Inspection Reports for MorningStar Memory Care at San Tomas

The visit was an unannounced Plan of Correction (POC) inspection conducted to verify correction of deficiencies issued on 2025-07-08 during a prior Complaint Investigation visit.

No deficiencies were cited during this POC visit. The facility had submitted a Plan of Correction for medication discrepancies found during the complaint investigation, and staff medication training was reviewed. A Letter of Deficiencies Citations Cleared was provided during the visit.

The original complaint investigation on 2025-07-08 was related to medication discrepancies found during a random audit of 4 residents' medications, specifically for Resident 8. A Plan of Correction was developed and submitted by the due date of 2025-07-09.

The inspection was an unannounced complaint investigation conducted in response to multiple allegations received on 2025-01-27 regarding infection control practices, food quality, resident falls due to staffing, medication ordering timeliness, and laundry services at the facility.

Based on investigation, records reviewed, and interviews conducted, all allegations were found to be unsubstantiated. The facility was found to be following infection control protocols, providing adequate laundry services, maintaining sufficient staffing, and ensuring residents received their medications timely.

The complaint investigation addressed allegations including improper infection control practices, inadequate laundry services, poor food quality, multiple resident falls due to insufficient staff, and untimely medication ordering. After interviews with residents, staff, and facility leadership, and review of documentation, all allegations were determined to be unsubstantiated.

The inspection was conducted as an unannounced complaint investigation based on complaints received on 2025-06-17 alleging that facility staff did not complete required training, hazardous items were accessible to residents, and staff did not assist a resident under hospice with feeding.

The investigation found all allegations to be unfounded or unsubstantiated. Staff had completed required training, no hazardous items were accessible to residents, and staff assisted residents under hospice with feeding as needed. Interviews and records review supported these conclusions.

The complaint investigation addressed three allegations: 1) Facility staff did not complete required training, 2) Hazardous items were accessible to residents, and 3) Staff did not assist a resident under hospice with feeding. The first two allegations were found to be unfounded, meaning they were false or without reasonable basis. The third allegation was found to be unsubstantiated, indicating insufficient evidence to prove the allegation.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-10-24 alleging insufficient staffing and lack of staff training in medication assistance.

The investigation found that staff and the Health Services Director stated there was sufficient staffing to meet residents' needs. Training records showed all med-tech staff had completed medication training. Resident and staff interviews indicated mixed responses but overall no evidence supported the allegations. The complaint was unsubstantiated.

The complaint alleged insufficient staffing and lack of staff training in medication assistance. The investigation included interviews with staff and residents and review of training records. The allegations were found unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation visit triggered by an allegation of staff mismanaging residents' medication received on 2024-10-24.

The investigation found substantiated medication administration errors, including medications not administered as documented and medications not listed on the centrally stored medication log. These discrepancies posed immediate health, safety, and personal rights risks to residents.

The complaint was substantiated based on medication audits and interviews. Medication M1 was not administered to residents R1 and R8 as documented, and medications for residents R7 to R10 were not listed on the centrally stored medication log. The Health Services Director was unable to explain the discrepancies.

An unannounced complaint investigation visit was conducted following allegations received on 2025-05-15 regarding inadequate supervision, staff under the influence of substances, medication mismanagement, and insufficient administrator presence.

The investigation found no preponderance of evidence to substantiate the allegations. Interviews with staff, residents' responsible parties, and record reviews indicated adequate supervision, no observed substance abuse by staff, proper medication administration, and sufficient administrator presence.

The complaint investigation was unsubstantiated. Allegations included inadequate supervision, staff under the influence of alcohol and drugs, medication mismanagement, and insufficient administrator presence. Interviews and record reviews did not support these claims.

An unannounced annual visit was conducted to evaluate the facility's compliance with licensing requirements.

The facility was found to be in good repair with adequate food supplies, updated resident and staff records, and proper medication storage. No deficiencies were cited during this inspection.

The visit was an unannounced case management follow-up to verify correction of a previously cited deficiency regarding chemicals and hygiene products observed in dementia resident bedrooms and to ensure adherence to the submitted plan of correction.

During the visit, 7 out of 12 resident bedrooms observed contained hygiene products accessible to residents diagnosed with dementia, but based on record review, these residents were not at risk. No deficiencies were cited per California Code of Regulations, Title 22.

