Facility Evaluation Report

On 12/16/2025 at 2:10PM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with caregiver, Khin Win and explained the purpose of the visit.

While LPA L. Alexander was conducting a complaint investigation (#15-AS-20251211101359 ) on 12/16/2025. During interview with Staff (S1) LPA was informed that Resident (R1) got sick and 911 was called on 12/06/2025. R1 was transported by Emergency Medical Transportation and S1 stated that they were notified by R1's relative that R1 passed away at the hospital. LPA asked S1 if a Unusual Incident Report (UIR) was submitted to Community Care Licensing Division (CCLD) and S1 stated that they had the UIR written but hadn't submitted the document to CCLD.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided