435202373-1-2-2026-26-AS-RMAO-DQNVDM-20260125152057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202373
Report Date: 01/02/2026
Date Signed: 01/02/2026 05:49:54 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/24/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20251024153025

FACILITY NAME:	TRINITY RCF, INC.- WILLIAMS		FACILITY NUMBER:	435202373
ADMINISTRATOR:	INI UBOH		FACILITY TYPE:	735
ADDRESS:	1330 MICH BLUFF DRIVE		TELEPHONE:	(408) 476-8772
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95131
CAPACITY:	6	CENSUS: 4	DATE:	01/02/2026
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Administrator Ini Uboh		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff did not prevent a client from wandering from the facility.
Staff did not properly report an incident involving a client.
Staff unlawfully evicted a client.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Ini Uboh.

On October 24, 2025 the Department received a complaint alleging Staff did not prevent a client from wandering from the facility.

On October 24, 2025, the Department received an incident report regarding resident R1. The incident report stated, at approximately 5:00am, on October 24, 2025, staff was assisting R1 to the bathroom. After assisting R1 back to his/her room, staff went back to clean the bathroom. Once staff completed cleaning, staff went to check on R1 but R1 was not in his/her room. Staff searched but was unable to find R1. Staff notified ADM. ADM advised staff to wait a few hours to see if R1 would return and to contact 911 to report a missing person. At 9:43am staff called 911 to report R1 missing. Later that same day, Staff was contacted by Local Law enforcement that R1 had been found at 1368 Rue Avati, San Jose. Page 1 Out of 7

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 9

Control Number 26-AS-20251024153025

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TRINITY RCF, INC.- WILLIAMS	FACILITY NUMBER: 435202373
	VISIT DATE: 01/02/2026

NARRATIVE

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Based on a google Maps search, the distance from the facility to the location where R1 was found, 1368 Rue Avati San Jose Ca, is 0.6 miles.

On October 30, 2025, LPA Chang interviewed Staff S3. S3 stated on October 24, 2025, around 5:00AM, R1 called night shift staff (S2) to take R1 to restroom. After R1 finished using the restroom, S2 took R1 back to his/her room to lay down, S2 went to restroom to clean up. After cleaning up, S2 went back to check R1 and found R1 was not in the room. S2 found the front door was locked and the side yard gate was open. S2 reported R1 was missing to S3. S3 and S2 checked everywhere in the facility and the neighborhood but cannot find R1. S3 stated he/she called ADM to notify that R1 was missing. S3 stated S1 came to work at 8:00AM and S3 asked S1 to drive the car to look for R1 but still cannot find R1. S3 stated he/she called police. S3 stated later on S1 notified him/her that police called him/him and S1 will go to pick up R1. HM stated S1 brought R1 back to the facility.

LPA Chang interviewed Staff S1. S1 stated on October 24, 2025, S2 was not able find R1. S3 reported to ADM immediately at around 8:00AM. ADM advised S3 to call 911. S1 stated Around 12:00 noon, police called S1 that police found R1 at 1368 Rue Avait, San Jose CA. S1 stated it is around 10 minutes walking from the facility. Police officer stated R1 was sitting in front of a house garage. S1 went to the address and identified the person is R1. S1 took R1 back to the facility.

On December 22, 2025, LPA Manuel Monter interviewed staff S2 and S4. S2 stated the day of the elopement, he/she had finished accompanying R1 to the bathroom and walked him/her back to his/her room. S2 stated he/she returned to make breakfast. S2 stated he/she later went to check on R1, but his/her bedroom door was locked. (S2 stated he/she doesn't remember the exact details of the time that passed between checks.) S2 stated he/she went to look from the outside window to see R1 via the window. S2 stated he/she saw R1 was not in his/her room and the side door was open. S2 stated he/she looked for R1 and asked the supervisor to stay in the facility while he/she searched. S2 stated they eventually called 911 and R1 was found a few hours later. S2 stated he/she didn't know about R1's behaviors. S2 stated he/she didn't read information regarding R1.

Staff S4 stated he/she only briefly met R1 and did not work with R1. S4 stated he had time off when R1 moved in and by the time he/she returned to work, R1 was no longer living at the facility. Page 2 Out of 7

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 26-AS-20251024153025

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TRINITY RCF, INC.- WILLIAMS	FACILITY NUMBER: 435202373
	VISIT DATE: 01/02/2026

NARRATIVE

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On December 22, 2025, LPA Manuel Monter interviewed Administrator Ini Uboh. ADM stated she was informed by the service coordinator that R1 will leave without informing staff. ADM stated R1 was brought to the home, after she was not in the country.

On December 22, 2025, LPA Manuel Monter interviewed Witness W1. W1 stated R1 has wandering behaviors and is resistive to care. W1 stated R1 will walk away from the facility. W1 stated R1 exhibited this behavior in the previous care home and is a known behavior on the IPP.

