Facility Evaluation Report

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management visit. LPA met with Assistant Manager (AM) Marianne Alfaro and we discussed the purpose of the visit. Licensee Ligaya Sanders arrived a short time after.This visit was conducted to follow up on information received during a previous unannounced complaint visit, during which Lic informed LPA that Client 1 (C1) had passed away. AM stated she was notified on 4/28/26 by a Telecare Case Worker that C1 passed away on 4/26/26. AM explained she did not have full details about the circumstances of the death and referred LPA to Telecare for additional information. LPA later contacted a Telecare Team Leader, who confirmed the date of death and provided basic information regarding C1’s passing.

During today’s visit, LPA reviewed the facility’s records and discussed reporting responsibilities with AM. AM stated that after LPA's visit, she did not submit a death report to Community Care Licensing (CCL) because she was instructed not to do so. AM reported that the Licensee told her not to submit the death report. FM stated that she was again advised by the Licensee’s stepson not to submit a death report to CCL. AM explained that the reasoning given to her was that the Licensee and FM had received conflicting or different information regarding the circumstances of the death, and they wanted to wait until the information was consistent before reporting. LPA explained to AM that the facility is required to report all client deaths within seven days regardless of conflicting details or incomplete information. The facility must report what they know at the time and may submit updates later if needed.

LPA confirmed that the facility did not submit an LIC 624 Unusual Incident Report or any death report to Licensing within the required timeframe.