complaint·November 20, 2025

On today's date, LPA Cho observed masking and Coronavirus (COVID-19) signs posted on the front door with masks and hand sanitizers provided in the entry way. LPA Cho was greeted by staff wearing a mask. LPA reviewed the resident roster dated September 15, 2025, and the residents currently registered to the facility were not present at the time when the complaint was received. LPA interviewed two staff both denying the allegation indicating that COVID-19 protocol and visitation policy was strictly enforced including masking, and confirmed masks were worn properly by all visitors, staff, and residents. Regarding the allegation, resident on hospice transported via non-medical transportation, it is alleged that the transfer in the vehicle caused R1 to decline. R1 was admitted to the facility on August 1, 2021 per the face sheet. Hospice agreement confirms R1 was admitted to hospice on February 25, 2022 with a diagnosis of Alzheimer's Disease. Per the Department's COVID-19 records, the census was five on October 6, 2022. Four out of five residents and two out of two staff tested positive on September 30, 2022. Because R1's roommate and all the other residents tested positive with COVID-19, R1's representative had agreed to move R1 to an alternative location and responded with a "Thank you!!" which was communicated via text on September 30, 2022 at 3:30pm. Based on the review of the admission agreement signed by R1's representative, the option for facility to provide transportation was declined. According to the admission agreement, facility is responsible to "plan and arrange" transportation which is covered under Basic Services. For non-emergency transportation, Transportation Policy indicates that "if a resident requires unscheduled non-emergency medical transportation, the facility will arrange for a taxi or other transport service to transport the resident." In R1's situation, Admin had indicated that R1 was transported by the facility vehicle due to 911 emergency not providing non-emergency medical transport and R1's family not taking action to provide transport even though it was declined on the agreement. Admin stated that the facility vehicle (van) which had access to a ramp, transferred resident safely. Based on the review of hospice records, there was no evidence that the facility vehicle transfer was related to, or resulted in R1's decline. Therefore, based on observation, interviews, and record review, the allegations, facility is not following the proper protocol for COVID-19 and resident on hospice transported via non-medical transportation are deemed unsubstantiated. An exit interview was conducted by telephone with Ban Nguyen and Caregiver Jayvee Angeles, and a copy of this report was provided at exit.