Complaint·August 8, 2025

The review of records showed that the LTC insurance company has sent a letter to R1/R1’s responsible party advising of not receiving certain documents on 01/21/2025 and 05/02/2025. In the letter dated 05/02/2025 that was sent to R1's responsible party's address, it states that on 04/09/2025, 05/18/2025, and 05/27/2025 the LTC company requested but did not receive certain information in order to continue processing the claim. On 05/15/2025, the RP states that facility acted upon the issue and reached out to R1’s LTC insurance. 2 staff members (S1 – S2) were interviewed. S1 started his/her position in mid-February 2025 and S2 started his/her new position in late February – early March 2025. Based on interview, S1 stated that typically the facility would be informed by the resident’s responsible party if the LTC insurance company is missing forms, as the LTC insurance company communicates directly with the resident and/or responsible party. S1 and S2 states that they were only informed that R1’s LTC insurance company was missing forms on 05/13/2025 by R1’s responsible party. S1 and S2 denied being informed in March or April, that R1’s LTC insurance company was missing forms. S1 stated to have only received an email from R1’s responsible party regarding issues with the LTC insurance on two occasions, which was on 05/13/25 and sometime last year. It was stated that upon receiving the email from R1’s responsible party on 05/13/2025, the facility immediately sent the required form to the LTC insurance company and followed up with the LTC insurance company as well to confirm receipt. Based on interview, 2 out of 2 staff members thought it was the facility’s responsibility to submit all forms to the resident’s LTC insurance companies. Page 2 of 3. Upon following up with the facility’s regulatory team on 05/20/2025, S1 confirmed that it is actually not the facility’s responsibility to submit the forms to the LTC insurance company. It was stated that facility was filing the resident’s LTC insurance as courtesy to the resident, as this service is not indicated in their admission agreement or included in service plan. It was stated that the facility will continue to assist in filling out necessary forms such as the care needs assessments and monthly residence form, however it is the resident or resident’s responsible party to submit all necessary forms to the LTC insurance afterwards. 8 staff members who were interviewed all denied R1’s care ever stopping despite issues with R1’s LTC insurance. 8 out of 8 staff stated that R1 was always provided assistance with care. Based on review of R1’s admission agreement and service plan, the service of the facility filing R1’s LTC insurance is not written in the admission agreement or service plan. As per the RP, the service of filing R1’s LTC insurance was offered as from a discussion when R1 first moved in. On 08/08/2025, the facility's process when it comes to residents LTC insurance is to continue to work with the resident and/or resident's responsible party on completing forms required by the facility to fill out. However, the resident and/or resident's responsible party's is now responsible in sending the paperwork(s) to the LTC insurance. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded, meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Val Baldugo-Macasieb and a copy of the report was provided. Page 3 of 3.