San Carlos Elms

On 5/16/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a case management in regards to the facility's Hospice waiver request. LPA Calandra was greeted by Kristin Marcos, Assistant Director of Operations and Maribel Carino, Director of Health Services. LPA reviewed facility sketches and fire clearance which states the facility can have 9 bedridden persons in care. However, the facility sketch and fire clearance do not indicate which rooms are approved for bedridden persons. The Department will submit a request for updated fire clearance to the fire department to inspect the facility and indicate which rooms are approved for bedridden persons. No citations issued. An exit interview was conducted. A copy of the report was reviewed with facility representatives and a copy of the report left at the facility.

On 5/2/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to complete the Annual 1-year required inspection. LPA Calandra was greeted by Lisa Maldonado, Business Office Manager and explained the purpose of the visit. Maribel Carino, Director of Health Services and Kristin Marcos, Associate Director of Operations arrived later during the visit. LPA Calandra reviewed 12 resident records and 6 staff files. All were observed to be complete. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility. LPA interviewed 5 residents. LPA obtained copies of the following documents during the visit: -Articles of Incorporation -Administrator's Certificate -LIC 309 -Liability Insurance -Control of Property No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with Maribel Carino, Director of Health Services and Kristin Marcos, Associate Director of Operations.

On 4/25/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Maribel Carino, Director of Health Services, and explained the purpose of the visit. LPA toured the physical plant. This is a 3 story building with a front common space, dining room, office, front patio, activities room, library, pantry, etc. LPA toured rooms 103, 111, 141, 157, 146 203, 202, 208, 210, 211, 304, 321, 329. All bedrooms had the required furniture and sufficient lighting. No accessible bodies of water or hazards were observed in hallways or the backyard. The facility's fire alarms and Carbon Monoxide detector were observed to be in working order. The facility's first aid kit was observed to have all required items. The facility's hot water temperature was measured within the required 105-120 degrees Fahrenheit. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. The facility's fire extinguishers were observed to be fully charged. All knives, sharp objects, detergent, soap, and poisons were observed to be locked and in-accessible to persons in care. The Annual inspection will be completed at a later date. No deficiencies were cited during today's visit. An exit interview was conducted. A copy of the report was left at the facility.

On 5/31/24, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Director of Health Services (DHS), Maribel Carino & Associate Director of Operations (ADO), Kirstin Marcos. LPA explained the purpose of the visit. LPA toured the facility including a random sample of resident rooms, common areas, and kitchen area. LPA observed some residents were having exercise activities, watching TV in the living area. While touring the facility it was observed that the temperature was at 76 deg F. Hot water was also tested in the resident rooms and the temperature was 108 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Facility has a sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. Resident call lights were checked and functioning. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drill are done every month. Six resident records and six staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility has 4 certified administrators on site with complete certification and training requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA received the following documents LIC 308, LIC610E, LIC 309, Copy of Deed. No deficiencies are cited at this time. Report is reviewed and copy is provided.

On 5/17/24, LPA Grace Donato made an unannounced case management incident visit. LPA met with Director of Health Services (DHS), Maribel Carino & Associate Director of Operations (ADO), Kristin Marcos. LPA explained the purpose of the visit. On 5/14/24, Desk Duty officer received a call from facility that a resident (R1) has passed. R1 was found by staff deceased in the bathroom. R1 appeared to have hung himself/herself in the shower pole. ADO was called and checked on the pulse to confirm death. 911 was called. R1 did not have any suicidal ideations and lives in assisted living. There was a suicide note that was left by R1 in the room. No signs of foul play. No deficiencies cited today. Report is reviewed and copy is provided.

