Health inspection·August 1, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide the office of the local Long-Term Care (LTC) Ombudsman (OMB, an official advocate who represents the interests of the residents residing in a LTC facility) a copy of the Notice of Transfer/ Discharge for Resident 1 prior to Resident 1's discharge from the facility. This failure placed Resident 1 at risk of not receiving the necessary protections and support of the LTC Ombudsman office. Findings: A review of Resident 1's clinical document titled, admission RECORD, indicated Resident 1 was admitted to the facility in May of 2024. A review of Resident 1's clinical document titled, NOTICE OF TRANSFER/DISCHARGE, indicated .Notification Date: 6/21/24 .Effective Date: 6/27/24 .Transfer/Discharge to .Shelter for the Homeless .This notice is to inform you that transfer/discharge is necessary for the following reason .The transfer or discharge is appropriate because your health has improved sufficiently .If you intend to file an appeal of this transfer/discharge, it is important that you do so within 10 days .The facility may not transfer or discharge the resident while the appeal is pending .Copy to State LTC Ombudsman Office date: 6/27/24 . During a telephone interview on 7/31/24, at 4:15 PM, the OMB stated their office did not receive notice of Resident 1's pending discharge. The OMB further stated their office learned of Resident 1's discharge plan during a visit to the facility, when Resident 1 reported he had not received a 30-day notice of discharge. The Ombudsman stated the facility informed Resident 1 of his pending discharge but not of his right to appeal. The OMB further stated the OMB office assisted Resident 1 to initiate the appeal process. The OMB stated the Office of Administrative Hearings and Appeals (OAHA) notice was received by the facility on 6/25/24 and an appeal hearing was scheduled for 7/15/24. The OMB further stated the facility Operations Manager (OM) was notified by the OAHA not to discharge the resident prior to the hearing. The OMB stated their office became aware of Resident 1's discharge on [DATE] when they were researching his medical eligibility and previous address to determine if the homeless shelter was the appropriate placement for him. The OMB stated during their research they discovered he applied for food stamps due to becoming homeless on 6/27/24. The OMB further stated Resident 1 was discharged on 6/27/24 prior to the hearing and was now homeless and could not be located. A review of an email notification provided by the LTC Ombudsman office, from the Staff Services (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555105 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Noble Care Center 2740 North California Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)