Incident investigation·January 7, 2026

On 01/07/2026 at 2:50 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident that was sent on 12/11/2025. LPA met with Director of Operations, Angel Lee, and explained the purpose of the visit. The Executive Director was not available during today's visit. Incident report indicated that on 12/06/2025, R1 was sent to the hospital for a change in condition. On 12/10/2025, the facility was notified by R1's responsible party that R1 was diagnosed with a stage 3 pressure ulcer. During the visit, interview with S1 and a review of the after-visit summary dated 09/26/2025 and 11/21/2025, R1 was diagnosed with stage 2 pressure ulcer. LPA reviewed and obtained Home Health Care Visit Communication Form, Physician Fax Reports, hospital progress notes, and service plan. Documents reviewed indicated that R1's pressure ulcer would reopened once healed. Interview with S1 and Physician Fax Report dated 06/13/2025, revealed that since June 2025, R1's home health was initiated for wound care and home health has been monitoring the wound. Since R1's hospitalization, R1 has not returned from hospitalization. No deficiencies cited. Exit interview conducted with Lee and copy of this report is provided.