Facility Evaluation Report

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced case management visit to follow up on observations made during a complaint investigation on April 17, 2026, complaint number 22-AS-20231211124258. During the facility tour, LPA observed resident 1 (R1) in resident 2 (R2)’s bedroom on their wheelchair with a restraint belt across their lap. LPA interviews with two out of two staff stated R1 has a restraint because they’re always attempting to get up from the wheelchair. One out of the two staff added the restraint is on for three to four hours per day. The remaining staff added the restraint is on all day. LPA interview with Administrator (AD) Sheryl Tongol stated she was unaware of the restraint being used. AD stated she was in the facility yesterday (April 16, 2026) and did not notice the restraint on R1. LPA took a picture of R1 with the restraint. AD stated there is no doctor order that could be located indicating the restraint can be used as a postural support.

In addition, LPA observed R2 with full bed rails installed on their bed. AD stated R2 is not on hospice. LPA record review of R2 indicated there is a bed rail order. However, Title 22 does not allow for full bed rails for residents who are not on hospice. Only half rails may be used.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An immediate civil penalty is being assessed. This report was discussed with the facility representative and a copy was provided along with appeal rights.