Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance inspection to this facility and deficiencies found during complaint # 21-AS-20260505100622 investigation, LPA met with Licensee Nicholas Ray. LPA was following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 03/04/2026:

87405 (a) Administrator - Qualifications and Duties – Licensee failed to provide required information and documentation to carry out the solvency audit for the facility. On 4/27/26, the department’s financial unit sent an engagement letter regarding solvency audit process initiated after lack of commitment from the Licensee to provide requested financial documents pertinent to the facility. During today’s visit, LPA learned that Licensee has not submitted the requested forms and supporting documentation, but its planning to submit it timely.

87213 Finances - The licensee failed to have a financial plan that conforms to the requirements of Section 87155...shall maintain adequate financial records; submit such financial reports as may be required upon the written request of the licensing agency. The department has requested forms (LIC 401, 401A, 403 & 403A) & supporting documentation needed to conduct solvency audit to ensure facility is not in financial distress.

During complaint # 21-AS-20260505100622 investigation, LPA learned after requesting resident’s (R1) hospice intake documentation to determine staging of R1's pressure injuries on 5/15/2026 when Licensee told LPA that R1 passed away on 5/5/26. Licensee could not provide an answer why they did not report to the department that R1 passed away on 5/5/26. Upon arrival, LPA smelled strong urine odor at the facility. Per Licensee, its in the process to clean the carpet to resolve the odor present at the facility. Deficiencies are cited from the California Code of Regulations (CCR), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.