Facility Evaluation Report

05/14/2026, Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Deficiency visit and met with Staff, Philomene Desire. The purpose of this case management was to address issues found during conducting a complaint investigation.

While conducting investigation into allegations of complaint 21-AS-20260429140111, it was noted that resident (R1) had an unstageable wound as per R1s LIC602 (physicans report) dated 03/10/2026. LPA contacted facility on 05/07/2026 for R1 to get sent out to the Emergency Room for further testing to confirm that stage of the wound. Facility provided additional information to community care licensing (CCL) on 05/08/2026 that showed R1 was discharged from the Emergency Room and noted that R1s wound is a stage 2 pressure ulcer. CCL did not receive an exception to retain a resident with a prohibited condition once it was believed that R1 could have had an unstageable wound in March 2026.

LPA was also informed by facility staff that individual (I1) had worked at the facility before being suspended. LPA confirmed that I1 was not background cleared and associated to the facility. (*Civil Penalty being assessed in the amount of $500)

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.