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Immediate Jeopardy: Death And Neglect Inside A Troubled California Nursing Home Chain
A large nursing home business — and the state-run system designed to regulate it — were failing California’s most vulnerable even before the pandemic struck, advocates and patient families said. That failure intensified as COVID-19 gripped the state.
Cynthia Carrillo
Cynthia Carrillo
(Chava Sanchez
/
LAist )
(Chava Sanchez
/
LAist )
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At a nursing home in Glendale, a certified nursing assistant was charged with raping a mentally ill patient in her room. After the incident, according to investigators, the victim said she felt "scared, sad, wanted to kill herself."

At a facility in Simi Valley, the daughter of one elderly resident told LAist that staff didn't adequately care for her mother, who developed a gruesome bedsore. "I could stick my pinky in it," she said. "It was down to the bone."

At a nursing home in Compton, a schizophrenic patient with one leg was inappropriately discharged. He went missing, only to turn up two weeks later in a park, unconscious, under his wheelchair. Regulators charged that the facility's lapses presented "imminent danger or a substantial probability" that if the man hadn't been found, he would have suffered grave harm, even death.

Griffith Park Healthcare Center
At Griffith Park Healthcare Center in Glendale, a certified nursing assistant was charged with raping a patient. The nursing home received an "immediate jeopardy" for the incident.
(Chava Sanchez
/
LAist )
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All three nursing homes are connected to ReNew Health Group, a fast-growing chain of skilled nursing facilities founded in 2014 and headquartered in Southern California. ReNew Health and its CEO, Crystal Solorzano, own or are affiliated with at least 26 facilities throughout the state. Solorzano owns, or is applying to own, the majority of them; in five other facilities her company has been involved in management or in administration. The network stretches from Orange County to the Central Valley to the Bay Area.

In its short time caring for California's most vulnerable — many of them elderly and mentally ill — the company has racked up an inordinate number of red flags and citations, many for infractions known as "Immediate Jeopardies," the most severe federal citation a nursing home can receive.

The facilities connected to ReNew and Solorzano provide care for one in 50 of the state's nursing home residents, but they are responsible for nearly one in 10 Immediate Jeopardies in California since 2019, according to LAist's analysis.

Last year, as COVID-19 raged, state regulators denied Solorzano's request to take over nine nursing homes, citing violations and serious deficiencies at "facilities [Solorzano] owned, managed, or operated, directly or indirectly." In fact, by that point they had already deemed her unfit to be a nursing home administrator and moved to revoke her license.

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50:38
Unprotected: How Some Nursing Homes - and the State - Have Failed to Care for the Most Vulnerable.

But that didn't stop Solorzano from growing the nursing home chain she founded. Due to what advocates say is a flawed licensing process, Solorzano is allowed to run those nine nursing homes — and others across the state — as she appeals the state health department's decision.

It's a distressing situation for any Californian with family in one of the state's 1,200 licensed nursing homes, which house around 100,000 patients at any given time.

"California has, in a sense, rolled out the red carpet for bad providers," Tony Chicotel, an attorney with California Advocates for Nursing Home Reform, recently told LAist. "It doesn't matter if you're a bad provider in California. You can get in the building, you can be a squatter, and they can't get you out."

You can get in the building, you can be a squatter, and they can't get you out.
— Tony Chicotel
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As COVID-19 vaccines were about to reach nursing home patients late last year, Solorzano spread misinformation in a series of anti-vaccine posts on social media.

Solorzano declined LAist's interview requests. In a statement, ReNew spokesman Dan Kramer wrote:

"Ms. Solorzano is fully qualified to own and operate nursing homes, and in fact has specialized in acquiring troubled facilities and turning them around to preserve and maintain critical bed space that would have otherwise been unavailable during the pandemic."

The statement went on to say that "Solorzano's only focus is maintaining the health and safety of our employees and residents."

Since reporting on a COVID outbreak at a ReNew facility last summer, LAist has pored over hundreds of court documents and public records, and spoken with dozens of sources — former ReNew employees, families of ReNew patients, advocates, industry experts and attorneys.

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Their message was urgent: ReNew, and the state-run system designed to regulate it, were failing California's most vulnerable, even before the pandemic struck. That failure intensified as COVID-19 gripped the state.

'Severe Lack Of Staffing'

Poor care and understaffing made nursing homes across the country especially vulnerable when the coronavirus slipped through their doors. At facilities connected to ReNew Health, at least 198 people have died from COVID-19, according to an analysis of federal data by LAist.

