Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted a case management visit to cite deficiencies d iscovered during a complaint investigation and met with Azenethe Gregoire, Administrator.

LPA learned through records review and interviews with Licensee the facility has failed to obtain an updated physician’s report (LIC602) and care plan for resident (R1) after they have a significant change of condition and ambulatory status. According to R1’s physician’s report (LIC602) dated 12/4/22, R1 had a diagnosis of dementia, they were ambulatory, they did not have a history of skin breakdown and did not require reposition. However, medical records obtained by the Department revealed that R1 was bed-bound and receiving home health services for wound care since September 2, 2025. Although R1 clearly had a change of condition and ambulatory status requiring repositioning of the resident due to bed-bound status, the facility did not obtain an updated physician report and care plan. Furthermore, R1’s medical records revealed that on 9/10/25, R1 was transported to the emergency room with acute severe ankle problem due to a fall while they were getting out of the bath and fell twisting the left ankle, it was unclear in the after visit summary if R1’s was still ambulatory or not, but LPA reviewed incident report logs for this facility and the fall nor the hospitalization was not reported to the Department as stated in regulations. On 12/18/25 at approximate 8:56am, Licensee contacted LPA to notify the Department that R1 passed away while in the hospital after two days hospitalized. LPA inquired about reporting requirement regulation, but Licensee stated that they have mailed the required death report, but LPA did not receive it until 1/2/26.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. 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 copy of this report was provided.