Facility Evaluation Report

12/8/25, Licensing Program Analyst (LPA) J. Leffall conducted a case management and follow up on a previous complaint regarding Resident (R1) Admission Agreement.

During the Investigation of a complaint received by the Department on 9/23/25, the assigned LPA to the facility, the Licensing Program Manager and the Investigator assigned to the complaint requested from the facility R1's Admission Agreement. The facility submitted a blank Admission Agreement. Upon review of R1's file, the LPA, LPM and Investigator concluded that R1 did not possess an Admission Agreement in R1's file.

A citation is being issued on the attached 809-D in accordance with California Code of Regulations, Title 22,Division 6.

A copy of this report with Appeal Rights was issued to Administrator whose signature confirms receipt of this report.