Complaint·February 5, 2026

According to the administrator/licensee, prior to R1’s hospitalization, R1 already required a higher level of care that the facility can't 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 administrator/ 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 administrator/ 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, administrator/licensee stated that the sitter needed to be trained so they can care for R1. The responsible party stated that the administrator/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 was 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, 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, 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/Plan of Operation, it 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 to allegation of – staff did not provide a 30-day notice to responsible party, the reporting party stated that the licensee denied R1’s admittance back to the facility when R1 was ready to be discharged from the hospital and the 30-day eviction notice was not provided. As part of the investigation, LPA interviewed R1’s responsible party, and the licensee. The licensee denied the allegation and stated that two written notices via email dated November 21, 2025 and November 30, 2025, were sent to varies recipients and one of them was R1’s responsible party. The licensee stated that the emails served as a 30-day notice that indicated the facility will not be able to readmit R1 as R1 required a higher level of care. LPA interviewed R1’s responsible party who acknowledged of receiving the above emails. However, the responsible party had no idea that the licensee would not allow R1 back to the facility even after additional staffing support was arranged by Golden Gate Regional Center (GGRC). Based on the documents provided, LPA observed the 30-days notice emails were provided to the responsible party and others, but it did not include all the required details based on the regulation. Therefore, the 30-day notices via email were invalid as they were not incompliance. After the investigation, this allegation is deemed to be 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/ Licensee and caregiver. A copy of the report and Appeal Rights were provided.