Follow-up on corrections·November 20, 2025

On 11/20/2025, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to this facility to conduct a case management -deficiency visit for deficiencies observed on 10/20/25 and 11/7/2025. LPA met with care staff Josaia Sigavata (S1) and explained the purpose of the visit. S1 called Licensee, Salote Lewis, to inform the LPA was at the facility. Licensee told S1 to assist LPA with this visit. Based on interviews with S1, R3, and R4 stated R4 it was reported that R4 had an ER visit due to sustaining a rib fracture when they were with their family member in which S1 called the ambulance when R4 was complaining of pain on the night of 11/4/25. Discharge paperwork for R4 dated 11/5/25 state R4 obtained a rib fracture (when out with their family on 11/4/25) an incident report was not sent to Licensing. S1 stated Licensee was informed resident was transported via ambulance. At 3:00 PM 11/7/25, S1 stated Licensee was made aware S1 called 911 for R4 due to their rib pain. At around 2:10 PM, LPA spoke with Licensee over the phone on 11/7/25 and they stated there was no recent incidents to report. As of, 11/19/2025 Facility did not meet timely reporting requirements. Additionally, Record review does not show there was an updated appraisal/care plan for facility staff created for R4 after they were discharged with a fractured rib, which constitutes a change of condition. Moreover, LPA observed there was a Tylenol bottle that was over half way full next to R4s bed. Tylenol is listed as a PRN for R4, and should locked and inaccessible to resident in a centrally stored location, this deficiency was cited on a separate LIC 9099 dated 11/19/25. On 10/30 and 11/7/25 LPA Tamayo observed the kitchen refrigerator stored a lock box insulin needles for one resident was closed but it opened freely because the it was not locked with a key, S1 and R2 stated they did not know where the key is. Although R1 is able to self administer medications with some assistance, LPA Tamayo observed insulin needles are stored in the mini-refrigerator of R1’s bedroom without any locking mechanism. CONTINUED ON 809-C At around 1:00PM on 11/7/2025, a maintenance person arrived to repair a hole on the side of the homes exterior leading into the garage as well as the hallway toilet. The maintenance worker told S1 they will remove the toilet and make the repairs by end of day. Resident 1 R1 stated they went to use the bathroom and almost fell into the hole where the toilet was previously placed, "no one told me …. there was no toilet … I could have seriously hurt myself ... I'm blind". S1 stated they did not tell R1 the toilet was removed, because R1 was on the phone. LPA spoke with staff regarding providing accommodations including informing residents with visual impairments if furniture items are moved, ensuring there are no obstructions, or hazards as stated on the needs and services plan. The facility did not ensure accommodation for all residents are being done. LIC 602 for R1 states the resident needs direction with moving around the facility, “ensure environment is clutter free and easy to maneuver … free of tripping hazards … [staff will] provide orientation and mobility training as needed”, however, LPA has not observed staff assist R1 with direction around the facility on 7/28/25, 9/10/25, 10/30/25, 11/7/25, or 11/19/25. During LPA’s visit 11/7/25, LPA observed the right side basin of the kitchen sink was filled with water and had a sealed packet of meat floating inside the sink. Witness 1 (W1) stated they have seen meat thawing on the kitchen sink on more than one occasion. Staff stated they would get a separate basin to thaw meats. LPA conducted record review of staff records for S1, S2, S4, and S5 and there was no staff file for S5, incomplete documents for S4, including LIC 501 , and there were incomplete training verifications available for review for S1, S2, S4, and S5. On 11/19/25, LPA observed S1 was using a separate designated basin to thaw a steak that was going to be prepared for dinner. Additionally, It was reported that Staff 1 (S1) had their family over on the evening of 11/6/2025 for dinner time. Staff is not able to host personal gatherings especially with individuals who do not have criminal background and TB clearance prior to entering the care home. As a result of this case management visit, the facility is not in compliance with Title 22 Regulation. An exit interview was conducted with the Licensee, and a copy of these LIC 809, 809-D reports and appeal rights were left at the facility.