Facility Evaluation Report

On 6-4-2025 at 2:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding information gathered from complaint # 27-AS-20250320120901. LPA met with Administrator Lourdes Fernandez and explained the purpose of the visit. LPA conducted brief interview with Administrator and reviewed facility file documentation including facility license and discharge paperwork from skilled nursing rehabilitation facility pertaining to resident1 (R1). LPA also conducted a previous observation of facility on 4-30-25. Based on record reviews, interviews, and observation, it was determined that R1 was sent back to facility from skilled nursing on or about 3-14-25 with a walker. Record reviews and interviews further revealed the walker was essential for R1’s mobilization and safety. Review of license revealed facility may accept up to six ambulatory residents only. R1’s use of walker defines R1 as a non-ambulatory resident per Community Care Regulations (CCR) Section 80001(n)(2) and Health and Safety Code Section 13131 as it pertains to above cited regulation. LPA observed walker placed in R1’s room.

Upon further interview and record review, it was revealed that neither Administrator nor Administrator’s designee secured an appropriate fire clearance for R1’s non-ambulatory status. As a result, citation is issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.