At Orinda Care Center, a Bay Area nursing home Crystal Solorzano has owned since 2015, officials found nearly every resident was infected with COVID-19 last spring.

Devaughn Greene began working as a housekeeper at the 47-bed facility in April 2020, as the virus was spreading. Greene told LAist that staff members who were clearly symptomatic and coughing continued to work.

"Before you knew it, everybody had it," Greene said.

Orinda Care Center
On April 8, 2020 a sign at the entrance to the Orinda Care Center stated the facility was closed to visitors.
(Ben Margot
/
AP)

By early that April, 25 staff members and 27 patients at Orinda Care Center were infected with COVID.

Another reason for the spread, Greene said, was a lack of personal protective equipment. He'd have to request PPE and then reuse what he was given, stashing his face mask in a cardboard box so he could wear it again and again, shift after shift.

"[There's] only so much you could do when you're wearing the same mask," he said. "I was definitely scared."

Others were concerned, too. Authorities had come to suspect elder abuse at Orinda Care Center. As the outbreak tore through the nursing home, Contra Costa County health officials paid a visit. Greene would later tell investigators that, before inspectors arrived, the nursing home's management staged the facility to create a favorable impression of safety measures.

"They went around and put PPE on every little station — wipes, gloves, all that — but that shit wasn't like that every day," Greene recounted to LAist. Once inspectors left, he told investigators, management gathered up protective gear and locked it in an office.

Despite management's alleged efforts to appear well-equipped, inspectors found Orinda Care Center wasn't properly or consistently using PPE. They also pointed to a "severe lack of staffing" and that, on average, the center lacked three to four nurses per shift. A citation by the state health department said that "deficient practices resulted in a widespread outbreak of COVID-19" at Orinda.

Four residents died.

Graphic
(Graphic: Chava Sanchez
/
LAist )

Last spring, officials found that Orinda Care had the highest rate of COVID-19 infections at any nursing home in the area. To alleviate the staff shortage and slow the spread of the virus, Contra Costa public health officials sent county nurses to the facility. Several weeks later, the county District Attorney's office obtained a search warrant for Orinda Care Center to investigate possible elder abuse. According to the warrant, county nurses there found "that the Orinda Care Center leadership (Solorzano) was not responsive to the center's needs, including requests for more staffing, which only worsened during the pandemic."

The DA's office eventually turned the investigation over to the California Attorney General. A spokesperson for the AG said the office could not comment on "a potential or ongoing investigation."

Devaughn Greene didn't last long at Orinda Care Center. He said he quit after less than two months. "I realized, like, they really didn't care."

Former Resident's Sister: 'I Just Wish I Could Turn Back The Time'

It was only supposed to be temporary.

In December 2019, Cynthia Carrillo placed her older brother David at Villa Mesa Care Center, a nursing home in Upland, 40 miles east of Los Angeles. She was seeking more permanent living arrangements for him, but it wasn't easy. David, 65, had Down syndrome, and had been living with Cynthia in her family's two-story home.

"He was very, very active," she told LAist. "His favorite was Elvis ... He loved to dance and sing."

Most days, he'd attend a day program for adults with disabilities, where he was among friends. But on Christmas Day in 2019, Cynthia said his behavior changed. David was agitated. "He was kind of yelling, screaming. And we're like, OK, something's wrong," Cynthia recalled. She said David was afraid to walk down the stairs. Fearful that her brother was having a medical emergency, she took him to a nearby hospital. There, David was diagnosed with dementia.

Cynthia began looking for a single-story home to accommodate David, while searching for a place he could stay in the meantime. The answer, she decided, was Villa Mesa, the 99-bed nursing home across the street from the hospital. At the time, she wasn't familiar with ReNew or Crystal Solorzano. A year and a half later, she knows a lot more. "I just wish I could turn back the time," Cynthia said.

At Villa Mesa, Cynthia said she watched David's condition quickly deteriorate. That winter, he stopped walking and was often in his wheelchair. He was no longer able to feed himself. And he wore the same clothes for days, she said.

Villa Mesa nursing home
After the shutdown last March, Cynthia Carrillo couldn't visit her brother David inside Villa Mesa. He died in April of 2020 from COVID-19.
(Chava Sanchez
/
LAist )

Once, Cynthia showed up to find David asleep during the day, which was unusual. She claimed someone at the facility had given him a psychotropic drug without her permission.

David was just not the same.
— Cynthia Carillo

Cynthia knew she had to act. "Our goal was to be able to get him out as quick as we could," she said. By March of 2020, she was ready to transfer him to a group home while she continued her house search. But it was too late. The pandemic had hit California and lockdown orders were in effect. There was nothing she could do but hope staff members were doing right by her brother.

