Caleo Bay Alzheimer's Special Care Center.

On July 10, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with Executive Director, Maria Arriaga. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 66 Adults and is currently operating at a capacity of 46 Adults (740). The facility has a dementia program and approval for locked perimeters with an alarm and signal system. The facility does not have any bodies of water. The facility is approved for 20 hospice residents; currently the facility has 15 residents receiving hospice services. LPA Mixson toured the facility along with Maria Arriaga and made observations pertaining to the annual visit. LPA inspected the facility inside and outside. There were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. The facility is a Community type facility located at 47805 Caleo Bay Drive La Quinta, CA. 92253. Physical Plant: The facility phone number is (760) 771-6100 and it is operable. LPA Mixson observed a sampling of the residents’ living units, and each was equipped with required furniture as per Title 22 at the time of this annual inspection. LPA Mixson inspected a sample of the facility bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately currently. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the PUB 475. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit. 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 Medications : Were locked and inaccessible to residents in care. There were a sufficient supply of medication for each resident. Overall facility is clean, furniture is in good condition, the Community Facility is free of odors. Facility's cooling system and other appliances were operable currently at the time of this visit. Licensee informed LPA there were night lights for safety throughout the facility, for night. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. Care & Supervision / Administration: Adequate staff are present for the supervision of resident in care, and floor plans, telephone numbers and personal rights were found posted throughout the facility. Listed Administrator possesses a current administrator’s certificate with an expiration date of 11/07/2026, Maria Arriaga. LPA observed it is posted in the facility. Records Reviewed and Resident/Staff Files: LPA reviewed staff files and reviewed the staff schedule. Staff files reviewed have criminal clearance and updated training along with First Aid Certification. Resident files reviewed possessed requested documentation and current weight records. Disaster preparedness: LPA Mixson reviewed facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill was conducted on 06/19/2025, was facilitated by Licensee, and met regulations. Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms, PPE equipment, and cleaning supplies. LPA reviewed the facility's infection control plan and found required infection control measures. There were no observable deficiencies noted or cited per Title 22, Division 6 of the California Code of Regulations at the time of this annual inspection. An exit interview was conducted where a copy of this report was discussed and given to Executive Director, Maria Arriaga.

party made the request for S1 not take care of Resident #2 (R2), as they felt S1 was rough and upsets R2. On 11/30/23, Further documentation revealed that Resident #3 (R3) made the statement while being in the hallway and observing S1 and stating "hey that's the one had pulled my hair". Per Executive Director Maria a body check was conducted and there were no visible marks or bruises observed. In addition S1 denied the allegation, and handling any residents in a rough manner and pulling their hair. S1 stated that most residents require Per an interview conducted with R1, R1 could not identify S1 when shown a picture or recall the incident. R2 and R3 were unable to be qualified as a witnesses due to their medical diagnosis. On 12/01/23 the facility called and self reported the incident, and explained the actions that were taken as well as there was an active investigation pending and the staff was suspended and unable to return to work until the conclusion of the investigation, which will lead to termination of employment. Therefore based on observations, interviews and records review the allegation is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted and a copy of report was reviewed and provided to Maria Arriaga, Executive Director.

with feeding as indicated or needed. Per interviews with multiple facility staff revealed corroborated what was documented in R1s progress notes. Which was R1 would eat some days, and would not eat others, but the attempts were made. There is insufficient evidence to corroborate or refute the allegation of facility staff did not assist resident with meals as needed , therefore the allegation is UNSUBSTANTIATED at this time. A finding of UNSUBSTANTIATED means that 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. An exit interview was conducted, a copy of this report was reviewed and provided along with the 9099C, and appeal rights were given to Executive Director Maria Arriaga.

