Follow-up on corrections·October 23, 2025

L icensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced on 10/23/2025 to conduct a case management visit. LPA Lee met with care staff Atelaite Peti and explained the purpose of the visit. The census is six with one facility staff. LPA Lee was later met with Assistant Administrator Veresa Taqasi. The purpose of this visit is to follow up on deficiencies learned during complaint investigation control number 27-AS-20250918210117 . The investigation revealed that Resident 1 (R1) experienced multiple incidents resulting in hospital visits on the following dates: 08/08/2025 (fall), 08/14/2025 (seizure disorder), 08/19/2025 (rib pain), 09/04/2025 (pericarditis), and 09/11/2025 (mood problems). A review of facility records and Community Care Licensing Division (CCLD) electronic facility files indicated that the facility did not report these incident to CCLD and R1's responsible party. LPA Lee also observed that the facility has an incident report binder. Based on a review of these incident records there were one incident report for the month of June, six for July, twelve for August, two for September, and five for October. Moreover, the LIC 624 incident reports did not indicate which agencies or individuals who was notified of the incidents. The facility was also unable to provide LPA Lee with documentation showing that some of these incidents had been reported to CCLD and residents’ responsible party. Furthermore, during interviews with two facility staff members, it was learned that they were unaware that, according to R1’s LIC 602 Physician’s Report, R1 requires supervision for safety during repositioning, transferring, and toileting as well as having a poor safety awareness such as unsafe wandering. In a separate interview, Staff 1 (S1) confirmed that during R1’s incident on 09/15/2025 , in which R1 fell in the bathroom and hit their head on the toilet, S1 was not providing supervision at the time of the incident due to not being aware of R1’s needs per R1’s physician’s report. CONTINUED LIC 809-C During today’s visit, LPA Lee also observed that the broken tiles in the kitchen were repaired. Once LPA Lee received the rest of the POC cited on 10/21/2025 LPA Lee will clear the citations. The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page. An exit interview was conducted with care staff Peti and a copy of the 809 report, 809-D page, and appeal rights were given to the facility.