Cynthia would call Villa Mesa to check on David. A couple of weeks into the pandemic, she visited through a closed window near the facility's reception area, looking at her brother in his wheelchair on the other side of the glass. "David was just not the same," she said. "You could tell that he was heavily medicated."

Cynthia noticed something else. She said there was a directive on the door instructing that no one could enter without masks, but she didn't see staff wearing them. "It was very hard for us to see the staff walking around like nothing was going on."

Cynthia said she was confounded when the infection control nurse told her the staff didn't need masks.

Ten days later, Cynthia and her husband woke up to a call from the hospital. David was in respiratory distress and needed to be immediately sedated and put on a ventilator. Even if she could have arrived before the procedure began, COVID protocols would have stopped her at the hospital entrance. "I couldn't be there with him to even let him know that everything would be OK," she said, fighting back tears. "He was probably wondering where I was."

Cynthia never got to say goodbye. David died a week later from COVID-19. He was 65.

David Carillo
David Carrillo's playing cards and his favorite bear, which he called "Boo Boo."
(Chava Sanchez
/
LAist)

Cynthia has filed a wrongful death lawsuit against the nursing facility. The case is pending.

"All the years of loving on him and taking care of him, and then you place him in a place where you're thinking they're going to do everything they can, and live up to what their standards are, they are going to take care of your loved one," she said. "In reality, that didn't happen."

Since last spring, at least 23 residents at Villa Mesa, including David Carrillo, have died from COVID-19, according to federal data.

A charge nurse at Villa Mesa spoke with LAist about the conditions there when David got sick. (She asked to be identified only by her middle name, Anna, for fear of retribution.) Her recollection echoed what Devaughn Greene told LAist, and what investigators learned at Orinda Care Center, the ReNew facility 400 miles north.

Anna said management at Villa Mesa didn't provide N-95 masks to staff. "They had them locked up in the administrator's office," she said, "and we were told that we didn't need them."

The Inland Counties Emergency Medical Agency delivered N-95s, gowns and face shields to Villa Mesa at the request of facility staff, the agency said.

As David and other patients fell ill in early April, Anna and another worker at the facility who spoke to us about conditions there said managers told them there was no COVID outbreak. "Well, slowly after that happened, then employees started turning up COVID-positive," Anna said. "I didn't feel safe there anymore." With a husband suffering from kidney failure, Anna said she left the facility in April because she couldn't risk infection.

Villa Mesa and Orinda Care Center were not the only facilities connected to ReNew or Crystal Solorzano that struggled to contain outbreaks of the coronavirus.

Villa Mesa Sign
Since last spring, at least 23 residents at Villa Mesa Care Center in Upland have died from COVID-19, according to federal data.
(Chava Sanchez
/
LAist )

At Porterville Convalescent in the Central Valley, 85 residents at the 99-bed facility contracted COVID-19, one of the highest rates of infection in the state; 36 of them have died.

Presented with the number of cases and deaths in homes connected to ReNew, spokesperson Dan Kramer noted that the company had facilities in areas besieged by COVID. He wrote, "All our facilities continue to follow infection prevention protocols to protect the health and wellbeing of our residents and staff."

A Loophole For Nursing Home Businesses That's 'Absolutely Absurd'

ReNew Health founder Crystal Solorzano's rise in the nursing home industry has been swift. She acquired six facilities in 2015, and her network has steadily grown in the years since. The 26 facilities connected to ReNew now provide care to about 2,000 nursing home residents in California.

The growing business has been slammed by state regulators. Last April, the California Department of Public Health denied applications that Solorzano submitted to take ownership of nine facilities.

The change of ownership process is a necessary step for anyone seeking a license to take over a nursing home. Typically, it's paperwork-intensive but routine, and the state rarely denies ownership petitions. LAist's analysis of state data found that, of more than 250 such applications submitted for nursing homes since 2015, just 5% have been denied. And the department hadn't denied a single ownership change application submitted between 2016 and 2019 — until it rejected the nine from Solorzano.

Change of Ownership Applications Graphic
(Aaron Mendelson
/
LAist )

The California Department of Public Health's denial letters to Solorzano cite a long list of serious issues at her facilities. Regulators reviewed three years of records and found 128 federal violations — including 14 in the most severe category of Immediate Jeopardy. An "I.J.," in industry shorthand, is a situation so dire that regulators determine it "caused, or is likely to cause, serious injury, harm, impairment, or death to a resident."