The visit was an unannounced case management - deficiencies inspection conducted due to violations observed during a complaint investigation for complaint control number 26-AS-20240923130821.

The Licensing Program Analyst observed that 9 out of 11 resident rooms on the 2nd floor had hygiene products accessible to residents with dementia, which should have been locked. This posed an immediate health, safety, and personal rights risk to persons in care, resulting in a cited deficiency under California Code of Regulation, Title 22.

The visit was triggered by a complaint investigation for complaint control number 26-AS-20240923130821. The deficiency cited was related to violations observed during the complaint investigation.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-10-24 regarding allegations of neglect and injury to a resident.

The investigation found the allegations to be unsubstantiated, with no deficiencies observed or cited. It was determined that the resident's injuries were due to their own aggressive behavior and cognitive issues, and staff were available to assist residents as needed.

The complaint alleged that a resident was covered in feces due to staff neglect and sustained a laceration with unclear details. The investigation concluded the allegations were unsubstantiated due to lack of preponderance of evidence.

The visit was an unannounced complaint investigation conducted due to a complaint received on 2023-11-16 regarding neglect and lack of supervision by staff to a resident who assaulted another resident.

The investigation found that a resident (R1) was aggressive and prone to physical confrontations, causing fear among residents and staff. The facility failed to provide adequate one-on-one supervision until after several incidents occurred. The complaint was substantiated and deficiencies related to staffing and supervision were cited.

The complaint was substantiated based on the preponderance of evidence. The allegation involved neglect and lack of supervision by staff to a resident who assaulted another resident.

The visit was an unannounced complaint investigation triggered by an allegation that staff left medication unattended and accessible to residents in care.

The investigation included interviews with staff and observations of the facility. It was found that the alleged medication left unattended were empty bubble packs being discarded, and no medications were left accessible to residents. The allegation was determined to be unfounded.

The complaint alleged that staff left medication unattended and accessible to residents. After investigation including interviews and observation, the allegation was found to be unfounded.

The inspection visit was an unannounced initial complaint investigation triggered by complaint control number 26-AS-20241007160553, which then prompted a case management - other visit due to observed violations.

During the facility tour, it was observed that 2 out of 2 side exit gates in the patio, considered emergency exits, were locked with combination locks without fire clearance approval, posing an immediate health, safety, and personal rights risk to persons in care. A deficiency was cited per California Code of Regulations, Title 22.

The visit was initiated as an initial complaint investigation for complaint control number 26-AS-20241007160553. The deficiency related to locked emergency exit gates was substantiated.

Licensing Program Analyst Manuel Monter conducted an unannounced annual inspection visit to evaluate the facility's compliance with regulatory requirements.

The inspection found no deficiencies. The facility was toured inside and out, including residential areas and activity spaces. Safety equipment and food storage were compliant, and medication storage was secure. Fire safety equipment was up to date and drills were current.

The visit was an unannounced case management incident investigation triggered by an incident report received on 07/19/2023 involving a resident who was allegedly pinched by staff during a redirection attempt.

The investigation found that staff member S1 pinched and twisted the resident's nose causing bleeding, with no evidence that the resident bit the staff. The incident was reported late to the Department, and staff S1 was terminated. The facility conducted in-service training and notified the resident's physician and family. A deficiency was cited for failure to report the incident within seven days.

The complaint investigation substantiated that staff member S1 pinched and twisted the resident's nose causing injury. The incident was not reported to the Department within the required seven days. Staff S1 was placed on leave and subsequently terminated.

An unannounced pre-licensing inspection visit was conducted to evaluate the facility prior to licensing.

The facility was toured and inspected, including bedrooms, common areas, and safety equipment. All observed safety features such as fire alarms, detectors, and locked storage rooms were functioning properly. Infection Control Plan was reviewed and no deficiencies were noted.

The visit was an initial licensing evaluation conducted via telephone interview to verify the applicant/administrator's understanding of community care facility licensing laws and readiness for licensing.

The applicant and administrator demonstrated understanding of licensing laws, facility operation, admission policies, staffing requirements, emergency preparedness, complaints reporting, and pre-licensing readiness. Identification was verified and required documentation was obtained.