Facility Evaluation Report

Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20250825094140). The purpose of the visit is to issue a citation for a deficiency observed during the initial complaint investigation.

During the course of the investigation, it was revealed that Resident #1 (R1) was not feeling well and had stomach issues. Per family’s request, R1 was sent out to the hospital to be evaluated and treated. Record review revealed that a written Unusual Incident/Injury Report (LIC 624) was not submitted to Community Care Licensing (CCL) within seven (7) days of the occurrence, as required by reporting regulations, for R1’s hospital visit.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.