Facility Evaluation Report

On 03/16/2026 at 2:20 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit to follow up on the incident reports sent on 03/06/2026. LPA met with Business Office Director, Mimi Co, and explained the purpose of the visit. Executive Director, Beena Kumar, was unavailable during today's visit.

Incident Report (LIC624) for R1 indicated that the incident occured on 02/20/2026 and R2's incident occured on 02/24/2026. Both R1's and R2's Incident Report was reported to the Department on 03/06/2026. Facility did not follow the reporting requirements. LPA and Co discussed the reporting requirements regulation.

During the visit, LPA reviewed and obtained Resident Roster, R1's service plan dated 01/20/2026, R2's service plan dated 01/20/2026, and R2's physician fax reports. Per Co, R2 did not return back from the hospital and passed away on 03/14/2026.

LPA is requesting for the facility to send R1's after visit summary from the hospital and R2's death certificate by 03/25/2026.

A Technical Violation has been issued for Reporting Requirements, Section 87211(a)(1).

Exit interview conducted and a copy of this report provided.