Follow-up·June 9, 2026

This case management visit was conducted by LPM Naira Margaryan and LPA Nicholas Reed to discuss the citations previously issued to the facility during licensing visit conducted on 04/08/26. Initially on 02/26/2026, LPM Margaryan and LPA Smith visited the facility and conducted complete inspection of the entire facility. LPM and LPA noted that the facility is operating in substantial noncompliance of Title 22 Regulations. Some of the noted deficiencies were addressed as a part of complaint investigations. Other issues and concerns were addressed under the Case Management visit. LPM Margaryan and LPA Smith had extensive discussions about noted issues and concerns with the Licensee and VP of operation, who arrived to the facility few hours later. Licensing representatives were notified that noted issues required immediate attention and corrections. The topics of discussion included but not limited to the following deficiencies: 1. The facility did not have sufficient support staff and sufficient number of qualified personnel to assist residents. 2.The facility’s Emergency Plan of Operation was reviewed, and it was noted that the plan does not address how the facility personnel will assist non-ambulatory residents to bring them down from the upper floors. Non-ambulatory residents were observed on the 2 nd and 3 rd floor, and it was not clear how staff would assist them during an emergency. 3. Residents’ records were incomplete and/or outdated. 4. Physician reports and other records were not updated as required. Licensee indicated that all noted issues will be addressed, and written documentation will be submitted to Licensing Office informing how the Licensee will correct noted deficiencies. Licensee was advised that no deficiencies will be cited during the visit with expectations that noted issues will be corrected as soon as possible. Between 02/26/26 and 04/08/26 LPA Smith made numerous Licensing Visit to the facility, and no documentation was provided to the LPA explaining the steps that facility is taking to correct noted issues and bring facility to compliance. · No updated emergency plan has been submitted to the Licensing office for review and approval. · No documentation was submitted to explain how the facility is addressing staffing shortage. · No written notification was provided to the Licensing office verifying that all resident records had been updated and corrected. Due to failure to submitting required documents, on 04/08/2026, LPA Smith visited the facility and noted that the issues discussed during Licensing visit on 02/26/26 were not corrected as discussed. Therefore, LPA had another discussion with the Administrator and issued citation for the noted deficiencies. Up to date facility failed to submit plan of corrections to clear the citations. Furthermore, during licensing visits LPA was informed that the facility is unable to maintain required staffing. The staff that they were hiring or planning to hire either quit or did not complete hiring process. The issue regarding updates for emergency disaster plan was discussed and Licensing representatives were informed that the facility will use evacuation chairs to bring residents down from the upper floors during evacuation. At the time of this visit LPM and LPA were informed that the facility has 3 evacuation chairs. The plan will be updated to identify the assistance with evacuation chairs.