LPA interviewed S4 who stated that staff was documenting when F1 was being given and that staff were providing this for the resident. Therefore, based on the above information LPA was unable to corroborate the allegation that staff was not provided with F1. Therefore, the allegation is unsubstantiated . Findings that are unsubstantiated mean that although the allegation may be valid, the preponderance of the evidence standard has not been met. An exit interview was conducted with Executive Director, Maria Arriaga, where this report was reviewed and provided to them. 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 department interviewed staff who stated they are assigned a “round” described as an assignment of residents for the day. The staff stated there are six (6) “rounds” with a staff assigned to each “round”. Staff #1 (S1) stated that on 09/06/2022 the facility was “short staffed” and only had four (4) caregivers to cover the six (6) rounds. Staff #2 (S2) confirmed that R1 was one of the residents assigned to their “round” on 09/06/2022. Staff interviews revealed conflicting information. S1 reported they asked S2 to assist with R1. S1 reported they “struggled” lifting R1 to a standing position because R1 was “putting up a fight”. S1 reported R1 had been combative, and after changing had been “tugging” on the staff’s arm and as a result R1 tripped over the floor transition strip in the restroom and fell. S1 reported trying to catch R1, but due to the momentum of the fall, S1 fell “on the side” of the resident. S1 provided conflicting information when they were re-interviewed. S1 later stated they had fallen partially on R1’s body but denied placing their full body weight on R1. Staff interview with witness revealed, S2 assisted S1 with changing R1. It was reported S1 had “rushed” the resident, “pushed” the resident with their hand which caused the resident to trip over S1’s leg and fall onto their back. It was further reported, S1 tried to catch R1 but R1 was “too heavy” and S1 ended up falling with their “whole body” on top of R1’s leg, and R1 immediately screamed. A review of facility progress notes dated 9/6/2023 1:46 p.m, revealed a third version of what occurred, which was that S1 reported that R1 had fallen on their right knee, causing the resident to fall and be injured. A review of text messages starting 9/11/2022 from S1 to S2 revealed S1 making several attempts to convince S2 to “be on the same page” and report that R1 was being combative and fell over the floor transition strip. Based on the totality of evidence, from interviews conducted and records review; the allegation resident sustained a fractured femur as a result of staff neglect, is substantiated. An immediate civil penalty of $500 is being assessed in accordance with Health and Safety Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident is pending and under review by the Department. 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 Regarding allegation, “ Staff did not seek immediate medical treatment for resident.” R1 fell on 09/06/2022. Interviews with staff revealed, R1 screamed immediately after the fall. Staff reported seeing R1 in pain with a swollen knee and leg. This incident was reported to Staff #3 (S3) who assessed R1 and then called hospice. Hospice notes dated 9/6/2022 revealed hospice staff assessed R1. A mobile x-ray unit was requested and came out to the facility on 09/07/2022. The x-ray was completed for R1’s knee, as staff were told, R1 fell on their knees. Radiology report dated 9/7/2022 revealed, the x-ray was negative for an injury to R1’s knee. Staff interviews revealed R1 was still observed to be in pain after the x-ray. R1’s POA, then insisted on R1’s foot and hip being x-rayed. Additionally, Staff #4 (S4) documented on facility progress notes 9/8/2022 R1’s upper right thigh in an “awkward” position. On 09/09/2022, a second X-ray was conducted. Radiology report dated 9/9/2022 revealed, the x-ray showed a right femoral fracture. R1’s doctor requested R1 be sent out for possible surgery. A total of five different staff interviews, revealed, they believed R1 was in pain because R1 appeared “pale” in the face and had swelling and redness on their knee and leg. A review of progress notes, dated between 9/06/2022 and 09/09/2022, corroborated that R1 was changed and transferred to and from their recliner and had been observed to be in pain. Therefore, from the time of the fall on 09/06/2022 to 09/09/2022, three (3) days had elapsed where the resident was observed to be in pain and staff did not seek medical attention. Therefore, the allegation is substantiated. Regarding allegation “Staff do not inform resident's authorized person of incidents”, it was alleged that resident had fallen at the facility several times and that the resident’s POA had not been informed about some of the falls when they occurred. LPA conducted a file review of the facility and found that falls documented on hospice progress notes for 6/3/2022, 3/18/2022, 2/24/2022 and 2/21/2022 had not been reported to the department. LPA also found that fall resulting in a femoral fracture on 9/6/2022 had not been reported until 9/14/2022, past the 7-day reporting requirement. It was also found during department investigation that S1 had not given accurate account of events for R1’s fall on 9/6/2022. It was only found during this investigation and through re-interviewing S1 that S1 had fallen on top of R1. Therefore, based on this information the allegation is substantiated 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 Substantiated findings mean that the preponderance of the evidence standard has been met. Deficiencies were cited for substantiated allegations according to the California Code of Regulations Title 22 Division 6 Chapter 8. Plans of correction were documented and created with Executive Director, Maria Arriaga, along with deficiencies on an LIC9099-D page. An exit interview was conducted with Executive Director, Maria Arriaga, where this report along with civil penalty page LIC421IM, LIC9099-D pages, and appeal rights were reviewed and provided to them.