<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920073
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:28:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2024 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20240522124603
FACILITY NAME:WHOLESOME ELDERLY ON MAR VISTAFACILITY NUMBER:
345920073
ADMINISTRATOR:FAAMAUSILI, CHRISFACILITY TYPE:
740
ADDRESS:7401 MAR VISTA WAYTELEPHONE:
(916) 678-0268
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 4DATE:
01/16/2025
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Administrator -Juan Ramirez TIME COMPLETED:
02:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not dispense medications as prescribed.
Facility staff left residents home alone without supervision.
Facility staff did not keep accurate records.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/16/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings for a complaint Community Care Licensing (CCL) received on 05/22/24. LPA met with Administrator Juan Ramirez and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews and obtained pertinent documents relevant to the complaint investigation.

Please continue to LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
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 5
Control Number 59-AS-20240522124603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: WHOLESOME ELDERLY ON MAR VISTA
FACILITY NUMBER: 345920073
VISIT DATE: 01/16/2025
NARRATIVE
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
Allegation: Facility staff did not dispense medications as prescribed.
LPA reviewed R1s Medication Administration Record (MAR) and Medication list. LPA noted that the medication list received from the facility is dated from 2021. The MAR for February 2024 indicated that R1 only received their medication Insulin Glargine- YFGN 100 unit/ML SOPN was only given on February 11, 14, 18, 20 and 25, 2024. Per MAR the instruction for the medication is to inject 38 units under the skin daily at bedtime. There are no notes indicating why R1 was not given the medication on the other days throughout the month of February.
R1s medication Novolog Flexpen 100 unit/ML SOPN is to be inject three (3) times a day before meals. R1 was not given this medication before lunch February 3, 4, 9, 13, 16, 18 and 22, 2024 as prescribed. The medication was also not given before dinner on February 4, 2024. There are no notes indicating why R1 was not given the medication on these days during those times.

Based on LPAs record review, the facility did not ensure that residents were given their medication as prescribed. Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 regulations, Division 6, are being cited on the attached LIC 9099D.

Allegation: Facility staff left residents home alone without supervision.
On 05/30/24 LPA Ratajczak and LPA Hiratsuka arrived at the facility at 7:10AM and met with Administrator Noel Estillore. Administrator stated that the start time for the morning caregiver is 7AM and that Residents start to get up around 8 AM. The facility does have live in staff who is there throughout the night to assist residents with any needs during the nighttime. During time of LPAs visit live in staff was present at the facility but was not working that day.
On 09/20/24 LPA Ratajczak conducted a case management visit at the facility. LPA conducted interviews with both staff and residents it was revealed that on the evening of 08/30/24, residents were left at the facility without supervision for about 20 to 30 minutes. Staff hours are from 8 am to 6 pm. Outside of those hours, live in staff is expected to be at the facility.

Based on interviews staff left resident at the facility without supervision. Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 regulations, Division 6, are being cited on the attached LIC 9099D.

Civil penalties are assessed in the amount of $500 for absence of supervision.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20240522124603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: WHOLESOME ELDERLY ON MAR VISTA
FACILITY NUMBER: 345920073
VISIT DATE: 01/16/2025
NARRATIVE
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
Allegation: Facility staff did not keep accurate records.
During the course of the investigation LPA reviewed Resident #1 (R1) Medication Administration Record (MAR) for February, March, April and May of 2024. LPA observed the MARs for R1 to be incomplete. For the medication Novolog Flexpen 100 unit/ML SOPN, staff did not document on the MAR the site of the injection, blood glucose and the amount given. According to the MARs from February to April, 2024, staff did not fully complete the MAR until April 10, 2024.

Based on LPAs records review, the facility did not keep accurate records of the MAR. Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 regulations, Division 6, are being cited on the attached LIC 9099D.

Exit interview conduct and a copy of the report and appeal rights were left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20240522124603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WHOLESOME ELDERLY ON MAR VISTA
FACILITY NUMBER: 345920073
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2025
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will schedule a training with staff, topics to be covered medication administration, and how to use the MAR. Submit proof of planned training to LPA by POC due date. Once training is complete Licensee will send LPA proof of completed training by all staff.
8
9
10
11
12
13
14
Based on record review the licensee did not comply with the section cited above facility did not ensure that residents were given their medications as prescribed. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
01/17/2025
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
87411 Personnel Requirements-General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by
1
2
3
4
5
6
7
Licensee is to come up with a plan and schedule to prevent this from happening. Facility will also send LPA a statement of understanding for this regulation.
8
9
10
11
12
13
14
Based on interviews the license did not comply with the section cited above that on 08/30/24 residents were left at the facility without any staff which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20240522124603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WHOLESOME ELDERLY ON MAR VISTA
FACILITY NUMBER: 345920073
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2025
Section Cited
CCR
87405(h)(4)
1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties(h) The administrator shall have the responsibility to:(4) Recruit, employ and train qualified staff, and terminate employment of staff who perform in an unsatisfactory manner.
This requirement is not met as evidenced by
1
2
3
4
5
6
7
Licensee to write a statement of understanding of this regulation and to conduct a training by POC due date with all staff to ensure staff are following facility policies and procedures.
8
9
10
11
12
13
14
Based on file review the licensee did not comply with the section cited above as facility staff was not keeping accurate records of MARs.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5