Follow-up·December 23, 2025

Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a case management visit on incident reports received. LPA met with Josaia Sigavata (S2) and explained the purpose of the visit. Licensee (S1), Salote (Charlotte) Lewis, was not present during this visit. S2 stated that S1 was present at the facility this morning. LPA called S1 and left a voice message requesting a call back. The purpose of this visit is to follow up on an incident report and death report received for Resident 4 (R4). The incident received for R4 was dated 12/16/2025 regarding a resident being sent out to the hospital due to R4‘complaining of abdominal pain’. A Death report for R4 is dated 12/16/25 states that R4 died at the hospital on 12/15/25 due to “multiple underlying conditions”. S2 stated they do not know if the death certificate has been requested. Per records review, R4 was admitted to this facility on 6/3/2025. During a case management visit in November 2025, it was discovered that R4 had was transported to the emergency room on 11/4/25 due to a sustained rib fracture the day prior while out with their family, the facility did not submit a timely incident report. On 11/20/25, a deficiency was cited for 87211 Reporting Requirements (a)(1) which consisted of Licensee will submit incident report for R4 to licensing and responsible party along with a statement agreeing to review 87211(a)(1) and report all special/unusual incidents to licensing and responsible parties in a timely manner by 12/4/25. Incident report (SIR) dated 11/4/25 for R4 was not submitted to LPA as stated on POC due date 12/4/25; LPA observed SIR dated 11/4/25 was available for review at the facility (SIR binder). Contunued on 809-C Licensee will submit an additional SIR regarding the incident, as the one on file does not inform of the diagnosis of fractured ribs and discharge details. LPA observed R4’s reappraisal dated 11/4/25 was not in R4’s physical record/binder maintained at the facility. The re-appraisal was submitted to LPA via email. LPA observed all medical visit verifications including discharge paperwork, after care summaries for R4 were not available for review at the facility during this visit. LPA reviewed POC requirements and record keeping requirements with S2. As of 12/23/25, CCLD has not received a request to change administration designation to S1; the current assigned administrator is S2, whom is no longer working at the facility and is now disassociated. S1 stated they will submit a request to designate themselves as administrator. A civil penalty for repeat violation applies. On 12/22/25, LPA spoke with S1 via phone call to follow up on administrator status, S1 stated they are still in the process of hiring a new administrator and they are acting as administrator for this facility. At around 2:30PM on 12/23/25, S1 informed LPA they are not able to come to the facility during this visit due to being in Rocklin for “networking for administrator… Ill be there again this evening”. At around 4:08 LPA Tamayo and S1 set up a phone call for 12/24/25 at 9:30AM. At 3:40PM during this visit, LPA Tamayo observed a new resident arrived and was moving into the facility during this visit. S2 stated admission packet is set to be completed with the new resident this evening. LPA is requesting the following facility documents to be submitted by 12/24/25: November and December LIC 500s, LIC 9020, visitor sign in/out sheet (September - December) Additionally, the following records for R4 if they have not yet been submitted to LPA Tamayo on 12/23/25: All appraisals, admission agreement, LIC 601, LIC 602, incontinence logs, daily notes, Home health contact information, home health care plan and notes, verification of all incident reports, all doctor visit appointments, after care summary, all discharge paperwork, death certificate. As a result of this case management , there are two Title 22 Regulation deficiencies cited. Deficiencies can be found on the LIC 809-D page. An exit interview was conducted with S2 and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the S2.