Facility Evaluation Report

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit for a Plan of Correction (POC) clearance. LPA Lopez identified herself and was granted entry by Licensee Victoria Legaspi. LPA met with Licensee Legaspi and discussed the purpose of today’s visit.

On 4/24/25, the Licensee was issued multiple deficiencies regarding staff training, residents' functional capabilities assessments, residents' pending medical assessments, activities for residents, and facility financial records. At the time of the visit, California Code of Regulations (CCR), Sections 87506 Resident Records, 87456 Evaluation of Suitability for Admission, 87464 Basic Services, 87213 Finances, and Health and Safety Code (HSC), Section 1569.267 Resident’s Bill of Rights, were discussed with the Licensee. A POC was jointly developed with Licensee Legaspi and the deficiencies issued were due between 05/09/2025 through 05/15/2025.

During today’s visit, LPA requested copies of their POCs for five (5) of the deficient practice statements that were jointly developed, but they were unable to be produced by the Licensee. A failure to correct was issued for each of the deficiencies on the time elapsed, between the due dates of 5/9/25 through 5/15/25.

On 04/17/25, Licensee was issued a deficiency for CCR, Section 87211 Reporting Requirements, due 5/02/25. The licensee was unable to produce the POC, and this deficiency will be reissued and recited during today’s visit.

Also, on 04/17/2025, the Licensee was issued a Type A deficiency regarding false/misleading statements. At that time, CCR, Section 87207, was discussed with Licensee Legaspi. A POC was jointly developed with Licensee Legaspi with a due date of 4/18/25. On 4/24/25, Licensee was unable to produce the POC to clear the deficiency, and a failure to correct was issued for the time elapsed, between 4/18/25 through 4/24/25.