not met as evidence by:
Inspector finding
Based on interview and photos R1 was restrained in bed by a strap that was tied to bedrails which posed a potential health and personal rights risk to person in care.
Regulation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulation is not met as evidence by:
Inspector finding
Based on observation the dryer has an out of order sign and does not properly work. Staff has been hang drying clothes outside which poses a potental personal rights risk to persons in care
Other visitMay 14, 2024Type A2 deficiencies
Inspector: Alona Gomez
Plain-language summary
On May 9, 2024, a resident with a history of elopement disabled a door alarm and left the facility unassisted early in the morning; the resident was located in Antioch several hours later without physical injury and transferred to a hospital for evaluation. The inspection found that the facility did not have adequate staffing plans or monitoring procedures in place for this resident's known tendency to elope, and staff training records were not readily available for review. The facility was cited for these deficiencies.
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On 5/14/2024 at 9:25 AM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of an unusual incident report received 5/9/2024. LPA met with Caregiver, Hope Veneracion and explained the purpose of the visit. Administrator later arrived. On 5/9/2024 CCLD received an unusual incident report stating that a resident (R1) left the facility unassisted and was not found in their bedroom at approximately 8:30AM when facility staff went to get them ready for the day. Danville Police department was notified and a search for R1 was conducted. Administrator stated that resident disabled the door alarm and exited through kitchen door. Administrator also stated that facility staff (S2) saw the resident last at approximately 3:45AM when the resident went to the bathroom. On 5/13/2024 resident was located and transferred to Contra Costa Regional Center. Resident is reported to have been located without any physical injuries. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 111 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked in the kitchen. Smoke detectors and carbon monoxide detectors were observe. First-aid kit was complete. Fire extinguisher was purchased on 4/08/2024. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. Door alarms were observed and were in working order during visit. 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 LPA interviewed S1, S2, Administrator, and R2. LPA also spoke with R1's regional social worker over the phone as well as a Danville police officer. LPA obtained copies of R1's needs and services plan, as well as the police report number associated with he incident. Administrator is to fax over staff training's for review. During interview S1 stated that the kitchen door alarm was set at the end of their shift and they are unsure as to how it got turned off. S2 states that they also remember going over all door alarms with S1 and that they were set. S1 and S2 state that they are unsure if R1 would be able to reach the door alarm to disable it but that R1 observes staff closely and has attempted before to unlock other locks such as the medicine cabinet. S2 also states that they saw R1 go to the bathroom around 3:45am. During interview with R2 they stated that they did not hear R1 on the morning of elopement. R2 states that R1 has attempted to exit facility before and frequently walks around at night checking to see what doors are unlocked. R2 states that they did not hear any alarm go off on the day of elopement. During phone interview with R1's regional social worker LPA was informed that R1 has a history of elopement. Social worker states that R1 has "sneaky" behavior and has in the past been know to observe staff and use that as a means to elope or do other dangerous behaviors. Social worker stated that R1 has had psych evaluations that show that R1 is high functioning but lacks the cognitive abilities to think out the consequences of their actions. 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 During phone interview with Danville police officer LPA learned that it is estimated that R1 eloped from the facility around 6:00-7:00AM. R1 is suspected to have left in this time frame based on eye witnesses as well as an estimated walk time from facility to local bus stop. Officer advised LPA that R1 called their son who reported the call to police. Police then located R1 in Antioch and transferred R1 to a local hospital. R1 was observed to be lucid and without injury. The following Deficiencies will be cited: Adequate staffing/plan was not available to ensure that resident with elopement tendencies was properly addressed. Staff training's are not readily available for review at facility The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. 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.
Regulation
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...require such additional staff for the provision of adequate services. This requirement is not met as evidence by:
Inspector finding
Based on report of resident with previous elopement behavior eloping from facility the staff were not competent in how to address the behavior and prevent the resident from being missing for days.