Immediate Jeopardies documented at Solorzano's facilities have run the gamut, from rodent feces in a kitchen to neglect and violence. At one facility, a resident pepper-sprayed a roommate and stabbed another in the chest with a metal fork, but afterward still remained unsupervised.

At another Solorzano home, a certified nursing assistant was charged with raping a 52-year-old woman who had both physical and mental illnesses. The patient called 911 three days after the incident, telling the dispatcher she had been suffering from vaginal bleeding and was unable to eat or sleep. The Glendale Police Department investigated the incident, and the nursing assistant was later arrested and pled no contest to elder abuse. The patient told state investigators that she didn't notify the facility staff of the assault because she feared they might hide evidence.

"Those [incidents] are really, really bad," said Bill Artigliere, an attorney who has represented nursing home patients in other cases of alleged neglect and abuse. Artigliere said the rape allegation was particularly alarming. "I've seen that in my career maybe four or five times, in 17 years of doing this."

The California Department of Public Health also documented 51 state violations issued at Solorzano's nursing homes, and three instances in which her facilities failed to meet even minimum staffing requirements. According to the state's denials of Solorzano's petitions to take over nine facilities: "You have not provided evidence satisfactory to be licensed."

In addition to considering quality of care, regulators who review change of ownership applications also determine whether an "applicant is of reputable and responsible character." They found Solorzano lacking. The department wrote to her that its review "revealed that in or around July 2008, you submitted fraudulent documents to obtain your nursing home administrator license," specifically a fraudulent college transcript from Touro College. A bachelor's degree or higher is a requirement to enter a training program and become a nursing home administrator in California.

Staff at both Touro College and Touro University confirmed to LAist that Solorzano had not received a degree from their institutions.

While the circumstances around Solorzano's transcript are unclear, a Touro College admissions director was sentenced to prison in New York in 2009 for his involvement in a diploma mill. Ten people were indicted with charges that included the granting of bogus degrees to physicians' assistants.

Nursing Homes - Tear 2
(Graphic: Chava Sanchez
/
LAist)

California's Department of Public Health moved to revoke Solorzano's nursing home administrator license due to "unprofessional conduct" stemming from her alleged fraudulent transcript. Solorzano has appealed. Nearly two years later, a hearing date has not been set.

But the state's license denials had no practical impact. One year after CDPH cited 179 violations in Solorzano's facilities, alleged she had submitted fraudulent documents, and deemed her unfit to take over the nine nursing homes, Solorzano's businesses continue to operate those very facilities, according to CDPH.

That's because in California, someone can take over operations at an existing facility without first getting approved by the state. Advocates for nursing home residents say the change of ownership process is tilted heavily in favor of operators — even when they have poor performance records. "It's a really bizarre, completely exploited process," said Chicotel, the staff attorney for California Advocates for Nursing Home Reform.

Potential buyers, such as Solorzano, can sign management agreements with nursing home owners while the state scrutinizes their applications to take over facilities. If an application is denied, potential owners can appeal, a process that can drag on for years. And they're allowed to operate the facilities while they wait for a decision. "We now have operators — including Solorzano — who seem to understand that you don't need a license to operate a facility in California," Chicotel said. "Maybe ever."

Advocates point to far stricter licensing processes in other industries: Barbers need a license before they can cut hair, surgeons need a license before they can operate.

It's the same for dentists. California Assemblymember Jim Wood (D-Santa Rosa), a dentist by training, sold his practice while running for the statehouse. He said he was required to find a buyer with a license in good standing, and was surprised to learn nursing homes don't work the same way. In 2018, Wood requested a state audit on nursing homes, which found that change of ownership decisions "appear inconsistent" because the process is poorly defined. (Wood also authored legislation on transparency in nursing home finances that passed in 2018.)

The legislator was dismayed to hear that Solorzano's businesses were able to operate nine facilities, despite being denied a license to do so. "It's pretty shocking, quite frankly," Wood said. "Do we grant them the ability to grow their businesses, without some requirement that they actually show improvement? That they show that they have changed the way they're doing things?"

Molly Davies, Los Angeles County's ombudsman for long-term care, called the loophole "absolutely absurd." Davies believes nursing home operators who are denied ownership applications should face additional scrutiny.

"What about the residents and the patients that live in those buildings?" she asked. "Don't they have the right to access safe, good nursing home care?"

Santa Fe Heights Health Care Center
Santa Fe Heights Health Care Center in Compton.
(Chava Sanchez
/
LAist )

Mark Reagan, general counsel for the industry group California Association of Health Facilities, takes a different view. "At the end of the day, I don't think that patient care is being compromised," he told LAist. Just because an application is rejected, Reagan said, doesn't mean the state forfeits its regulatory tools. Reagan argues that the slowness of the ownership-change process creates headaches and uncertainty for owners — even with the vast majority of applications that are approved.

