Inspector’s narrative
What the inspector wrote
According to the administrator/licensee, prior to R1’s hospitalization, R1 was already requiring a higher level of care that the facility was able to provide. She stated that R1 was high risk for fall, R1 had many sessions of physical therapy and many doctor’s appointments. She stated that since R1’s hospitalization, she has visited R1 and R1 presented with medical conditions that required a higher level of care such as high risk for fall, difficulty with swallowing, and a foley catheter. In addition, the licensee stated she has visited R1 at the skilled nursing facility where she observed R1 of having a one – to – one caregiver and needed a lot more assistance than Sonas Home can provide.
According to R1’s responsible party, initially the licensee stated that R1 cannot return to the facility unless R1 had a night sitter because she felt R1 was at risk for fall and R1 needed a higher level of care so the responsible party spoke with Golden Gate Regional Center and a night sitter was granted. Then, the licensee stated that the sitter needed to be trained so they can care for R1. The responsible party stated that the licensee was making excuses not to take R1 back despite R1 being back to his/her baseline upon discharge from the hospital. In addition, the responsible party stated that R1’s discharge documentation from the doctor indicated that R1 can return to the board and care home with increased caregiver support.
According to the GGRC Representative, GGRC was in support of R1 returning to the facility as it was recommended by R1’s hospital discharge planner and hospital physician. GGRC has arranged for additional staffing support upon R1’s return. In addition. The licensee was informed that they would work with the facility either to provide additional staffing support to care for R1 or assist with discharge planning in a proper process.
According to the hospital discharge planner, R1 required some assistance with Activities of Daily Living (ADLs) but R1 did not get up unattended at night. The discharge planner stated that the discharge plan was for R1 to return to the board and care, but the administrator did not want to take R1 back due to lack of staff at night. Subsequently, additional night staff were provided but the administrator continued not willing to take R1 back. Therefore, R1 was discharged to a skilled nursing facility despite R1 being back to baseline upon discharge.
According to former staff #1 (S1) and current staff #2 (S2), R1 was able to walk with a walker with some supervision and R1 required some assistance with toileting and showering. They stated that R1 was not difficult to care for and R1 was very calm and pleasant.
Based on the hospital discharge note by the physician, it indicated that once the board and care and or family arranged for increased caregiver support then R1 will return there.
Based on hospital physical therapy treatment note dated 11/19/2025, R1 was making great progress, and the recommendation was returned to board and care facility with assistance from home health physical therapy.
Based on GGRC annual and quarterly reviews, it indicated that the licensee and staff verbalized that R1 was easy to care for, and R1 was a sweet person. In addition, it indicated that additional help was offered to the licensee for caring for R1 but it was declined by the licensee. The documentation did not indicate that R1’s care was increasing and required additional support.
After the investigation, this allegation is deemed to be substantiated as the hospital records/physician's note, the physical therapy and the physician indicated that R1 has made great progress, and they recommended R1 to return to board and care with additional staffing. GGRC was in support of R1 returning home and arranged for additional support, but the licensee continued not willing to take R1 back resulted in R1 transferring to a skilled nursing facility. Furthermore, the Facility Program stated that Sonas Home’s goal is to provide 24 hours / 7 days assistance and care with ADLs ( bathing, dressing, grooming, feeding) , however, they refused to take R1 back who required the level of care that was described in the Facility Program as per the physical therapist note dated on 11/21/25 (the day prior to R1’s discharge) that R1 was ambulating in to chair/bathroom in hallway with minimum assist with a Front Wheel Walker (FWW), safety maintained.
Regarding the allegation of- staff did not properly communicate with client’s responsible party, the reporting party stated that the facility administrator/licensee informed GGRC that R1 had always been beyond their level of care. However, this concern had never been communicated to the GGRC representative and the responsible party during any of R1’s annual or quarterly meetings, nor via email or phone.
As part of the investigation LPA interviewed the administrator/licensee, R1’s responsible party, GGRC representative, and reviewed documents.
According to the responsible party, during R1’s stay at the facility, he/she visited R1 often and he/she was never informed that R1 was difficult to care for and R1 was above the care level that the facility was approved of by Golden Gate Regional Center (GGRC).
According to GGRC representative, the administrator/licensee and staff members have not expressed that R1 required a higher level of care during the quarterly and annual face-to-face meetings. The GGRC representative stated that during the annual meeting, the licensee and the facility staff stated that R1 was very easy to care for.
According to the Golden Gate Regional Center Person Center (GGRC) Individual Program Plan dated 12/9/2025 and the subsequent quarterly reviews dated 2/5/2025, 5/30/2025 and 9/9/2025, they did not indicate that R1 required a higher level of care. In fact, the quarterly review dated 5/30/2025 indicated that the facility was offered additional funding to care for R1 and it was declined by the administrator/licensee and she stated that “R1 was easy to work with”. The documentation also indicated that this funding was offered in the past and it was refused as well.
According to the semi-annual meeting notes provided by the administrator/licensee, it did not indicate that R1 required a higher level of care and the facility was not able to care of R1.
After the investigation, this allegation is substantiated.
Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.
Report was discussed with Administrator and caregiver. A copy of the report and Appeal Rights were provided.
The administrator/licensee denied the allegation and stated that she has had great communication with R1’s responsible party from the date of R1’s admission. She stated that a lot of their communication was via text messages, and they even talked about personal topics that were not related to R1. The administrator stated that R1 required a higher level of care resulting in R1 not returning to the facility and it did not have anything to do with personal relationship.
Based on documents provided, LPA observed communication between R1’s responsible party and the administrator/licensee and there was no proof that R1 was abandoned due to personal relationship between the administrator/licensee and the responsible party.
After the investigating, this allegation is deemed to be unsubstantiated.
Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
This report is reviewed and discussed with the administrator and the caregiver. A copy is provided.
