Facility Evaluation Report

During the course of investigation of a complaint (15-AS-20200312114218), Licensing Program Analyst (LPA) Delmundo learned that resident (R1) sustained bruise at bottom of right eye and right arm back in September 2020. Review of records revealed the facility did not submit incident report.

LPA discussed with Simporiana Jugarap, administrator, the above incident and Title 22 Reporting Requirement.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. F ailure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.