complaint·December 18, 2025

· LIC 624 Special Incident Report (SIR) . Medication Administration Record First allegation: Resident sustained unexplained injuries while in care This investigation consisted of observation, interviews, and record review. It was stated that R1’s family member had unexplained bruising on their knees. Staff 1 (S1) stated that the bruises on R1 were old bruises, and those bruises were not recent. LPA Hayes interviewed PZ1 and asked them if they were aware of any conversation or incident with their family member or S1 regarding unexplained injuries with their family member or other residents in the facility and they said they were not aware of this. LPA interviewed Nurse 1 (N1) and they stated the allegation that a resident sustained unexplained injuries that they have no specific knowledge of this. LPA Hayes observed that R1 was admitted in the facility on 02/12/25 through records review of the Admissions Agreement. LPA Hayes learned that R1 was taken out of the facility shortly after this incident involving R2 on and left the facility on 03/10/25. LPA Hayes also observed no additional incident reports involving R1 was sent to the Department by this facility Administrator. No additional evidence was found for this allegation. The preponderance of evidence standard has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. Second allegation : Staff did not seek medical attention for injured client This investigation consisted of observation, interviews, and record review. LPA Hayes interviewed one staff, R2’s POA (PZ1), R2 and the Hospice Nurse (N1) and the Reporting Party (RP). The Reporting Party (RP) alleged that the Administrator was negligent for failing to call Emergency Medical Services (EMS) for the injured resident. PZ1 stated that when the incident occurred, Staff 1 (S1) immediately contacted them and sent photographs of the resident’s injury. PZ1 reported that after reviewing the photographs, the injury did not appear to “be that bad”. PZ1 stated, “It was not that bad. It didn’t look like she needed to go to the hospital.” Through a file review, LPA Hayes confirmed that S1 is a licensed registered nurse. LPA Hayes attempted to interview R2 regarding their experience. They stated that they did not go to the hospital after the injury. LPA Hayes interviewed (N1) and they stated that regarding the allegation that staff failed to seek medical attention, they did not have specific knowledge of how that situation was handled. The preponderance of evidence standard has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. Continued on 9099-C Third allegation: Staff uses medication restraint on residents in care. This investigation consisted of observation, interviews, and record review. LPA Victoria Brown interviewed S1, and they denied using medication to restrain residents. They stated they were a licensed medical professional and never have done this. R2’s responsible party (PZ1) stated they are unaware of any medication restraints. Their mother and other residents seem to be fine and engaged when they visit. N1 stated that S1 did not request medication changes, and none were necessary, as R1 was declining rapidly. According to N1 there were no concerns about medication restraints, the facility was very conservative with medication use. N1 stated all medications were administered under hospice direction. Medication counts were accurate, and no discrepancies were found. N1 also stated that S1 is a licensed nurse. LPA Hayes reviewed the Medication Administration Record (MAR) R1 and R2 and observed no deficiencies or issues. The preponderance of evidence standard has not been met; therefore, the above allegation that staff uses medication restraint on residents is found to be UNSUBSTANTIATED. Fourth allegation: Staff places time restrictions on residents’ visitors. PZ1 reported that this allegation is not true. During their visits, they observed family members spending time with residents at the facility without any pressure or direction to leave at a specific time. PZ1 stated that on one occasion, they spent approximately six hours at the facility playing cards with their family member without any interference or time limitations imposed by staff. S2 stated that visitors were never restricted from visiting the facility. S2 explained that there was a miscommunication regarding parking in or around March 2025. The only limitation communicated to visitors involved parking restrictions in the surrounding neighborhood. The gated community where the facility is located is in new development. A Homeowner’s Association (HOA) officer informed visitors that parking on the street was limited to one hour at a time. The HOA officer reportedly took photographs of vehicles, which caused concern and frustration among some visitors. The Administrator clarified that these parking limitations were imposed by the HOA and not by facility staff and did not restrict visitation time inside the facility. Parking at that time was limited to 1 hour on the street. N1 said due to restrictions imposed by the HOA and facility administration, hospice staff were often required to wait outside until another healthcare provider had left before being allowed entry. Since then, the HOA officer has apologized to families about miscommunication. Families are now able to park at the facility during operating hours. Continued on 9099-C LPA Hayes interviewed R2, who stated they do have visitors, but they do not know if the facility asks them to leave. A review by LPA Hayes of visitor logs from February 2025 and March 2025 showed no documentation indicating any visitation time restrictions. LPA Hayes observed the LIC 603A, Resident Appraisal states that family members visit R1 almost every day and support. Admissions statement signed for R1 states visiting hours for this facility is between the hours of 9:00am to 7:00pm and if guest will be visiting after 8:00pm or before 8:00am, “we ask that they ring the doorbell and they will be let in by staff.” The preponderance of evidence standard has not been met; therefore, the above allegation staff places time restrictions on residents’ visitors is found to be UNSUBSTANTIATED. No deficiencies were cited during today’s visit. An exit interview was conducted with Youngsuk Cho, Licensee/Administrator. A copy of the report was given to the Licensee/ Administrator, Youngsuk Cho. This is an amended report. Licensing Program Analyst (LPA) Sommer Hayes amended this report to remove an extra page that was inadvertently included during the original visit to this facility. This page is intentionally left blank due to a report amendment. An additional page was inadvertently included in the original report for this facility visit.