Facility Evaluation Report

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced visit at the facility in conjunction with a complaint investigation that occurred today. LPA met with Administrator, Sophia Bonoan, and explained the purpose of the visit. Entrance interview conducted.

During today’s facility tour and record review conducted with the Administrator, the LPA observed that Resident’s #1(R1’s) file, with an admission date of 11/01/2025, did not contain all required on-boarding documentation. Specifically, the pre-admission appraisal form, a reappraisal form, or an appraisal/needs and service plan. The administrator stated that R1 was referred by the hospital and believed it was not necessary to complete a pre-placement assessment on R1 prior to admission. Regarding the appraisal and the appraisal/needs and service plan, the administrator explained that R1 had a short stay at the facility due to health complications, and the facility did not have sufficient time to complete these documents.

Additionally, it was noted that the facility did not notify Community Care Licensing (CCL) of an apparent fall incident or of a 911 emergency response in which R1 was transported to the hospital. According to the administrator, on 11/01/2025, Resident #1 (R1) slid from their bed; however, the caregiver on duty cushioned the fall with one of their feet. The facility notified R1’s family member, who declined to have emergency services contacted. On 11/04/2025, R1 received an Xray due to ongoing discomfort and pain. On 11/30/2025, R1 was subsequently transported to the hospital via Emergency Services due to an apparent Urinary Tract Infection (UTI). When LPA inquired about the details of the fall, the administrator stated they were not present when the fall occurred.