Facility Evaluation Report

On 02/24/2026 at 1:55 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported death report. The facility sent in a death report on 02/18/2026 that indicated that R1 passed away on 02/08/2026 at 1:05 PM. LPA met with Administrator (ADM), Antonia Mari, and explained the purpose of the visit.

During the visit, LPA reviewed facility’s incident report, death report, physician report, appraisal needs and services plan, hospice binder, and Physician Orders for Life-Sustaining Treatment (POLST). LPA spoke with ADM who stated that R1 was on hospice and R1's health was declining. ADM stated that R1 on puree diet and was not consuming much. During the visit, LPA and ADM spoke with hospice agency to obtain progress notes of R1 while on hospice.

The following deficiencies were observed:

At 2:05 PM, LPA observed Peridex in the bathroom.

At 2:25 PM, LPA observed that the death report was reported to CCLD on 02/18/2026 but R1 passed away on 02/08/2026.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with staff. Appeal Rights, LIC421FC, and a copy of this report provided.