The California Department of Public Health declined LAist's interview request, but, in an email, disputed the comparison to other industries. The agency asserts that allowing potential owners to operate under current owners' licenses isn't a problem.

ReNew spokesman Dan Kramer defended Solorzano's record. "Ms. Solorzano is fully qualified to own and operate nursing homes," he wrote. His statement did not address the violations mentioned in the state's denial letter or the college transcript that CDPH said is fraudulent, although LAist raised both in the letter to Kramer.

Dramatic changes could be coming for the change of ownership process. AB 1502, a bill introduced in February by Assemblymember Al Muratsuchi of Torrance, would require new owners to secure a license before taking over operations at a nursing home.

"For these bad actors to be able to continue to operate without a license, and with a record of past abuses, is simply not acceptable," Muratuschi told LAist. "The current system is broken. And we need to fix it."

Yet shortly after a March press conference announcing the bill as part of a series of proposed nursing home reforms, legislators and industry group CAHF told LAist it had been tabled until 2022.

The 'Blonde Gorilla' Behind ReNew

Crystal Solorzano
ReNew CEO Crystal Solorzano has embraced the nickname "the Blonde Gorilla," which adorns a trophy and hat she has shared on social media.
(Portion(s) of images from Solorzano's Instagram account)

Crystal Solorzano's place in the California nursing home business was hardly preordained. Solorzano, 38, has said she began working in nursing homes when she was 15. According to a résumé she filed with the state, her first nursing home job came in 1999 in Colorado Springs, Colorado. She worked at facilities in the area for another six years, eventually departing for Northern California. In 2007, Solorzano filed for bankruptcy and said she was living in an apartment in Fairfield, about halfway between San Francisco and Sacramento.

In 2009, Solorzano became an administrator at a nursing home in Imperial County, 25 miles from the U.S.-Mexico border. Nursing home administrators make decisions about the business and patient care, and require a license. (The state's allegation that Solorzano submitted a fraudulent college transcript dates to the application for that license.)

In 2012, Solorzano, the facility and other employees were sued for elder abuse by an 84-year-old patient who was recovering from a broken leg. His lawyer alleged that staff at the facility neglected to care for him. He developed a pressure ulcer, according to a nurse's note reviewed by a state investigator, that became "beefy red in color."

Matthew Paré, the attorney who represented the man, told LAist: "There [were] some really gruesome things, such as maggots that were literally growing inside of his leg."

The octogenarian lost his leg, and Paré said the lawsuit settled. Lawyers for the nursing home denied the allegations.

The Imperial County facility was owned by Brius, the largest provider of skilled nursing in California. Brius, which controls about 80 nursing homes, is run by a Los Angeles man named Shlomo Rechnitz. At 6-foot-8 inches, Rechnitz is literally a towering figure in California's nursing home industry, and has himself been the subject of intense scrutiny from the media, healthcare worker unions, and the state, which has also denied some change of ownership petitions he submitted. (Solorzano and Rechnitz are the only operators to have applied since 2015 to have had ownership applications denied, state records show. Brius also continues to operate several nursing homes despite these denials.)

By 2012, Solorzano was a regional administrator in Rechnitz's company, and was described by a state investigator in legal testimony as "a very good and key employee for Mr. Rechnitz." She later took a job with a nursing home management company active at many Brius facilities. But she eventually left. In a 2013 severance package from the company, Solorzano received $650,000, according to testimony at a state hearing.

(Read CalMatters investigation into Rechnitz's 'change-of-ownership' applications)

Two years later, Solorzano began buying nursing homes across California, ranging from 47 to 99 beds. It remains unclear whether Solorzano launched her enterprise with the severance, or had other investors; her business is private, and public documents don't provide more insight into ReNew's origins.

In recent years, Solorzano has chronicled a glamorous, jet-setting lifestyle on her Instagram account. She now owns three residential properties in Redondo Beach and Hermosa Beach, valued at more than $11 million, according to assessor records. She was photographed with future governor Gavin Newsom in 2018, whose campaigns ReNew has supported with $20,000, according to campaign finance data.

[UPDATE: On April 12, the Newsom campaign said it would donate last year's $10,000 contribution from Solorzano to the governor's re-election effort to the AARP; her previous donation was to his 2018 campaign.]

And she's embraced the nickname "the Blonde Gorilla," which adorns a trophy and hat she has shared on social media.