Regulation
All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidence by:
Inspector finding
Administrator did not have training records readily available for review upon LPA's request
Other visitApril 16, 2024No deficiencies
Inspector: Alona Gomez
Plain-language summary
A follow-up inspection was conducted on April 16, 2024, after a resident reported that no staff was available to help them get ready for bed between 9 and 11 p.m. on April 15, 2024, when an off-duty staff member at the facility declined to assist and told them to wait for the next scheduled caregiver. The facility's staff schedule showed full coverage for that time, and staff members denied a gap in coverage, but because the facility does not keep a sign-in sheet for staff, the inspector could not confirm whether there actually was a staffing gap. No violations were cited, though the inspector discussed the importance of staff availability and suggested implementing a sign-in system.
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On 4/16/2024 at 12:50PM Licensing Program Analyst (LPA) A Gomez conducted a case management as a result of information received during a complaint visit. LPA spoke with Administrator, Merdith Castro and informed them of the nature of the Case Management. During interviews for a complaint received 4/11/2024 R1 stated that on 4/15/2024 there was not staff on schedule available to assist them with going to sleep from 9:00pm to 11:00pm. R1 stated that an off duty staff was at the facility cooking themself dinner and that when R1 asked for assistance the staff told them that they would need to wait for the next caregiver to be on duty. LPA reviewed the staff schedule and spoke with S1 and S2 over the phone who both stated that there was no gap in the schedule. The facility does not have a sign in sheet for staff. Administrator also provided LPA with a copy of the staff schedule that showed full coverage for the night. LPA was unable to determine if there was a gap in coverage for 4/15/2024. LPA went over the importance of having staff readily available and discussed the facility possibly implementing a sign in and out sheet for staff on duty. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Other visitApril 9, 2024No deficiencies
Inspector: Alona Gomez
Plain-language summary
State inspectors visited this facility on April 9, 2024 to check conditions after the facility took in residents displaced from a fire elsewhere. The inspector toured the bedrooms, bathrooms, kitchen, and outdoor areas, reviewed food and medication storage, and verified that safety equipment like smoke detectors, fire extinguishers, and carbon monoxide detectors were in place and working. No violations were found.
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On 04/0/92024 at 3:50 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of CCLD receiving notification of Residents being relocated to facility due to a fire at another facility. LPA met with Caregiver, Hope Veneracion and explained the purpose of the visit. Administrator was unavailable. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 110.2 degrees F in the bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked. Smoke detectors are interconnected with the sprinkler system. A comfortable temperature was maintained at 77 degrees F. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was purchased on 4/08/2024. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. LPA spoke with R1 and R2 to see how they are adjusting to the facility. R1 and R2 have dementia and were unable to give coherent answers. Administrator has residents files at the facility and medications at the facility No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
ComplaintOctober 4, 2023No deficiencies
Inspector: Laura Hall
Plain-language summary
This was a pre-licensing inspection in October 2023, meaning the facility was being checked before it could open. The inspector found the facility met safety requirements: bedrooms and bathrooms were properly equipped, grab bars were installed, medications and hazardous items were locked up, fire safety equipment was in place, and hallways were clear of obstacles. The facility was approved to move forward in the licensing process.
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On 10/4/2023 at 4:00pm,, Licensing Program Analyst (LPA)L. Hall arrived unannounced to conduct a pre-licensing inspection. LPA met with Meredith Castro, designee and explained the purpose of the visit. The facility has an approved fire safety clearance for five (5) non-ambulatory and one (1) bedridden resident. LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage and back yard. The facility has a total of five (5) bedrooms, two (2) bathrooms. There were no bodies of water present during inspection. There is sufficient lighting around the facility. Residents rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with grab bars. Passageways and hallways are free of obstruction. Locked cabinets available to store medications and toxins. Locked cabinet to store sharps. Hot water temperature is measured at 114.3 degrees Fahrenheit. Fire extinguisher was last serviced on 12/1/2022. Carbon monoxide and smoke detectors present. First-Aid kit was observed complete. Licensing Program Manager (LPM), H. Humpal gave approval to waive Comp III. No issues were noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.
Federal summary
CMS Care CompareNot a CMS-certified facility
California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.
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