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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003007
Report Date: 11/06/2025
Date Signed: 11/06/2025 04:59:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
09/15/2025 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20250915085945
FACILITY NAME:STA. RITA'S SENIOR CAREFACILITY NUMBER:
347003007
ADMINISTRATOR:FLOWERS, RITA C.FACILITY TYPE:
740
ADDRESS:8978 MERLOT WAYTELEPHONE:
(916) 689-5828
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:5CENSUS: 5DATE:
11/06/2025
UNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Rita FlowersTIME COMPLETED:
05:29 PM
ALLEGATION(S):
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Staff did not take preventative measures to ensure resident does not sustain pressure injuries.
Resident sustained unexplained injuries while in care.
Staff did not meet resident's diapering needs.
Staff did not properly transfer resident's items to new facility.
Staff did not notify resident's responsible party of incidents.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Cynthia Tamayo made an unannounced inspection to the Sta. Rita Senior Care RCFE on 11/06/25.The purpose of this visit is to o conclude the investigation of the above allegations and to deliver the findings for the allegations above. LPA Tamayo met with care staff Joel Cruz (S2), and explained the purpose of the visit. S2 called facility administrator, Rita flowers (S1) via phone call, S1 stated they are out of the country and will return 11/10/25 but are available via phone call. The most current LIC 308 lists two staff whom are no longer working at the facility, S1 stated the visit may be conducted with S2.

The investigation into the above allegations consisted of interviews and record reviews.

The Department conducted interviews and records review for the above complaint allegations.

CONTINUED ON 9099-D
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
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 8
Control Number 27-AS-20250915085945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: STA. RITA'S SENIOR CARE
FACILITY NUMBER: 347003007
VISIT DATE: 11/06/2025
NARRATIVE
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It was alleged that staff did not take preventative measures to ensure resident does not sustain pressure injuries. LPA conducted staff interviews and review of records the allegation; Interview with a witness (W1), hospice resident (R1) was found to have multiple wounds and sores injuries. W1 stated that a hospice staff informed facility staff of some injuries were the result of R1’s being double diapered by facility staff. Interview with another witness (W2 ), confirmed that staff did take preventative measures to ensure resident does no however this was not the case in 2-3 occasions in which facility staff was double diapering R1 which could have resulted in pressure injuries and delayed healing. Record review of hospice records indicate a pressure ulcer was documented on 8/21/25 on right hip, 8/19/25 on left foot, 8/26/25 on lower right back, and on left thigh on 9/4/25 . Skin tears are noted. on 8/28/25 on right wrist and right knuckle and a blister on the tight waist. Hospice notes stated education was provided to facility staff on how to care for and off-load pressure areas.

Interview with Administrator, S1 confirms hospice staff held a meeting with the facility to address double diapering of staff in which staff was instructed to no longer do so. S1 stated the staff member that was double diapering the resident is no longer working at the facility since April 2025. S1 and S2 confirm R1 did not have any pressure wounds prior to their admission to the facility, although the R1 had "sensitive skin". W2 stated that although total wound healing was not expected, one facility staff could have done more to prevent pressure injuries. S1 instructed care staff to start maintain progress notes for R1 per Long Term Care Ombudsman's recommendation. LPA reviewed progress notes for R1 from 8/26-9/5/25. Based on the observations of the LPA and review of records the allegation staff did not take preventative measures to ensure resident does not sustain pressure injuries is substantiated.

It was alleged that resident sustained unexplained injuries while in care. LPA conducted staff interviews and review of records the allegation; LPA observed photographs of wounds sustained by R1 in the pinky knuckle of their hand, the side of their toe on their foot, and on their knee. W1 stated when facility staff asked what happened to R1 or how a certain skin tear occurred, Staff would respond "I don’t know". S2 stated they conducted body checks but there was no log, S2 would sometimes report observed wounds to family but not always due to hospice reporting to family already.


CONTINUED ON 9099-D
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 27-AS-20250915085945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: STA. RITA'S SENIOR CARE
FACILITY NUMBER: 347003007
VISIT DATE: 11/06/2025
NARRATIVE
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S1 and W2 stated R1 had very " fragile skin". W2 stated this meant it needed more care. W2 stated they advised that patients should not be sitting all day, as they lay down after meals to off-load pressure, but this was sometimes not done per family's request to not have R1 to be isolated in their room during the day.