Crystal Solorzono
Solorzano was photographed in 2018 with Gov. Gavin Newsom, whose campaign ReNew supported with $20,000.
(Screenshot from ReNew's Instagram account)

ReNew throws glitzy anniversary parties for employees, including a 2018 affair at the Millennium Biltmore in downtown L.A. that called for white formalwear.

Conditions at her nursing homes are another matter. At one Compton facility visited by LAist reporters, trash littered the property. At another in Glendale, the L.A. County ombudsman Davies documented a leaky roof that left patients exposed for years. "The staff didn't attempt to move them out of the room that was really wet," Davies told LAist. "Pieces from the ceiling were coming down. Splashing was audible when you walked through the room, because the water was so high."

Sante Fe Heights Health Care Center
Trash on the street outside Santa Fe Heights Health Care Center in Compton.
(Chava Sanchez
/
LAist)

The 26 facilities connected to ReNew average just two out of five stars on the system the federal government uses to rate nursing homes. The average rating for nursing homes in California as a whole is 3.6 stars out of 5.

Many ReNew facilities score particularly poorly on the federal measure for nurse staffing; the majority had a 1- or 2-star rating. A 2021 New York Attorney General's report documented "a strong correlation" between staffing ratings and the COVID-19 death rate at nursing homes.

Internal issues have also dogged Solorzano's company. A 2018 lawsuit alleged that Paul Rust, a ReNew administrator and Solorzano's father, had sexually harassed multiple women, sending an "inappropriate and offensive" sexual photo to one nursing home staffer, and embarrassing another with "his constant glaring and inappropriate comments" about her looks. Rust's attorney denied the claims, and the case settled in 2019.

Another of Solorzano's associates is a man named Chaim Kolodny. Kolodny is listed as a ReNew representative on an industry group's website. He's also in business with Shlomo Rechnitz as co-owner of a facility in Maywood, according to state records.

In 2016, a former employee at that nursing home filed a lawsuit alleging that Kolodny diverted Xanax for his own use. During a meeting, the former employee alleged, Kolodny brandished a 9 mm pistol and told her, "This is how we take care of things — the Bronx way." She also alleged that Kolodny directed someone to install a camera "at crotch level" to film female employees. Kolodny denied the allegations and the case settled.

In ReNew spokesman Dan Kramer's response to LAist's reporting, he wrote that the allegations against Chaim Kolodny are "unrelated to Ms. Solorzano or ReNew," and that details of Solorzano's severance are "in no way relevant to ReNew." Rust and Kolodny did not respond to requests for comment.

Sante Fe Heights Health Care Center
Santa Fe Heights Health Care Center at dawn.
(Chava Sanchez
/
LAist)

Other lawsuits paint a disturbing picture of conditions in one ReNew facility. In 2020, a former director of nursing at Santa Fe Heights in Compton sued the nursing home and alleged that patients didn't receive adequate food or water and had bedsores that were improperly treated. She also said Santa Fe Heights lacked working toilets and was infested with rats and roaches. ReNew denied the allegations, and an attorney for the former nursing director said the case was dismissed.

Jacqueline Macias
Jacqueline Macias in a family photo. "She was beautiful," her sister Barbara said. Jacqueline died after a month stay at Santa Fe Heights Healthcare Center in 2017.
(Courtesy Barbara Macias)

In 2017, Barbara Macias sued Santa Fe Heights for abuse and wrongful death after her 49-year-old sister Jacqueline died following a short stay at the facility. Jacqueline had been diagnosed with bipolar disorder, schizophrenia, and diabetes. When Barbara and her father visited, they were distressed by her condition. She had lost 12 pounds within a week, and was throwing up repeatedly.

Jacqueline died after just a month at the facility. An autopsy determined her cause of death was heart disease. It found that ketoacidosis, a poisonous buildup of acids in the blood, was a contributing factor.

Macias told LAist that she didn't learn about her sister's death until two days after the fact. "They just left a voicemail," she said.

Macias' case — her father was also a plaintiff — settled for an undisclosed amount.

In the wake of Jacqueline's death, the California Department of Public Health found the facility failed to carry out her treatment plan; the agency fined Santa Fe Heights $20,000 and imposed a Class A citation, which are issued when there’s “imminent danger of death or serious harm to patients, or a substantial probability of death or serious physical harm to patients.” Santa Fe Heights has received at least three more "Class A" citations since Jacqueline Macias' death.

