Facility Evaluation Report

This case management visit was conducted by LPM Naira Margaryan and LPA Nicholas Reed to discuss the citations previously issued to the facility during licensing visit conducted on 04/08/26.

Initially on 02/26/2026, LPM Margaryan and LPA Smith visited the facility and conducted complete inspection of the entire facility. LPM and LPA noted that the facility is operating in substantial noncompliance of Title 22 Regulations. Some of the noted deficiencies were addressed as a part of complaint investigations. Other issues and concerns were addressed under the Case Management visit. LPM Margaryan and LPA Smith had extensive discussions about noted issues and concerns with the Licensee and VP of operation, who arrived to the facility few hours later. Licensing representatives were notified that noted issues required immediate attention and corrections. The topics of discussion included but not limited to the following deficiencies:

1. The facility did not have sufficient support staff and sufficient number of qualified personnel to assist residents.

2.The facility’s Emergency Plan of Operation was reviewed, and it was noted that the plan does not address how the facility personnel will assist non-ambulatory residents to bring them down from the upper floors.

Non-ambulatory residents were observed on the 2 nd and 3 rd floor, and it was not clear how staff would assist them during an emergency.

3. Residents’ records were incomplete and/or outdated.

4. Physician reports and other records were not updated as required.

Licensee indicated that all noted issues will be addressed, and written documentation will be submitted to Licensing Office informing how the Licensee will correct noted deficiencies. Licensee was advised that no deficiencies will be cited during the visit with expectations that noted issues will be corrected as soon as possible.