Facility Evaluation Report

While at the facility investigating complaint (Complaint Control # 15-AS-20220427141253), Licensing Program Analyst (LPA) Delmundo learned that residents (R1, R2, and R3) were tested positive of COVID-19. Review of faxed documents revealed a report was not made to Community Care Licensing (CCL) and Local Public Health (LPH). LPA interviewed R1, Lilibeth Toco and Yuka Ono who confirmed the positive cases.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Yuka Ono, administrator, over the phone and with Lilibeth Toco. Licensee indicated she can not come to the facility and authorized Lilibeth Toco to sign and receive this report,

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