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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004894
Report Date: 06/03/2025
Date Signed: 06/03/2025 04:20:31 PM

Document Has Been Signed on 06/03/2025 04:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOMEFACILITY NUMBER:
372004894
ADMINISTRATOR/
DIRECTOR:		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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Licensee Nelly PanaoTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies which were identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Nelly Panao.

Records and interviews showed: On 06/13/2021, Staff #1 (S1) directly witnessed Resident #1 (R1) sexually groping/molesting Resident #6 (R6). [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] Licensee did not personally witness, but was still later told by R6: On 07/30/2021, R1 touched R6 inappropriately. On 09/13/2021, R1 exposed their genitals to R6, without R6's consent. Thereafter, Resident #2 (R2) told Licensee that R1 entered their own bedroom and sexually groped/molested R2 on 09/18/2021, during which time R2 cried out for help for 20-30 minutes. The incidents did not result in physical injuries to either R6 or R2.

Despite having constructive knowledge of the above incidents/allegations, Licensee did not report any of them to either CCLD, the Long Term Care Ombudsman (LTCO), or police within the required time frame of twenty-four hours, as required. Licensee also did not submit written incident reports for these same events to CCLD and the responsible persons for R1, R2, and R6, within seven (7) days of incident occurrence, as required.

During CCLD’s subsequent complaint investigation: Licensee/S1 was made false/misleading statements to the Department about the extent of their knowledge of R1’s abuse against R6, as evidenced by discrepancies between their verbal statements to CCLD, verses S1’s earlier own dated and handwritten progress/care notes on R1 and R6. [CONTINUED ON LIC 809-D]

NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 809]

Records review, confirmed by manager interview, showed: Licensee did not have on file a completed and signed written Pre-Placement Appraisal (or equivalent document) for R2 and Resident #5 (R5). While Licensee did have a Pre-Placement Appraisal document on file for R1, it was dated the same day of R1’s move-in to the facility. Staff interviews showed that R1 was not interviewed or assessed, and their responsible person was not meaningfully interviewed, prior to R1 physically arriving at the facility. Licensee was thus unaware at time of move-in that R1 was a registered sex offender (RSO) and the risk they would be inheriting.

Per their LIC602 Physician’s Report, R1 was diagnosed with Dementia and tended to wander. R1’s physician determined that R1 was not safe to leave the facility unassisted. Care records showed: R1 moved in on 05/05/2020 and eloped from the facility later the same day during waking hours without staff seeing; police had to be called. Staff and resident interviews aligned to further show: During R1’s residency at the facility (which ended in February 2022), there were many subsequent occasions of R1 going into the facility’s outdoor yards at night without staff being aware, harassing multiple housemates by peering into their bedroom windows and unsuccessfully trying to enter their bedrooms using their side doors. A preponderance of evidence existed to show that facility staff did not provide consistent supervision/observation to R1, R2, and R6. Licensee also did not maintain staff alert devices on exterior doors (which was required when caring for persons with Dementia who are at risk for elopement, such as R1).

Six (6) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). 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 809-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST 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
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/03/2025 04:20 PM - It Cannot Be Edited


Created By: Dang Nguyen On 06/03/2025 at 01:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
87211(c)

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87211 Reporting Requirements: “(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, R1, R2, and R6 each no longer live at the facility, their responsible persons have since been told of the incidents, law enforcement and the ombudsman have been told of the incidents, and CCLD has investigated these matters. Licensee agreed to have all current staff receive remedial education on California Mandated Reporting Requirements (as articulated in SOC341A) through a third-party training source, and to E-mail proof of completion to LPA, by the POC due date
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Based on records and interviews, Licensee did not report suspected physical abuse affecting 2 of 6 residents (R2 and R6), but not resulting in serious bodily injury to either, to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours. This posed a potential safety and personal rights risk to persons in care.
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Type B
07/03/2025
Section Cited
CCR87211(a)(1)(D)

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87211 Reporting Requirements: “(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. (D) Any incident which threatens the welfare, safety or health of any resident…” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, R1, R2, and R6 each no longer live at the facility, their responsible persons have since been told of the incidents, and CCLD has investigated these matters. Licensee agreed to have all current staff receive remedial education on Incident Reporting Requirements (as articulated in CCR 87211) through a third-party training source, and to E-mail proof of completion to LPA, by the POC due date
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Based on records and interviews, Licensee did not submit a written report to the licensing agency and the persons responsible regarding incidents which threatened the welfare and/or safety of 3 of 6 residents (R1, R2, and R6), within seven days of incident occurrence. This posed a potential safety 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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/06/2025 08:08 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/06/2025 08:05 AM


Created By: Dang Nguyen On 06/03/2025 at 01:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
06/03/2025
Section Cited
CCR
87207

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87207 False Claims: “No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility…” This requirement was not met, as evidenced by:
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As of the date deficiency issuance, R1 and R6 each no longer live at the facility, and CCLD has investigated these matters. No Plan of Correction was formed. Licensee was advised that repeat violations of this regulation may result in civil penalties and/or administrative action.
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Based on records and interviews, during a formal CCLD investigation, Licensee made a false or misleading statement regarding the extent of their knowledge of abuse against 1 of 6 residents (R6). This posed a potential safety and personal rights risk to persons in care.
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Type B
06/03/2025
Section Cited
CCR87457(c)

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87457 Pre-Admission Appraisal: “(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria…” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, R1, R2, and R5 no longer live at the facility. No Plan of Correction was formed. Licensee was advised that repeat violations of this regulation may result in civil penalties.
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Based on records and interviews, for 3 of 6 residents (R1, R2, and R5), Licensee did not meet/interview the resident and their responsible person to determine the resident’s suitability for admission, prior to admission. This posed a potential health, safety, 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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/03/2025 04:20 PM - It Cannot Be Edited


Created By: Dang Nguyen On 06/03/2025 at 01:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
06/03/2025
Section Cited
CCR
87466

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87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed…” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, R1, R2, and R6 no longer live at the facility. No Plan of Correction was formed. Licensee was advised that repeat violations of this regulation may result in civil penalties.
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Based on records and interviews, Licensee did not ensure that for 3 of 6 residents (R1, R2, and R6) were regularly observed. This posed a potential safety and personal rights risk to persons in care.
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Type B
06/03/2025
Section Cited
CCR87705(d)

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87705 Care of Persons with Dementia: “(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement…”
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As of the date of deficiency issuance, R1 no longer lives at the facility. The current residents in care are not diagnosed with Dementia or at risk of elopement. No Plan of Correction was formed. However, this does not preclude Licensee from proactively installing such devices on exit doors, in anticipation of future move-ins who may be at risk for elopement.
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Based on records and interviews, 1 of 6 residents (R1) had Dementia and was at risk for elopement, but Licensee did not ensure the facility had an auditory device (or similar staff alert feature) on its exterior doors. This posed a potential safety 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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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