Hospice staff provided training on how to prevent pressure injuries but staff did not always follow thru completely with training guidelines including turning R1. Hospice staff was not full time, so facility care staff was responsible for the full time care. Based on the observations of the LPA and review of records the allegation resident sustained unexplained injuries while in care is substantiated.

It was alleged that staff did not meet resident's diapering needs. LPA conducted staff interviews and review of records the allegation. W1 and W2 stated two diapers were observed on R1 on more than one occasion. The facility staff requested XL diapers even though R1 was not size XL. S1 and S2 stated they met with the hospice team to address double diapering not being allowed, as it was resulting in pressure injuries. A witness (W3) stated they saw blisters on thighs and inside of waist of R1.

Per plan of operation and admissions agreements the facility agrees to provide “… routine observation, care and supervision, and personal assistance and care with their needs and activities of daily living. These needs are indicated by the results of the preadmission appraisal, family and resident interviews, physician consult, etc. Personal assistance and care includes dressing, grooming, eating, bathing and assistance with taking prescribed medications’”. Based on the interviews and review of records the allegation, staff did not meet resident's diapering needs, is substantiated.

It was alleged that staff did not properly transfer resident's items to new facility.LPA conducted staff interviews and review of records the allegation. Based on interview with S2, they stated they put everything is in the boxes with everting they think R1 needed, in the "care-kit". S1 stated they told R1's family to check the room, in which they did but did not take anything additional. R1's daughter returned back to the facility due to diapers, toiletries, personal blanket, razors, dentures, and belongings that were not packed the first time. S2 stated they did not pack those items because they thought they didnt need them or where donations. R1's son requested R1's POLST, and S2 stated they did not have one. S1 stated R1 does have a POLST but S2 did not understand what a POLST was.

CONTINUED ON 9099-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
09/15/2025 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20250915085945

FACILITY NAME:STA. RITA'S SENIOR CAREFACILITY NUMBER:
347003007
ADMINISTRATOR:FLOWERS, RITA C.FACILITY TYPE:
740
ADDRESS:8978 MERLOT WAYTELEPHONE:
(916) 689-5828
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:5CENSUS: 5DATE:
11/06/2025
UNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Rita FlowersTIME COMPLETED:
05:29 PM
ALLEGATION(S):
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Staff mismanage resident's medications.
Staff did not ensure resident's grooming needs were being met.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Cynthia Tamayo made an unannounced inspection to the Sta.Rita Senior Care RCFE on 11/06/25.The purpose of this visit is to o conclude the investigation of the above allegations and to deliver the findings for the allegations above. LPA Tamayo met with care staff Joel Cruz (S2), and explained the purpose of the visit. S2 called facility administrator, Rita flowers (S1) via phone call, S1 stated they are out of the country and will return 11/10/25 but are available via phone call. The most current LIC 308 lists two staff whom are no longer working at the facility, S1 stated the visit may be conducted with S2.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Tamayo was unable to corroborate the above allegation.

It was alleged that staff did not ensure resident's grooming needs were being met.

CONTINUED ON 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 27-AS-20250915085945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: STA. RITA'S SENIOR CARE
FACILITY NUMBER: 347003007
VISIT DATE: 11/06/2025
NARRATIVE
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Per plan of operation: basic services provided include “assistance with bathing, dressing, grooming, toileting, eating, continence, transferring from bed or chair, and other personal needs”.

LPA conduced records review and interviews. S1 stated the facility did not maintain a grooming log including shaving, nail maintenance, and showering schedules. S2 stated hospice staff and they were both in charge of grooming for R1. S2 and W2 stated R1's family member requested for staff the shave R1s beard by putting staff's fingers in R1's mouth to assist with shaving due to R1 not having any teeth, however care staff states this was not safe to do. Interview with two witnesses (W1 and W2) as well as one Staff (S1) confirm R1 did not have any teeth which made it "challenging" or "unsafe" to fully shave R1 often. S2 stated an electric razor was provided to the facility as it was requested, however. S2 reports R1 was not always "cooperative" and grooming attempts were attempted later on when R1 would be more "not combative"". Although R1 did not have teeth, "He tries to bite us" and "we will try again once the beard is a longer so its more do-able "Per department regulations it's a residents' personal right to refuse services at any time. Department has determined no violations were observed regarding grooming. Based on the observations of the LPA and review of records the allegation Staff did not ensure resident's grooming needs were being met is unsubstantiated.