Sharing Vaccine Misinformation On Social Media

Anti Vaccine posts
(Portion(s) of images from Solorzano's Instagram account)

This past December, as coronavirus vaccines were set to reach Americans, Solorzano used her Instagram account to spread misinformation about the life-saving vaccines to her 11,000 followers.

One misleading meme she shared was about Thalidomide, a drug from the 1950s that caused birth defects. The Associated Press deemed comparisons between COVID vaccines and Thalidomide false and misleading.

Solorzano also recirculated a claim that the COVID vaccine changes human DNA — a falsehood repeatedly debunked by medical experts.

A third post, which was shared from an anti-vaccine account that Solorzano followed, said in its description: "the COVID vaccine should be avoided at all costs."

Solorzano's social media misinformation stunned Dr. Michael Wasserman, a physician and nursing home industry insider who is part of California's Community Vaccine Advisory Committee. "This is a leader in nursing homes doing this?" he asked when shown Solorzano's posts by LAist reporters. "Wow. I mean to me, this is absolutely irresponsible."

Wasserman was particularly worried that nursing home staff would see the posts and avoid the vaccines. "It's unconscionable," he said, "that someone who is in a leadership position in a nursing home, or a nursing home chain, would do this."

California Is A 'Weak Enforcement State' When It Comes To Nursing Home Licensing

Hyde Park Health Center
Hyde Park Health Care Center in South Los Angeles is one of 26 nursing homes in California connected to ReNew.
(Chava Sanchez
/
LAist )

While Crystal Solorzano awaits an appeal hearing about the nine licenses the state declined to grant her, ReNew Health continues to operate them, according to state records. And Solorzano's businesses operate other nursing homes throughout the state that have records of providing substandard care.

Charlene Harrington is professor emeritus at UC San Francisco who headed the California Department of Public Health's licensing and certification efforts in the 1970s. She says dangerous conditions are common at nursing homes, and that the California Department of Public Health isn't preventing them. "We're a very weak enforcement state," she told LAist. The Department of Public Health, she said, "is not even enforcing these basic laws, like denials of licensing, which is so easy to enforce. They live in complete fear that some of these nursing homes are going to get closed."

The problem: finding new places for vulnerable patients to live.

Last year, Pasadena city health officials urged state regulators to address dangerous programs at Golden Cross, a nursing home they found failed to provide basic care. The facility, which is not affiliated with ReNew, racked up more than six "Immediate Jeopardies" in a single inspection. Ying-Ying Goh, director of Pasadena's public health department, told LAist that she visited the facility last spring as COVID cases were rising: "We were in full PPE, and it reeked of urine."

Nursing Homes - Golden Cross
Relatives of a Golden Cross Heath Care facility worker remove belongings in June 2020. Pasadena health officials say the state's decision to evacuate Golden Cross last year should have happened sooner.
(Mark J. Terrill
/
AP)

Still, Pasadena officials said authorities, including the state, were slow to take action.

"What's maddening about this — as the person who's responsible for emergency medical care in our city — is that no one was doing anything," said Bryan Frieders, then-chief of the Pasadena Fire Department. He had developed a plan to evacuate the nursing home residents from the facility at the end of May, but the state didn't make the decision until June 11. "We have patients that are physically being harmed and compromised as a result of a failing bureaucracy."

Max Huntsman, L.A. County's Inspector General, noted in a February report that "substandard conditions festered for more than one month before an evacuation was initiated" at Golden Cross. In that time, 71 residents and 32 staff contracted COVID-19, and 16 residents died. The report focused on Golden Cross and another nursing home in Pasadena that was evacuated.

The inspector general suggested there is a key reason the evacuations were in a single city. "The city of Pasadena is a comparatively affluent city with its own public health and fire departments, which provide an additional layer of oversight when operations fail," Huntsman said.

Unlike Pasadena, hundreds of cities and counties in California either lack the funding or regulatory authority to monitor their nursing homes.

Even if they did have the ability, there's another obstacle to enforcement. In the modern nursing home ecosystem, facilities can be owned by one business and managed by another. The proliferation of entities — such as limited liability corporations — that make up nursing home chains makes it difficult to connect the dots for patient families, politicians and even regulators.

"Piercing the veil of LLCs is really, really, really difficult," said Wood, the dentist turned lawmaker.

Take five of the 26 nursing homes connected to ReNew. They aren't owned by Solorzano, according to state records, and she isn't applying to own them either. Their ties to her business, detailed in state and federal public records, in interviews with staff, and in ReNew statements and in company social media posts, are intricate, making regulation and enforcement even more difficult.

