Incident investigation·September 11, 2025

On 09/11/25, LPA Steve Chang and LPM Romeo Manzano conducted an unannounced Case Management Visit-Incident during a complaint investigation. On 08/08/25, the Department received a self-reported unusual incident and death reports that on 7/25/25, a resident (referred as R1) was sent to ER by home health nurse to check on R1's Foley Catheter due to R1 expressed a significant discomfort and pain level of 8/10. R1 was taken to the hospital due to infection and died on 08/02. On 09/09/25, LPA/LPM interviewed S3. S3 stated that R1 was sent to ER via ambulance on 07/25 due to Home Health Nurse (HHN) was unable to replace R1's Foley catheter during visit. S3 stated HHN came to see R1 after staff reported of possible infection. During today's inspection visit, LPA and LPM toured the facility. LPA and LPM met with resident (referred as R2) in bedroom#2. R2 was observed naked in bed wearing a undergarment. R2 noted to have long toenails on both feet. ADM stated that R1 does not have medical insurance but being visited with HHN; however, ADM did not consult a podiatrist, nor there is no appraisal about R2's feet and his/her behavior of being naked. R2's medication was also observed on R2's side table accessible, unlocked Staff (referred as S1) stated that he/she forgot to locked it after he/she administered medication. Two other medications were also observed accessible in the dining area, 2 medicines belongs to R3. Continue on LIC809-C. Page 1 of 2. At 3pm, LPA/LPA met with Administrator (ADM), LPA/LPM asked for a copy of facsimile report for R1's LIC624 wherein the Fax Call Report states an RCFE facility. ADM stated that she works at this RCFE facility since 2008 M to F, 8-5pm. According to LIC500 Personnel Summary report, ADM works at the facility M to F, 20 hours a week (8am-11am). ADM states she is available on the weekends and after 5pm. ADM stated that she will adjust her work hours and make herself available in the facility 20 hours a week. LPA/LPM found out that staff who are scheduled to work 7pm to 7am sleeps in the facility living room. Facility does not have a designated staff bedroom in the facility. ADM stated that they will utilize the two vacant bedrooms temporarily. LPM/LPA called licensee over the phone. LPA/LPM spoke to licensee to informed them about today's inspection visit. We discussed about the availability of the ADM and explained to them that ADM must be available during business hours, M to F 8-5pm. Licensee stated that they are in out of the country. LPA/LPM spoke to licensee's son, Ganty, to explain the purpose of visit and deficiencies. Deficiencies cited during today's visit. See LIC809-D. Exit interview was conducted with ADM. The report was provided to ADM for review. A copy of the report was provided to ADM.