Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to follow up on a self reported death incident and met with Caregiver, Robertson Cirineo. The purpose of this case management inspection is to follow up on a self-report death report submitted to Community Care Licensing (CCL) on 10/15/25.

According to death report sent in by the facility, resident R1 was rushed to Kaiser Emergency Room on 10/8/25 at about 7am due to vomiting, R1 reported to be in pain, and black/tarry appearance. Responsible parties were notified. According to death report dated 10/14/25, R1 was diagnosed with renal failure and passed away on 10/9/25 at 1:45pm. During today's visit, LPA conducted file review and spoke with Administrator. File review indicated that R1 had a previous hospitalization back on 9/21/25 and returned to the facility within two days on 9/23/25 where they were seen due to abdominal pain, chronic ulcer of left heel -unspecified depth (chronic), pressure ulcer of sacrum-unspecified stage. The hospitalization was reported to CCL, but the unstageable wound was not reported to CCL. After visit summary indicates follow up visit for wound care on 9/25/25. Also, R1 had history of urinary tract infections (UTI). According to Administrator, R1 only had a small red dot in their sacrum, but ignores the reason why Licensee did not report it to CCL. LPA have requested to the Administrator R1's death certificate to be submitted for review and it was agreed that they will submit it once receive it. Also, LPA was unable to review R1's records including Physician's Report, chart notes and care plan, because records were not available at the facility for LPA's review. The Department will be reviewing documents once received to investigate the unexpected death of resident due to R1 was not receiving hospice services and death was unexpected.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22 (Div- 6), Chpt 8 & the H&S Code. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal Rights Given. Exit interview conducted with Administrator and a copy of this report was given.