Follow-up·December 29, 2025

On 12/29/25, Licensing Program Analyst (LPAs) Cynthia Tamayo made an unannounced case management visit to this facility to conduct a case management visit. LPA met with Susan McClure (S2), Dietary Manager and assistant administrator and explained the purpose of today's visit. Administrator, Sherry Richardson (S1) an d Rabindar Singh (S3) . Current administrator, Sherry Richardson (S1) was not present during this visit. LPA discussed the plan of correction deficiencies cited 12/18/25: -87405 Administrator - Qualifications and Duties (a); S2 stated an updated LIC 610 will be emailed to LPA by end of day 12/29/25. The administrator will be changed to S3, The request will be submitted to licensing by 12/30/25. -87203 Fire Safety has been cleared. -S2 stated the patio repairs are completed and ready for re-inspection from code enforcement. the roof repair is expected to start in April 2026 and no contract has been completed as of this date. The roof repair will consist of re-roofing and not re-patching. LPA followed up on incident report received by the Regional Office on 12/19/25. R1 had an unwitnessed fall that occurred on 12/17/25. S2 stated that staff reviewed video footage and saw that dementia resident 2 (R2) pushed resident 1 (R1) due to R1 trying to enter their room. S2 stated R1 was sent out to the emergency room and is still in the hospital and it seems like they have a fracture on hip. S2 stated an amended incident report was sent to regional office on 12/29/25. The incident was unintentional Reporting requirements were reviewed. CONTINUED ON 809-C Three staff interviews corroborate that at the same time as the incident, there was a care staff Christmas party on 12/17/25 happening around 12:30PM in which there should have been some care staff supervised the floor. The administrator nor S2 were present during this incident. S3 stated they were at the facility but did not assist with this incident. S4 reported that R1 stated "someone pushed me". The Medication Technician was called by S4 and R1 was transported to the hospital. Three staff reported R1 often knocks on other resident doors thinking it was their room. R2's care plan stated supervision and re-direction shall be implemented. On 12/29/25, S3 stated R1 was being evaluated by their physician for medication adjustment due to their diagnosis and behaviors. LPA went on a facility tour with S3 at around 2:00 PM. LPA observed there were ceiling panels pieces that were damaged from the roof leaks, there is water dripping from three new missing panels/panel pieces on the second floor hallway, in which there are trash bins placed below to catch the water. S2 stated no residents have fallen due to wet floor and maintenance is periodically checking for new leaks and ensuring there is no fall hazards. LPA is requested for facility to have the building evaluated to ensure it is safe and habitable for residents. At this time, the roofing is not able to be repaired until spring of 2026 and it is uncertain if residents are being exposed to mold and asbestos particles as a result to the ongoing water damage. LPA observed some trash bins have accumulated over a gallons worth of water. LPA provided guidance around ensuring preventative measures are being taken, including cleaning up water leaking onto the floor and bins catching water leaks are being emptied out at least twice per day. LPA requested delayed egress fire clearance verification, to be submitted to licensing by 1/2/25. There is one deficiency cited during this case management visit. An exit interview was conducted with the Licensee, and a copy of these LIC 809 reports were provided to the facility.