Follow-up on corrections·December 17, 2025

Licensing Program Analysts (LPAs) Quoc Huynh and Emily Peraldi conducted an unannounced Case Management visit in conjunction with Complaint # 29-AS-20250806084714. LPAs arrived at 09:52AM and met with the Executive Director (ED) Francesca West and Wellness Director (WD) Jovany Guerra. Entrance interview conducted. Between 11:06AM and 12:10PM, LPAs conducted a physical plant tour, reviewed and obtained pertinent documents, and interviewed staff. No immediate concerns were observed. Between 06/02/2025 to 06/17/2025, Resident #1 (R1) sustained one (1) Stage II pressure injury to their upper right buttock that required daily wound care and dressing changes. Hospice visit notes on 06/02/2025 indicated wound care would be performed by a SN (skilled nurse) or facility staff. On 06/03/2025 and 06/11/2025, visit notes documented that the Hospice nurse was unable to assess R1’s wound or provide wound care because “caregiver completed care.” While the ED and WD denied staff providing wound care, interviews with staff confirmed that caregivers occasionally provide residents with wound care, without notifying the med-techs. The expectation is for caregivers to notify med-techs, who in turn notify residents’ Home Health or Hospice Agency for wound care services. It was also confirmed that staff are not licensed professionals. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.