Facility Evaluation Report

**amended**Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a Case Management. LPA spoke to Arthur Alcones, Administrator.

Related to complaint 21-AS-20250612104410, LPA found the facility to be deficient in timely reporting. LPA received evidence that licensee was aware that R1 was hospitalized on 5/3/25 but did not submit an incident report to CCL as required per regulation 87211 ( deficiency cited, see 809D )

On 7/28/25, LPA reviewed all incident reports submitted by this facility beginning with the year 2021. LPA found that only one incident report has been submitted, on 7/11/2022. Considering the facility has a capacity of six residents, it seems unlikely that there was never another occurrence of any incident which threatened the welfare, safety or health of any residents, including but not limited to residents falling or needing medical attention. The appearance of a lack of reporting by this facility is concerning to LPA.

Furthermore, the facility has submitted ten [10] Death Reports for the years 2021-present day 2025. Each of the 10 reports indicate the cause of death as cardiac arrest, including the report for R1, subject of complaint 21-AS-20250612104410. However R1’s cause of death was listed as septic shock and renal failure per R1’s official Death Certificate.

LPA discussed lack of incident reporting with Administrator and their responsibility to ensure accurate reporting when submitting the cause of death for residents.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.