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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 372004894
Report Date: 06/03/2025
Date Signed: 06/03/2025 04:26:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2025 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20250417130623
FACILITY NAME:TIERRASANTA VERNANEL CARE HOMEFACILITY NUMBER:
372004894
ADMINISTRATOR:PANAO, NELLY, D.FACILITY TYPE:
740
ADDRESS:11085 ZAGALA COURTTELEPHONE:
(858) 569-1870
CITY:SAN DIEGOSTATE: CAZIP CODE:
92124
CAPACITY:6CENSUS: 2DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee Nelly PanaoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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-Licensee did not meet resident’s incontinence care needs.
-Licensee did not ensure resident had clean linen.
-Licensee did not maintain facility cleanliness.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Nelly Panao.

The Complainant alleged that Licensee did not meet Resident #1’s (R1’s) incontinence care needs, that Licensee did not ensure R1 had clean linen on their bed, and that Licensee did not maintain facility cleanliness. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved multiple unannounced facility tours/welfare check and interviews of relevant residents, staff, and outside sources. The Department also reviewed pertinent facility and hospice agency care records.

[CONTINUED ON LIC 9099-C, 1 of 3]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
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 08-AS-20250417130623
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: TIERRASANTA VERNANEL CARE HOME
FACILITY NUMBER: 372004894
VISIT DATE: 06/03/2025
NARRATIVE
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[CONTINUED FROM LIC 9099]

Staff #1 (S1) was the primary caregiver at the facility during the complaint time frame, with Staff #2 (S2) serving as their back up. However, starting 04/14/2025, S1 ceased their direct care tasks, and S2 took over as the primary caregiver at the facility.

Interviews of staff and outside sources, corroborated by hospice records, showed: R1 moved in on 03/28/2025 under the concurrent care of hospice. R1 spent all day in bed and was unable to turn/reposition themselves in bed. R1 was both incontinent of bowel and bladder and fully depended on staff to check/change their incontinence briefs. Per R1’s hospice nurses, R1 was supposed to have their briefs checked at least once every two (2) hours.

S1 told CCLD that during the complaint timeframe, they typically checked/changed R1’s briefs five (5) times per day (i.e., around 8:00 AM, 10:00 AM/11:00 AM, 3:00 PM, 7:00 PM/8:00 PM, and 11:00 PM, respectively). However, interview of R1 showed they were only changed three (3) times per day (i.e., morning, midday, and evening). Interview of S2, who took over for S1 starting 04/14/2025, showed that they too were only checking/changing R1’ briefs three (3) times per day, prior to CCLD starting is complaint investigation.

Several hospice personnel who regularly visited R1 at the facility described having at least one site visit during which they observed R1 wet/soiled upon arrival, having to change R1 themselves (instead of facility staff doing it). Multiple hospice personnel said they observed R1’s briefs saturated to the point that urine and/or feces escaped from R1’s brief and stained their bed. One medical professional saw dried feces stuck to R1’s thigh and hip. One non-medical visitor said that out of six (6) visits they made, R1’s brief had a urine and/or fecal odor during five (5) of those visits.

S1 admitted to CCLD that they physically struggled to turn/move R1 in bed (which is needed to change R1’s briefs). S1 had also expressed the same to R1’s hospice agency. S2 also admitted to CCLD that they too struggled to move R1 in bed, and that R1 required the joint-assistance of two caregivers to have their brief changed in bed. This latter point was reiterated in the 30-day eviction notice which Licensee issued to R1 and their responsible person on 05/12/2025. [CONTINUED ON LIC 9099-C, 2 of 3]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20250417130623
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: TIERRASANTA VERNANEL CARE HOME
FACILITY NUMBER: 372004894
VISIT DATE: 06/03/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 3]

Hospice records and interviews revealed multiple personnel had concerns regarding the condition of R1’s bed. One professional said they found R1’s bed “completely dirty” upon their arrival, across six (6) different site visits, and that they personally changed R1’s bed linens each time. They saw food both on R1’s body and on their bed. On one occasion, they saw R1 laying on top of a Scotch tape dispenser that had stuck to R1’s back. A second professional on a different day described seeing R1 laying on top of a large metal flashlight, a TV remote, colored pencils, and a pencil pouch. They saw multiple stains, including urine and fecal stains, on R1’s bed linen. A third professional on a different day described seeing R1 laying on top of a pack of pretzels that had “fully imprinted” into R1’s back. They added that very near R1’s body (but not directly under them) was also an Icebreakers mint container, phone chargers, and an empty bottle of hand sanitizer.

