Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a unannounced Case Management Visit-Deficiency on 05/08/2025, stemming from initial complaint investigation (28-AS-2025050170249) visit on 05/08/2025. Caregiver Stephaine Mariano answered the door, and LPA explained the purpose of the visit.

Upon review of resident#1 (R1) resident record, LPA Ramirez did not observe original signed and dated Admission Agreement for R1. Per Title 22, Division 6, Chapter 8, Article 09. Resident Records- Admission Agreements- 87507(d)- The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. This poses a potential risk to the health, safety, or personal rights of persons in care.

LPA Ramirez did not observe pre-admission appraisal for R1. Per Title 22, Division 6, Chapter 8. Article 08. Resident Assessments, Fundamental Services, and Right- Pre-Admission Appraisal- 87457(c)(1)(A)- Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factor. This poses a potential risk to the health, safety, or personal rights of persons in care.

Based on observations and records reviewed, LPA Ramirez will issue two (2) deficiencies.

Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided via email.