Facility Evaluation Report

On this day, January 29, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 2 complaint (Complaint #15-AS-20250127122838). LPA met with Lulin 'Lucy' Wu, back-up administrator (BUA), and informed the reason for visit.

LPA obtained copies of LIC9020 Register of Facility Residents. When verified for total number of residents on LIC9020, BUA stated resident (R1) passed away on 1/15/25 in the hospital; however, review of documents and LPA's efaxed folder for the facility revealed no Death Report submitted. LPA also observed Unusual Incident Reports and SOC341 on resident's (R2) file but these documents were not submitted nor received by the Department. Facility did not report to the Department within 2 hours upon knowledge of the suspected abuse.

LPA toured the facility inside out with the BUA. LPA inspected the common areas, activity room, dining room, kitchen, ensuite toilets, shower room. LPA randomly selected 6 residents rooms for inspection.

-at 2:19 pm to 2:21 pm, auditory signal on the exit door in one of the resident's rooms not in working condition. LPA also observed extra hospital bed sideways against the wall and detached baseboard and wall moulding with protruding nail in this room.