The Mayo Clinic’s encyclopedic entry titled “Bedsores (Pressure Ulcers)” states, “Skin becomes more vulnerable with extended exposure to urine and stool,” and that “constant pressure on any part of the body can lessen the blood flow to tissues” which also contributes to skin breakdown. Review of hospital and hospice agency records showed: R1 moved into the facility with an existing Stage 2 pressure ulcer on their sacrum. However, per hospice nursing assessment, on 05/01/2025, R1’s sacral pressure ulcer worsened to Stage 3.

Hospice records and interviews revealed multiple personnel had concerns regarding the cleanliness of R1’s bedroom: During a visit, one professional saw multiple pieces of trash and multiple opened/uneaten chocolates on R1’s bedroom floor; they clean up R1’s floor and threw away other expired food seen in R1’s bedroom. A second professional said that R1’s room was so cluttered with objects that it was difficult to walk through R1’s room or even set their workbag down. A third professional reiterated the clutter in R1’s room and said R1’s bedside table was “sticky” and R1’s furniture was dusty. One non-medical visitor said they and another visitor sometimes saw dust on R1’s furniture, which they personally wiped clean. They also threw away expired food seen in R1’s room.

[CONTINUED ON LIC 9099, 2 of 3]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20250417130623
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: TIERRASANTA VERNANEL CARE HOME
FACILITY NUMBER: 372004894
VISIT DATE: 06/03/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 3]

A separate outside source revealed: Resident #3’s (R3’s) bed linens were also not consistently clean; they saw stains on R3’s pillows, bedsheets, and mattress during the complaint timeframe. This person said R3’s bedroom floor was “very dirty,” and that they personally cleaned it as a result. They also said that the facility’s shared bathroom was not kept clean during the complaint timeframe, and that there was evidence of insects at the facility. During his 06/03/2025 site visit, LPA himself observed a few gnats flying in the dining room area.

Based on records and interviews, a preponderance of evidence exists to show that Licensee did not meet R1’s incontinence care needs, that Licensee did not ensure resident had clean linen, and that Licensee did not maintain facility cleanliness. These allegations are therefore Substantiated, and three (3) deficiencies were cited for them per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D pages). Since one of the deficiencies contributed to the worsening of an injury to R1, an Immediate Civil Penalty of $500 was charged/assessed (refer to the LIC421-IM page). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Licensee Nelly Panao, to whom a copy of this report, the LIC 9099-D pages, the LIC421-IM page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20250417130623
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TIERRASANTA VERNANEL CARE HOME
FACILITY NUMBER: 372004894
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2025
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence: “(b) …the licensee shall be responsible for the following: “(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, Licensee has issued a 30-day eviction notice to R1. Licensee has also doubled the number of caregivers on duty, as witnessed by LPA. These actions resolve the deficiency. Until R1 moves out, Licensee agreed to maintain the current staffing levels to ensure that R1’s briefs are checked/changed and that R1’s body is repositioned in bed, at least once every two hours.
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Based on records and interviews, Licensee did not ensure that 1 of 3 residents (R1) who was incontinent was kept clean and dry and free of odors from incontinence. This posed an immediate health and personal rights risk to persons in care.
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Type B
06/03/2025
Section Cited
CCR
87307(a)(3)(C)
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87307 Personal Accommodations and Services: “(a)(3) …The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads…” This requirement is not met, as evidenced by:
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As of the date of deficiency issuance, R3 has moved out and Licensee has issued a 30-day eviction notice to R1. Going forward, Licensee agreed to ensure that all residents have their bed linens changed at least once per week, but also more often as necessary to ensure that linens are always clean. This action resolves the deficiency.
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Based on records and interviews, Licensee did not ensure that 2 of 3 residents (R1 and R3) had clean linen. This posed a potential health and personal rights risk to persons 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20250417130623
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TIERRASANTA VERNANEL CARE HOME
FACILITY NUMBER: 372004894
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: “(a) The facility shall be clean…at all times.” This requirement was not met, as evidenced by:
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Licensee agreed to hire a third-party professional housekeeper/cleaner to perform one deep clean of the facility, to include all bedrooms and common areas and bathrooms. Licensee agreed to send a copy of the paid receipt/invoice to LPA, by the POC due date.
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Based on interviews, Licensee did not ensure that the facility was clean at all times. This posed a potential health and personal rights risk for 3 of 3 residents [R1, Resident #2 (R3), and R3] 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6