Incident investigation·December 8, 2025

On 12/8/25, Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Tihesha Smith, conducted an unannounced Case Management visit to this facility. Upon arrival LPAs met with Shakila Ardakani Administrator and explained the reason for the visit. The purpose of today’s visit is to evaluate R1’s health condition, care plan, and the facility’s improper assessment practices related to R1’s return from the hospital. At approximately 10:50am, LPAs conducted a brief physical plant tour to ensure health and safety of the residents are protected. No health and safety hazards noted during the visit. On 10/17/25, LPA Khurshudyan received an Incident Report (IR) regarding R1, who developed wound on the right toe and per home health nurse evaluation R1 required antibiotic. On 10/23/25, LPA received another Incident Report regarding R1 being transferred to hospital due to wound infection on the toe. LPA contacted the Administrator for additional information regarding R1’s health condition. During phone conversation with the Administrator, LPA requested R1’s home health nurse visit notes, medical evaluation reports, hospital records, and informed the Administrator that to continue providing care under home health agency in the facility, the department will need an Exception Letter with care plan details before discharging R1 back to the facility with higher than stage 2 pressure ulcer. On 11/25/25, LPA received R1’s hospital discharge records and Home Health agency visit reports via email and revealed that R1 was discharged from the hospital back to the board and care on 10/28/25, with assigned home health care. According to discharge records, Resident 1 (R1) was diagnosed with a unspecified pressure wound (no stage noted) on the right fifth toe and sepsis in the body. The records note the presence of an infection, but do not indicate whether the infection had spread or become persistent." Continue on LIC809-C At the time of this visit LPAs spoke with the Administrator and the Administrator acknowledged that R1 was readmitted back to the facility while was getting antibiotics for unspecified infection through the IV Pick line. The Administrator verified that prior to readmission, she failed to contact Licensing Office to request an exception to readmit and/or retain the resident with the health conditions requiring higher level of care. LPAs spoke with the Administrator and informed them the time if resident’s readmission on 10/28/25 the facility was operating in major noncompliance with Title 22 Regulations that posed an immediate risk to R1’s health and safety. Based on today’s inspection, observation and record review, the following deficiencies were cited and recorded on LIC809D. During exit interview, the Administrator was informed that immediate Civil Penalty will be issued for readmission and retention of the resident with prohibited health condition. Deficiencies issued during today’s visit, check LIC809D pages. Exit interview conducted, copy of this report signed and delivered.