Complaint Investigation Report
The Community Care Licensing Department (CCLD) Infection Control Practices References Guide for RCFE states on page 9: “Facilities with COVID-19 cases retest all staff and residents in accordance with Community Care Licensing guidance, until no new cases are identified in two sequential rounds of testing.”
On 06/10/2024, the facility submitted an Incident Report stating that on 06/07/2024, resident R1 was found to have an elevated temperature and was transported to the hospital. At the hospital, R1 tested positive for COVID. R1 was returned to the facility on 06/08/2024.
During interview on 09/12/2024, LPA Marrufo interviewed Administrator (ADM) Engracia “Grace” Sandoval. ADM stated that after R1 returned to the facility, R1 was isolated in his/her living unit. R2 was the only other resident at the facility at the time. ADM stated that R2 did not need to be isolated since R2 was the only other resident in the facility besides R1 and R1 was being isolated in his/her living unit. ADM stated that the facility did not have COVID tests available when R1 was tested positive with COVID. ADM stated to have ordered more COVID tests and requested COVID tests from other facilities operated by the licensee. ADM stated staff S2 brought a COVID test from S1’s home and used it to test R2. ADM stated R2 took the COVID test and tested positive. ADM stated to have not sent an Unusual Incident/Injury Report for R2’s positive COVID case.
During interview on 09/12/2024, S1 stated to have not gotten COVID while working at the facility. S1 stated to have either had a cold or allergies. S1 stated to have had symptoms of coughing and a runny nose. S1 stated to have taken a COVID test at home, and it had a negative test result. S1 stated to have worn gloves and a mask while coughing and having runny nose symptoms.
On 12/10/2025, LPA Marrufo obtained a copy of a police report from local law enforcement. The police report stated that a police officer visited the facility on 06/14/2025. During the visit, the police officer conducted a welfare check on R1 and R2. The police officer observed appropriate protective personal equipment for COVID-19 outside of the apartments of R1 and R2.
On 12/24/2025, LPA Marrufo reviewed the facility file and did not find an LIC808 COVID-19 Mitigation Plan Report.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction