Follow-up·August 28, 2025

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. LPA met with Executive Director Mike Marion and explained the reason for the visit. During the investigation of complaint # 22-AS-20250722122317 it was revealed that a Resident (R2) was coughing and hacking in the dining room during mealtimes. 8 out of 8 residents reported that R2’s coughing and hacking has been occurring since January 2025, except for March 2025 when R2 was not present at the facility. 5 out of 5 staff interviewed verified this report. During the LPA’s initial 10-day visit, LPA witnessed R2 coughing and hacking and heard it from outside the dining room while in the lobby of the facility. 6 out of 8 residents interviewed reported this issue to the resident council and the resident council reported this issue at least 3 times to the Executive Director since January 2025. The Executive Director verified this report. 6 out of 8 residents reported that no action has been taken by the facility to address this issue. The Executive Director stated no action has been taken because R2 has the right to be in the dining room. The Executive Director reported that according to R2’s physician R2 is not sick, and coughing and hacking is most likely a nervous tick. During the investigation of complaint # 22-AS-20250722122317 it was discovered that there were two incidents involving a resident yelling at another resident and at a staff member. The incident on June 25, 2025, and the incident on July 8, 2025 were verified to have taken place. 8 out of 8 residents interviewed, 5 out of 5 staff interviewed and the Executive Director verified these incidents took place. Neither incident was reported to the Agency. The facility is required to report, “Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.” As stated in California Code of Regulations (CCR) Title 22 Division 6, 87211(a)(1)(D). In addition, all residents have the right to, “To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.” As stated by CCR, Title 22 Division 6, 87468.1 (a)(2). The facility has failed to address the issue of R2 coughing and hacking in the dining room, which violates the personal rights of the other residents at the facility. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report (LIC809 and LIC809D) along with a copy of the appeal rights was provided to the facility representative.