Facility Evaluation Report

While at the facility investigating a complaint (Control # 15-AS-20250514132244) and upon review of residents' records and interviews, Licensing Program Analyst (LPA) Delmundo observed the following:

1. Facility did not submit Unusual Incident Report for resident (R1) when R1 was sent out to the hospital on May 1, 2025.

2. The other resident's (R2) LIC602A Physician's Report on file was dated November 2021 and missing pages #'s 3 and 4. R2 was admitted to the facility on November 2021 and updated LIC602A was never obtained.

The above were discussed with House Manager (HM) Mateaki 'Mat' Ofenhengaue.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with HM. HM has to leave and gave permission to Gladys Corpuz, staff, to sign and receive this report.

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