At three of the facilities, a ReNew employee is listed in state records as an owner or board member. And at Villa Mesa in Upland, where David Carrillo stayed before he died, ReNew spokesman Dan Kramer told a local paper in 2020 that Solorzano was the facility's owner. However, CDPH records do not name Solorzano as an owner. ReNew Health has provided “administrative services” at Villa Mesa, according to a financial disclosure report submitted to the state.

The exact nature of such ties and who bears responsibility is unclear to even those who follow the industry closely. L.A. County ombudsman Molly Davies said she didn't learn about ReNew's involvement at some facilities through the formal change of ownership process. Instead, she just happened to notice changes in letterhead and patient discharge paperwork.

"There needs to be a real system that ensures that bad actors are not allowed to continue to thrive in the skilled nursing facility environment," Davies said.

'Their Lives Are In Your Hands'

Villa Mesa nursing home
A "Heroes Work Here" banner hangs over the entrance to Villa Mesa Care Center in Upland, California.
(Chava Sanchez
/
LAist )

Cynthia Carrillo, whose brother David died last year, can't drive by Villa Mesa Care Center anymore.

"I get angry, I get frustrated," she said, sitting on a park bench in Rancho Cucamonga on a sunny February morning. "I can feel the frustration of how he passed and how they didn't take care of him ... Just everything, it's unfair."

As she spoke about her brother, she fiddled with a deck of playing cards that belonged to David. Carrillo brought her brother's ashes, in a wooden box adorned with his photo. She kept them close. She said she wants to see consequences for what happened at Villa Mesa.

"There should be a line drawn in who they can even give a license to," she said. "I mean, their lives are in your hands. "

Since being denied licenses to take over nine nursing homes last year, ReNew Health's owner Crystal Solorzano has applied to take over another facility in Glendale. Earlier this year, Solorzano posted on Instagram that she had moved nearly 3,000 miles east, to the Miami area.

Her appeals to take over the nine nursing homes are still pending, with a hearing set for July. A hearing over her nursing home administrator license, which CDPH is seeking to revoke, has not been set.

At Villa Mesa, where David Carrillo stayed before he died of COVID-19, ReNew Health continued to provide services. David's grieving sister finds that hard to take.

"They don't deserve to manage. Not at all," Carrillo said.

"How do you go to sleep at night?"


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How we reported this story

Data & Methodology
  • LAist identified at least 26 nursing homes connected to ReNew and/or its founder and CEO Crystal Solorzano by reviewing California Department of Public Health (CDPH) documents and databases, and other sources.

  • Solorzano owns or is applying to own 21 of those facilities.

  • For the five others, LAist connected her and ReNew to the facility through:

    • Office of Statewide Health Planning and Development reports that nursing homes are required to file
    • LLCs listed in the National Provider Identifier registry that bear Solorzano's name as the authorized official and list the address of the facility
    • Documents submitted by facilities to CDPH, legal filings, posts on ReNew Health's social media accounts and interviews with facility staff and patient families.
    • Staff answering the phones at each of the five facilities answered "yes" when asked by reporters if the facility was managed by ReNew, on March 31, 2021.
  • Those sources of information explicitly connect the facilities to Solorzano and ReNew, but do not detail the exact services. Additional facilities identified by LAist that were not as clearly connected to Solorzano and ReNew in the public record were omitted from our analysis.

  • ReNew reportedly had "about 25 buildings in its portfolio," according to a Skilled Nursing News report in July 2020.

  • COVID-19 cases and death figures come from weekly data from the Centers for Medicare and Medicaid Services, which is reported directly by facilities. We used federal data because it is more precise than figures shared by local or state health officials in California. One note, the data may not consistently include cases and deaths prior to the week ending May 24, 2020.

  • Data on change of ownership applications came from CDPH in October 2020 (the most recent provided to LAist) and was filtered to only analyze skilled nursing facilities applying for changes of ownership since 2015. In early April, CDPH said that no change of ownership applications have been denied since October 2020.

Credits
  • Reporters: Aaron Mendelson and Elly Yu

  • Editors: Mike Kessler, Oscar Garza, Adriene Hill and Megan Garvey

  • Visuals: Chava Sanchez

  • Data Editor: Dana Amihere

  • Copy Editor: Sherri Hildebrandt

  • Web production: Brian Frank and Andy Cheatwood

UPDATE April 15, 2021: An earlier version of this story included the line “ReNew Health does have an agreement to provide ‘administrative services’ at Villa Mesa, according to CDPH,” based on a February 2021 email from the agency. The agency then contradicted itself in April 2021, after the publication of this story, saying it did not have such paperwork. CDPH did not clarify why the initial response was different.