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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004335
Report Date: 12/23/2025
Date Signed: 12/23/2025 10:38:15 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/04/2025 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20250804142753
FACILITY NAME:TALEGA TERRACEFACILITY NUMBER:
306004335
ADMINISTRATOR:JAYALAKSH PICHIKAFACILITY TYPE:
740
ADDRESS:24 VIA ANDAREMOSTELEPHONE:
(949) 545-7574
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 5DATE:
12/23/2025
UNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Jaya PichikaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident developed pressure injury due to staff neglect
Licensee did not provide assistance in meeting necessary medical needs
Licensee did not ensure that resident was properly fed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, the Department interviewed staff, residents and witnesses as well as reviewed and obtained documentation such as physician report. Regarding the allegations Resident developed pressure injury due to staff neglect; Licensee did not provide assistance in meeting necessary medical needs, and Licensee did not ensure that resident was properly fed, the investigation revealed the following:
Resident 1 (R1) was admitted into the facility on February 5, 2025 with a diagnosis of Lewy Body Dementia, non-ambulatory and unable to meet their needs without assistance per physican report dated 01/31/2025. There is no history of skin breakdown noted. Per interview with Administrator, she recalls seeing redness on both of the resident’s ankles during the pre-assessment of R1, prior to admitting into facility. However, pre-assessment conducted was conducted with CONT ON LIC 9099C DATED 12/23/2025
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 22-AS-20250804142753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TALEGA TERRACE
FACILITY NUMBER: 306004335
VISIT DATE: 12/23/2025
NARRATIVE
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R1’s then private caregiver who reported no such redness was observed. Around the end of June or beginning of July, R1’s responsible party (RP) noticed a small red mark on R1’s heel and brought it to the Licensee’s attention. R1’s RP reported Licensee began putting ointment on the red mark per physician order. Licensee initially confirmed statement regarding ointment but later changed the statement and denied the physician ordering the ointment; Stating instead, that the injury was due to poor circulation. As the RP visited 1-2 times weekly, it was observed that the pressure injury was getting progressively worse. R1’s RP requested Licensee seek medical attention for the pressure injury for R1, but no such medical attention was sought. Text messages obtained from July 7, 2025, to July 30, 2025, show RP repeatedly requested medical attention for the wound from the Licensee. Upon noticing the increasingly worsening condition, R1’s RP made an appointment with Home Base Medical to have one of their physicians visit R1 on June 30, 2025. RP requested that Licensee be present to discuss the pressure injury as RP was unable to make the appointment. During the appointment, it is unclear as to whether the pressure injury was brought to the physician’s attention as the Doctor denied being advised of the injury as well denied recommending any treatment for the pressure injury when interviewed. However, Licensee provided a note written with the attending physician’s signature indicating difficulty obtaining care due to the resident’s behaviors. While the physician confirmed they had signed the note, they reported they did not write the contents of the letter as that had been provided by Licensee. Per interview with Licensee, Licensee reported R1 was not seen by a medical doctor due to insurance issues and ongoing behavioral issues related to the resident’s diagnosis. During interview with the Department, Licensee stated a pressure injury was not a reason to go to the urgent care or Emergency Department. Licensee confirm witnessing an occurrence when R1 was being fed large chunks of meat by a caregiver without the dentures inserted. Licensee indicates there was no glue on-site for the dentures. RP denied ever receiving a request for denture glue from Licensee. Two out of two witnesses confirm Licensee later inserted R1’s dentures after it was brought to her attention, however, after the dentures were inserted, big chunks of meat continued to be forced into R1’s mouth. On July 31, 2025, the resident was removed from the facility by their RP. R1 was assessed for hospice care on August 07, 2025, after moving out of the facility. Hospice documentation notates that due to minimal activity and increased weakness, R1 developed pressure ulcers on the left and right foot. The diagnosis is deep tissue injury on the left lateral foot and stage 3 pressure injury on right lateral foot. On November 21, 2025, R1 passed away.

Based on interviews conducted and record review, there is sufficient evidence to substantiate the allegations. Therefore, the preponderance of evidence standard has been met, and the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D. CONT ON LIC 9099C DATED 12/23/2025
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 22-AS-20250804142753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TALEGA TERRACE
FACILITY NUMBER: 306004335
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2025
Section Cited
CCR
87464(f)(1)
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87464(f)(1)- Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This req is not met as evidenced by:
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Licensee to provide a written detailed plan on how to address resident's health needs and forward proof to LPA by POC due date.
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Based on interviews conducted and record review, Licensee failed to ensure care and supervision was provided to R1 resulting in the development of multiple pressure injuries. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED
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Type A
12/24/2025
Section Cited
CCR
87464(f)(6)
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87464(f)(6) Basic services shall at a minimum include: Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This req is not met as evidenced by:
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Licensee to provide a written detailed plan on obtaining medical care for residents and forward proof to LPA by POC due date,
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Based on interviews conducted and record review, Licensee failed to ensure medical care was obtained for R1 following reports of worsening skin redness. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20250804142753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TALEGA TERRACE
FACILITY NUMBER: 306004335
VISIT DATE: 12/23/2025
NARRATIVE
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A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f). An exit interview was conducted, and copies of this report, LIC 9099-D, Appeal Rights, Immediate Civil Penalty Assessment, and LIC 811 (Confidential Names) were provided to Licensee at the conclusion of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20250804142753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TALEGA TERRACE
FACILITY NUMBER: 306004335
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2025
Section Cited
CCR
87464(f)(4)
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87464(f)(4) Basic services shall at a minimum include: Personal assistance and care.. and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating... This req is not met as evidenced by:
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Licensee to provide an in-service to all staff regarding proper feeding techniques and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure R1’s assistance and care needed by R1 with feeding was met due to R1 being force fed chunks of meat without dentures inserted. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/04/2025 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20250804142753

FACILITY NAME:TALEGA TERRACEFACILITY NUMBER:
306004335
ADMINISTRATOR:JAYALAKSH PICHIKAFACILITY TYPE:
740
ADDRESS:24 VIA ANDAREMOSTELEPHONE:
(949) 545-7574
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 5DATE:
12/23/2025
UNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Jaya PichikaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Licensee did not provide assistance with obtaining medication refills
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the course of the investigation, the Department interviewed staff and witnesses. Regarding the allegation that Licensee did not provide assistance with obtaining medication refills, the investigation revealed the following:
R1 was admitted into the facility on February 5, 2025. Per responsible party (RP), all medication refills were strictly handled by themself. Facility Licensee confirms refills were handled by family. Therefore, the allegation is deemed UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit Interview conducted and a copy of this report was provided to Licensee.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6