Follow-up on corrections·July 24, 2025

Licensing Program Analyst (LPA) Kelly Dulek conducted case management visit to address deficiencies observed during the course of an unrelated complaint investigation. LPA initially met with facility staff and explained the reason for the visit. Facility Designee Amelia (Mae) Davis arrived at 02:25PM. Entrance interview conducted. During a visit at the facility on 02/12/2025, LPA noticed an injury to Resident #1 (R1)’s face and upper body. LPA inquired with staff as to how R1 sustained the injury. Staff interviewed stated that R1 had fallen while at the facility and had received outside medical treatment for R1’s injuries. After R1’s fall, staff had rearranged R1’s furniture in their room to help prevent further injury. During file review, LPA reviewed records for Resident #2 (R2) who passed away in early 2023. LPA reviewed all unusual injury/incident reports sent to the Woodland Hills North Regional Office (RO) and noted that 0 (zero) incident reports and 0 (zero) death reports have been received at the RO since the date the facility was licensed on 09/06/2022. LPA interviewed facility designee, who stated that death reports were sent via email to the RO, however facility designee was unaware that injuries to residents needed to be reported in writing to the RO, so those had not been sent. LPA reminded facility designee of the requirement to send reports for all incidents that threaten the health or welfare of any resident in care within 7 days of any such occurrence. Additionally, while interviewing staff and reviewing documents for R2, it was discovered that the facility was safeguarding R2’s items, such as R2’s wallet, including at least $500 cash, debit card, and green card. The facility did not maintain a LIC 621 for R2. Additionally, when R2 passed away and R2’s belongings were removed from the facility, the licensee did not sign or indicate R2’s items were removed. R2’s admission agreement indicates no refund will be issued following the death of any resident receiving hospice services. Report Continued on LIC 809-C However, health and safety code requires a refund to be issued to all residents’ families/estates, regardless of receiving end of life care. LPA also noted that the facility’s admission agreement does not follow the title 22 requirements related to pre-admission policy and refunds. Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.