Follow-up on corrections·April 23, 2026

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Susan O'Shaugnessy. Facility internal incident reports and progress notes, combined with hospice visit records and interviews of managers and outside sources, aligned to show: Resident #1’s (R1’s) terminal/admitting hospice diagnoses were “unspecified severe protein-calorie malnutrition” and “Alzheimer’s disease with late onset.” [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] R1 had an unwitnessed fall inside their bedroom on the evening of 03/31/2026, after which facility staff phoned R1’s responsible person (RP) and hospice agency. Per hospice notes, facility staff reported to hospice personnel that R1’s left elbow following the fall had redness, swelling, and pain with movement. A hospice nurse visited and assessed R1 that same evening, writing, “[R1’s] left elbow noted to be significantly swollen, red, warm to touch, and tender compared to right elbow…pain evidenced by grimacing and guarding left elbow.” The hospice nurse stated to facility staff that they believed R1’s left arm to have a fracture and recommended that R1 be sent to the hospital. However, R1’s responsible person did not want R1 sent to the hospital. Licensee deferred to the RP and did not call 911 for R1, which is still required when there is a medical emergency not directly related to the expected course of the resident’s terminal illness. (Per regulation, Licensees are required to call 911 in these situations. If a resident and their RP still refuse transport to the hospital, then they should do so directly to the first responders, after those first responders have evaluated the resident on scene and provided their own recommendations). [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Licensee’s own internal written policy titled “Medical Emergency” states, “The Administrator or caregivers are not required to obtain permission from the family/responsible party before summoning emergency medical services.” R1 remained at the facility through 04/04/2026, during which time Licensee did not seek or arrange for mobile X-ray to be performed on R1’s arm. R1 then passed away at home on 04/10/2026. Per the hospice agency, R1’s cause of death was “Alzheimer’s Dementia.” Licensee also did not submit an LIC624 Incident Report (or equivalent written report) to CCLD or R1’s RP, describing R1’s fall and symptoms. (Regulation requires such a written report to be submitted to both CCLD and the RP within seven days of incident occurrence.) Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee. LPA also provided Technical Assistance regarding CCLD’s interpretation of a resident’s right to privacy (refer to the LIC 9102-TA page). An exit interview was conducted with Administrator Susan O'Shaugnessy, to whom a copy of this report, the LIC 809-D page, the LIC9102-TA page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.