On December 29, 2023, Licensing Program Analyst (LPA) Komal Charitra met with Activities Director, Kathleen Sullivan for a Case Management visit to follow up on a substantiated allegation from an incident that occurred on May 28, 2023, regarding two residents; Resident 1 (R1) and Resident 2 (R2) who were physically abused by a staff member (S1). On September 22, 2023, the Department concluded an investigation which alleged that S1 physically abused R1 and R2 on May 28, 2023. The allegation of physical abuse was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § “87468.1(a)(2)” Personal Rights of Residents in All Facilities. The investigation revealed that S1 is a clerical/administrative staff member with no formal training in caregiving duties. S1 also failed to complete the criminal record exemption process after an arrest and was disassociated from the facility in 2021 but continued to work in the facility until their resignation on June 1, 2023. On May 27, 2023, the night shift had a last-minute call-off and S1 overheard the staffing concern and offered to volunteer to stay for overtime. Staff 2 (S2) and Staff 3 (S3) approved S1’s request for overtime as a last-minute caregiver to cover for the call-off for the night shift. According to the administrator, there are usually four staff members for the night shift, but on the evening of May 27, 2023, to the morning of May 28, 2023, there were only three staff members: S1, Staff 4 (S4) and Staff 5 (S5). During this shift, S4 only saw S1 when they arrived to work and denied having any further interaction with S1 the rest of the shift. During S5’s shift, S5 recalled that S1 and S5 went to three residents to offer incontinence care (diaper changes) at around 1:35 a.m., R1 was one of the residents but declined care. S5 denied seeing S1 after 3:00 a.m. R1 has a camera inside their room and camera footage captured S1 (identified by the administrator) entering R1’s room alone at 3:18 a.m. (Cont. to 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 The next day on May 28, 2023, both R1 and R2 reported that they felt someone come into their room and orally copulated them during the night. R1 and R2 do not know each other. R1 stated that they repeatedly told the abuser to stop the assault. R2 stated that no permission was given, it was unwanted and felt very embarrassed by the incident. At the time of the case-management visit conducted on September 22, 2023, an immediate civil penalty of $500 was issued. The Licensee was informed that an additional civil penalty was being determined and might be assessed based on Health and Safety Code § 1569.49 The Department has concluded an analysis and has determined that an additional civil penalty is warranted for a violation that resulted in R1 and R2 being physically abused by S1 while under the care of this facility. Physical abuse is defined by Welfare & Institutions Code section 15610.63 includes assault, battery, assault with a deadly weapon, force likely to produce great bodily injury, unreasonable physical constraint or prolonged or continual deprivation of food or water, sexual assault, and use of a physical or chemical restraint or psychotropic medication in certain conditions. This is evidenced by the Licensee failing to provide proper care and supervision which resulted in R1 and R2 being physically abused. Today, December 29, 2023, the Department is issuing a civil penalty per Health and Safety Code 1569.49 for a violation that the Department constitutes as physical abuse in the amount of $20,000.00 ($10,000.00 for each physical abuse of a resident). However, since an immediate civil penalty of $500.00 was previously issued on September 22, 2023, the amount of the civil penalty issued today will be $19,500.00. A copy of the LIC 421D was given to Activities Director, Kathleen Sullivan and originals were signed. Exit interview conducted with Activities Director. A copy of the report issued. Appeal rights provided. Kathleen Sullivan's signature on this report acknowledges receipt of the appeal rights., found on page two of the LIC 421D.

On October 18, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on a substantiated complaint number: 14-AS-20190327094949, regarding an allegation that staff failed to provide care, supervision, and services to meet the needs of Resident 1(R1) resulting in R1 sustaining multiple injuries. LPA met with Administrator, Scott Evans and explained the purpose of the visit. On November 26, 2019, the Department concluded a complaint investigation and the allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § “87468.2(a)(4)” Additional Personal Rights of Residents in Privately Operated Facilities for facility failing to provide care, supervision and services that met R1's needs that resulted in R1 sustaining serious bodily injury. The investigation revealed that the plan of care for R1 was not individualized to tailor fit R1’s needs. Furthermore, R1’s hospitalization dated January 16, 2018, indicated R1 has a diagnosis of gait disorder and the physical therapist (PT) assessment notes dated March 1, 2018, identified R1 as high-risk for falls. The facility did not reassess the resident to develop a plan of care to meet R1’s needs. R1 had three separate incidents at the facility. On April 26, 2018, R1 was found on the floor and sustained a large skin tear to the left arm. On August 9, 2018, R1 stood up, fell on the floor, and sustained a fracture to the right hip. R1 was hospitalized and had surgery for a right hip fracture. Per document review and Administrator interview, there was insufficient staffing with only one staff on duty and that staff was assisting another client when R1 had the first two falls. The third incident was discovered when R1 was noted with back and leg pain on October 4, 2018. R1 continued to report pain during the night and continued to the next day. On October 5, 2018, around 2:00 p.m., R1 was reported to be in severe pain, and staff called R1’s family member and informed them the facility would call an ambulance to transfer R1 to the ER for evaluation. Two hours later at 4:00 p.m., the facility called an ambulance to transfer R1 to the ER. R1 was taken to the ER and R1 was diagnosed with a compression fracture in their back and a left hip fracture. (CONT. TO 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 Based on interviews and record review, the facility was aware of R1’s risk for falls. However, the facility did not reassess R1 to update R1’s plan of care. The facility failed to reassess R1’s plan of care after the falls on April 26, 2018, and August 9, 2018. At the time of the complaint visit, on November 26, 2019, an immediate civil penalty of $500 was issued. The licensee was informed that an additional civil penalty was being determined and might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that an additional civil penalty is warranted for a violation that resulted in R1 sustaining serious bodily injuries while under the care of this facility. Welfare and Institutions Code § 15610.67, defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the licensee failing to provide proper care, supervision and services, which resulted in R1 sustaining multiple falls and injuries, that included a left hip fracture and a right hip fracture, which are serious bodily injuries. Today, October 18, 2023, the Department is issuing a civil penalty per Health and Safety Code 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000.00. However, since an immediate civil penalty of $500.00 was previously issued on November 26, 2019, the amount of the civil penalty issued today will be $9,500.00. A copy of the LIC 421D was given to Administrator, Scott Evans and originals were signed. Exit interview conducted with Administrator. A copy of the report issued. Appeal Rights provided. Administrator, Scott Evans signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.

