Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a Case Management visit 07/23/25 at 11:20 AM to follow up on a death report that was submitted to the department on 7/11/25. LPA was met by caregivers, Staff 2( S2) and Staff 3 (S3). Facility administrator, Dominic Legaspi (S1) was contacted and arrived at 11:45 AM and LPA informed them of the purpose of today’s visit.

The death report indicated the death of R1 occurred around 7:30 PM, however S1 stated the death of R1 took place the morning of 7/11/25, at around 7:30 AM. The Department received a death report timely, on 07/11/2025. Per review of the death report and staff interviews, the cause of death is unknown and they have not received a death certificate. LPA conducted documentation review of resident file for R1. LPA collected resident records for R1 and will add them to the facility file.

Per California Code of Regulations, Title 22, there were no deficiencies observed during today’s visit. Exit interview was conducted. A copy of this report was provided to S1.

This is an amended version of the original report created on 7/23/2025.