Facility Evaluation Report

Licensing Program Analyst (LPA) Huma Rahimi, met with the Administrator, and LPA explained the reason for the case management visit. The purpose of the case management visit is to address deficiencies observed during the course of complaint # 31-AS-20251209105654, The deficiencies were not alleged but observed by LPA.

During the visit, the LPA was informed that two residents (R1 and R2) passed away while residing at the facility. According to the Administrator, R1 passed away on 09/09/2025 and R2 passed away on 10/28/2025. LPA reviewed the Licensing Information System and did not observe any incident or death reports submitted for R1's and R2's death at the facility. The Administrator acknowledged that no death reports were submitted to the Community Care Licensing Division (CCLD) or to the Regional Office (RO). Based on Title 22 regulations, a written Unusual Incident/Injury Report (LIC 624) must be submitted to CCLD within seven (7) days of the occurrence. The LPA reminded the Administrator that all staff members are mandated reporters and are responsible for ensuring timely reporting of deaths and other reportable incidents.

The LPA instructed the Administrator to submit death reports for the following dates:

A deficiency was issued and appeal rights were explained.

An exit interview was conducted, and copy of this report signed and delivered.