It was alleged staff mismanage resident's medications. LPA Tamayo Reviewed medications and medications records for R1- R5. R2- R5 did not have any discrepancy showing any evidence of mismanagement of resident's medications. S1, and S2 stated all medications were administered to R1-R5. W2 stated they did not witness any discrepancy with medications or any medication mismanagement by the facility staff. W1 and W3 stated there was one medication that was not administered to R1 on a daily basis to to low refills. R1 and or R1's family took all their medications and some medication records with them upon move out on 6/9/25. LPA Tamayo reviewed record keeping requirements with facility staff. LPA was not able to corroborate the allegation staff mismanage resident's medications.

Although the allegations above may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of personal rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22.
Exit interview was conducted with facility staff and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 27-AS-20250915085945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: STA. RITA'S SENIOR CARE
FACILITY NUMBER: 347003007
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2025
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical .... routine medical ... care ...(1) ...l arrange, or assist in arranging, for medical ... care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by record review and
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Licensee will submit a plan to maintain turning schedule, and skin check monitoring, for all residents at risk for developing pressure injuries by POC due date.
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 interviews that corroborate staff did not implement preventative measures or follow care instructions provided by Hospice staff, which resulted in the resident developing pressure injuries while in care. This poses a potential or immediate health risk to residents in care.
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Type B
11/14/2025
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Licensee will implement a plan to ensure the facility is consistently communicating with hospice and responsible representatives by POC due date. Additionally, licensee will submit a plan for move out procedures for residents to ensure all belongings are relocated along with resident.
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This requirement was not met as evidenced by record review and interviews confirming resident 1 (R1) developed bruises and skin tears however Facility staff was unable to provide an explanation or documentation of all incidents; It was the hospice company who was mostly communicating incidents to responsible persons. Additionally, staff did not ensure all of R1's personal belongings were transferred to the facility upon relocation on 9/5/25. This poses a potential or immediate health 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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20250915085945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: STA. RITA'S SENIOR CARE
FACILITY NUMBER: 347003007
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2025
Section Cited
HSC
87464(c)
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87464 Basic Services (c)... basic services are desired and/or needed ... provided for, each resident...This requirement was not met as evidenced by records review and interviews. Based on records review and interviews, staff used two diapers on R1 instead of doing more frequent changing.
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Licensee will submit a plan to ensure diapering needs of resiednts are met by POC due date.

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"Double diapering" is a practice that can cause pressure injuries. Staff was told to discontinued double diapering but still continued to do so on more than one occasion. This poses an immediate health and safety risk to residents in care.
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Type B
11/14/2025
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) Each licensee ... (1) A written report shall be submitted to the licensing agency and to the person responsible....(D) Any incident which threatens the welfare, safety or health of any resident ...
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Licensee will submit a plan to ensure
staff did not notify resident's responsible party of incidents by POC due date.
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This requirement was not met as evidenced by staff not reporting when R1 had a wound to authorized representatives, 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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20250915085945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: STA. RITA'S SENIOR CARE
FACILITY NUMBER: 347003007
VISIT DATE: 11/06/2025
NARRATIVE
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S1 confirmed a copy of the POLST was available to the R1's authorized representative at move out.
Based on the observations of the LPA and review of records the allegation, staff did not properly transfer resident's items to new facility, is substantiated.

It was alleged that Staff did not notify resident's responsible party of incidents. LPA conducted staff interviews and review of records the allegation. Interview with S1 confirms staff tired notify resident's responsible party of incidents, but did not always do so. S1 had staff start to maintain 'progress notes" to serve as reporting as of 8/26/25 but there was no other reporting verification available to families before 8/26/25. S1 stated there is sometimes a language barrier between S2 and families and S2's word choice "could be better". S1 and S2 stated S2 could have been more consistent with ensuring better with S1 and responsible parties. S2 was instructed to notify S1 of any type of injuries or incidents that involved residents so S2 can communicate with families but S2 did not always do so. Based on the observations of the LPA and review of records the allegation, staff did not notify resident's responsible party of incidents is, substantiated.

As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with care staff Peti and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8