Since 4-23-2025 and within this yearly time period, Licensee has received a total of four A citations and one B citation. The regulated areas of which the citations occurred were Admission agreements, care and supervision, prohibited health conditions, observation of the resident, and administrator qualifications

Citations issued by the Department include:

{Cont. on 809C}

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

10-10-2025: Type A – Section 87615(a)(1) Prohibited Health Conditions. This facility was found to be deficient as evidenced by the retention of a resident diagnosed with a Stage IV pressure ulcer.

10-10-2025: Type A - Section 87466 Observation of The Resident. This facility was found to be deficient as evidenced by repeated visits to the local medical facility for a resident exhibiting the same medical issues eventually resulting in more serious health conditions.

3-19-2026: Type A – Health and Safety Code 1569.39(b) Assistance with accessing home health or hospice services; receipt of medical services. Licensee did not ensure appropriate and timely medical intervention for R1’s wounds leading to a worsening condition including severe sepsis.

3-19-2026: Type A – Section 87405(d)(1) Administrator-Qualifications and Duties. Licensee and designee did not ensure an appropriate exception request necessary for proper care and supervision of R1’s wound.

{Cont. on 809C}

· Care and Supervision

· Client Records – proper maintenance of various documentation

· Administrator qualifications and duties

· Prohibited Health Conditions

· Emergency protocols and when to call 9-1-1

The Licensee has agreed to the following for purposes of reaching substantial compliance:

· Facility program administrator will ensure compliance plan is being followed

· Licensee will ensure facility program administrator is physically present at facility for a minimum of 20 hours per week

· Licensee to send copy of a current skin check lists by end of day 4-24-2026.

{Cont. on 809C}

· Daily documentation of residents’ conditions including but not limited to: Participation in Activity of Daily Living (ADL) functioning, various changes in conditions including those warranting exceptions, waivers, or 9-1-1 calls

· Monthly audits of residents’ skin/body check forms to ensure accuracy

· Maintenance of other documentation including but not limited to: Care notes, needs and services plans (updated yearly or sooner if significant changes occur), physician’s reports, medication log sheets, and incident reports

· Submit an updated LIC 500 to include Administrator days and hours scheduled. Submit by end of day 4-24-2026.

· Submit an updated LIC 308 by end of day 4-24-2026.

For best practices and consistency purposes in regards to maintaining compliance, the above implementations are to also be included at licensee’s additional facilities: ST Mary’s Home #502701255 and ST. Stephen’s Home #502700261.

{Cont. on 809C}

Community Care Licensing Department (CCLD) will do the following:

· Quarterly visits to ensure above compliance plan and other Title 22 and Health and Safety code requirements.

Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.