Facility Evaluation Report

Licensing Program Analyst (LPA) Alviso conducted a case management inspection, on 2/23/2026 at approximately 2:00pm, and met with Interim Administrator, Omar Mendoza, and Tamra Richmond, Business Office Manager.

This case management is being conducted to address a resident incident (R1) that was reported by the facility as required. LPA conducted interviews with staff; and obtained additional information on the incident.

A dependent resident (R1) was left sitting on the toilet for a period of approximately fifty-five (55) minutes by a caregiver; The resident requested the staff to return within thirty (30) minutes, but the staff went off shift, leaving the facility.

The staff never returned to assist the resident. Resident was left waiting in the bathroom, until a visitor arrived and found them. The visitor notified staff on duty.

Administrator stated they suspended the staff, who was involved in the incident, pending an in-house investigation. Investigation was completed by staff, and staff S3 was terminated.

LPA was provided a copy of staff's termination. LPA was provided copies of training that was provided to direct care staff on residents' "personal rights", and "providing care needs to residents'".

There is sufficient information obtained to support a violation occurred regarding resident's personal rights.