On October 18, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to the case-management visit that was conducted on 9/22/2023. LPA met with Administrator, Scott Evans and explained the purpose of the visit. During the investigation conducted by the Department, it was revealed that Staff 1 (S1) had a clerical/administrative position while being employed at the facility. Based on documentation reviewed, S1 did not have any formal caregiving training to be able to provide care to residents at the facility. In addition, Staff 2 (S2) and Staff 3 (S3) acknowledged that S1 did not have any formal training in caregiving duties. During the investigation, it was also discovered that S1 required a criminal record exemption in October of 2020, however failed to complete the exemption process by January of 2021. S1 was disassociated from the facility on 1/12/2022 but continued to work in the facility until S1’s resignation on June 1, 2023. According to the staff interviewed, on May 27, 2023, the NOC shift had a last-minute call off and S1 offered to work overtime. S2 and S3 approved S1’s request for overtime as a last-minute caregiver to ensure the facility had enough staff for the night , however due to S1’s lack of training and caregiving experience, S1 was instructed to contact other caregivers on shift if a resident needed assistance. According to the Administrator, there are usually 3-4 NOC shift staff members, but on the evening of May 27, 2023 to the morning of May 28, 2023, there were only three staff members; S1, Staff 4 (S4) and Staff 5 (S5). During this shift, S4 only saw S1 when he/she arrived to work and denied having any further interaction with S1 the rest of his/her shift. S1 and S5 went to three resident rooms to provide incontinence care together, however at 3:18am, S1 was observed entering Resident 1’s (R1’s) room alone. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with Administrator; a copy of the report is provided with appeal rights. Copy of civil penalty is provided

On June 8, 2023 San Bruno Regional Office conducted a non-compliance conference meeting with Administrator, Scott Evans and Attorney, Joel Goldman. Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Manager, Cara Smith, and Licensing Program Analyst, Komal Charitra. During non-compliance meeting, the following violations were discussed, Additional Personal Rights of Residents in Privately Operated Facilities for Licensee failing to provide care, supervision and services that met Resident 1 (R1’s) needs that resulted in serious bodily injury sustained by R1. During this meeting, it was discussed, Community Care Licensing will increase frequency monitoring inspection visits to ensure compliance with this compliance plan of Title 22 regulation. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers The Administrator was informed that additional civil penalties may be assessed, pending review. Report is reviewed with the Administrator and a copy is provided via email. Administrator to sign report and submit to LPA by 6/8/23.

On June 6, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on two incidents that were reported to CCLD on 6/5/2023. LPA met with Administrator, Scott Evans and explained the purpose of the visit. During the visit, LPA reviewed files and obtained copies of pertinent documents in relation to the incident. This incident requires further investigation. This report is discussed and reviewed with the Administrator, A copy is provided.

On July 5, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on Death Report submitted to CCL Office on 6/28/22. LPA met with Activities Director, Kathleen Sullivan and explained the purpose of the visit. The Licensee reported on June 22, 2022, Resident 1(R1) was found in the bathroom floor faced down. According to the Licensee, R1 tried to ambulate with his/her walker but lost balance. R1 was found by a Med-Tech and was transported to the hospital shortly thereafter. During the visit, LPA observed R1's room, reviewed R1's file, and interviewed staff members. According to file reviewed and staff interviewed, R1 is an assisted living resident and has been a resident at the facility for 3 years. Interviewed staff indicated that R1 does not have a falling history and will call for help when he/she needed anything. According to interviewed staff, the day of the incident, R1 was alert and responsive during breakfast around 8:30am and at 10:20am, staff responded to R1's call. According to the Med-Tech who was present at the time of the incident, between 11:15am and 11:30am, R1 was found on the bathroom floor mumbling and semi-responsive. Med-tech immediately called 911. Facility records document that R1 is an assisted living resident and did require assistance with daily living activities, however R1 was able to express himself/herself. According to staff, assisted living residents get checked on every meal time unless resident's notify staff otherwise. No findings of foul play or fault were found by the facility. No citations were issued during the visit.