Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced case management visit to issue a deficiency found while investigating complaint # 29-AS-20251124083503. LPA Yee met with Marilou Mendoza, Administrator and explained the reason for the visit.

On 11/24/2025, Community Care Licensing (CCL) received a complaint alleging a resident passed away due to the facility not seeking timely medical attention. The Department conducted an investigation. On 11/25/2025, from 9:09am to 5:00pm, Licensing Program Analysts (LPAs) Yee and Chochian conducted an unannounced complaint visit. During this visit, LPAs toured the facility, collected relevant documents including Special Incident Reports with fax confirmations, and documents for Resident 1 (R1) and Resident 2 (R2). On 12/24/2025, at approximately 5:28 pm the Department conducted interviews with former Administrator Aaron Feingold; on 3/10/2026 at 2:24pm conducted interviews with Family 1 (F1); and on 3/13/2026, at 9:46 am conducted interview with former administrator Denise Gilroy. The Department attempted multiple times to interview former Staff 1 (S1), who was the staff directly involved when R1 went to the hospital. However, S1 did not show up to the interview location and did not answer additional attempts to contact them for interview.

R1’s facility file was reviewed, including home health records and Incident reports. Records provided that R1 had diagnoses of Anemia, End Stage Renal Disease, Type 2 Diabetes, and was on Dialysis. R1 did not have