Follow-up on corrections·August 26, 2025

On 8/26/2025 Licensing Program Analyst (LPA) M. Garza completed an unannounced case management visit. LPA met with Administrator, Aman Bains, explained reason for visit and was permitted entry into the facility. LPA completed tour of the 4th and 5th floors of the facility. There are currently 65 residents in the facility, none receiving hospice services. This case management visit is being conducted for reporting that was not completed by the facility. LPA visited the facility for an initial complaint visit on todays date. During interview with Administrator while gathering information for the complaint, it was brought to the LPAs attention 2 incidents were not reported to CCL as per regulations. R1 was found to be unresponsive but breathing in the shower. Staff preformed CPR and EMS was contacted. R1 later passed at the hospital. Administrator did not provide CCL with a death report or death certificate for this incident. R2 has an un-witnessed fall and was sent out to the hospital for treatment via EMS. Upon release from hospital resident did not return to the facility and was sent to SNF on grounds. Administrator did not report this incident as per regulations. Deficiencies cited during todays visit per Title 22. If deficiency is not corrected it could have a direct impact to persons in care. Exit interview completed with Administrator, Aman. A plan of correction was developed by Administrator and reviewed with LPA. A copy of this report, deficiency and appeal rights were provided.