The Department reviewed R1's Physician's Report, dated April 11, 2025. The physician's report states R1 is not able to leave the facility unassisted.

The Department reviewed R1’s Individual Program Plan, dated October 3, 2025. R1’s IPP states, R1 has a tendency to wander away when not supervised.

The Department reviewed Resident R1’s Appraisal/Needs and Services plan, dated October 21, 2025. R1’s Appraisal/Needs and Services plan does not address R1’s aggressive behaviors or elopement / wandering behaviors.

Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 wandering from the facility unsupervised.

Staff did not properly report an incident involving a client

On October 24, 2025 the Department received a complaint alleging Staff did not properly report an incident involving a client.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 26-AS-20251024153025

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TRINITY RCF, INC.- WILLIAMS	FACILITY NUMBER: 435202373
	VISIT DATE: 01/02/2026

NARRATIVE

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On October 22, 2025, the Department received an incident Report regarding R1. The report stated, on October 22, 2025, at approximately 8:00am, Staff S2 approached R1 to inform him/her that breakfast was ready and it was time for his/her medications. R1 responded by shouting at S2 and physically pushing him/her. S2 immediately left the room and notified his/her supervisor. Upon arrival of the supervisor, R1 repeated the same aggressive behavior, shouting and pushing as well. Staff S1 then attempted to intervene, but R1 physically assaulted S1 by punching him/her in the face and chest. R1 then exited the room throwing the food, water and medications prepared for him/her. R1 then entered another residents room and began shouting at another resident. Staff members acted quickly to redirect R1 and prevent a possible escalation or harm to others. Although R1 initially opened the front door, staff were able to speak with R1 and guide him/her back into the house.

On December 22, 2025, the Department interviewed Witness W1. W1 he/she was notified about R1’s eviction, on October 22, 2025. W1 stated the eviction letter noted that an incident occurred wherein R1 had assaulted other residents on October 22, 2025. W1 stated he/she did not receive an incident report for October 22, 2025, which described the incident where R1 had assaulted other residents. W1 stated he/she did receive an incident report which stated R1 was aggressive with staff but did not state that a resident in the care home was struck/assaulted by R1.

On December 22, 2025, LPA Manuel Monter interviewed Staff S2, S3 and S4. LPA asked staff member S2 to recount the incident that took place on October 22, 2025. S2 stated on October 22, 2025, staff S1 was stuck in the face. S2 stated R1 went inside resident R2's room. S2 stated he/she heard the commotion and went to see what was happening. S2 stated as he/she was entering, S2 pushed R2 to his/her bed. S2 stated he/she attempted to redirect R1, and R1 in turn, pushed S2, and left the bedroom, back to his/her bedroom. S2 stated he/she asked R2 what happened, and R2 motioned with his/her hands that he/she was pushed. S2 stated R2 is non verbal. S2 stated R2's roommate was asleep at the time. S2 stated he/she didn’t observe any bruising or bleeding on R2. S2 stated he/she has some trouble remembering the incident since it was months ago.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 9

Control Number 26-AS-20251024153025

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TRINITY RCF, INC.- WILLIAMS	FACILITY NUMBER: 435202373
	VISIT DATE: 01/02/2026

NARRATIVE

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LPA asked S3 to retell the incident that occurred on October 22, 2025. S3 stated that morning staff separated R1 who had hit another resident. S3 stated the resident who was stuck R2 did not sustain any bruising or bleeding. S3 stated he/she doesn’t know where R2 was hit. S3 stated it happened a while ago and doesn’t remember the event. Staff S4 stated he/she only briefly met R1 and did not work with R1. S4 stated he/she had time off when R1 moved in and by the time he/she returned to work, R1 was no longer living at the facility.

On December 22, 2025, LPA Manuel Monter interviewed ADM Ini Uboh. ADM stated there was an incident that occurred on October 22, 2025. ADM stated she wasn't present when this occurred. ADM stated she was informed by her staff that R1 had hit the staff and pushed a client, R3. ADM stated she doesn't know the details, and stated it did occur, but was inadvertently not added to the incident report.

On December 24, 2025, LPA Manuel Monter interviewed staff S1. S1 stated on October 22nd all the staff and residents were inside. S1 stated he/she and the other staff were preparing dinner, sometime in the afternoon. (S1 stated he/she doesn’t remember the exact details of the event.) S1 stated he/she heard resident R2 and R3 were yelling from their room. S1 stated he/she ran to R2 & R3's room. S1 stated as he/she ran inside, he/she saw R1 trying to grab R2 (by his/her shirt.) S1 stated R1 was angry, and he/she attempted to redirect R1 back to his/her room. S1 stated R1 then hit him/her in the face and chest. S1 state after the event, he/she asked resident R3 what had happened. S1 stated both residents are not able to communicate. S1 stated R1 had hit him. S1 stated R1 didn’t like that R2 was making loud noises, because R2 has high pitch voice.

On January 2, 2026, LPA Manuel Monter interviewed residents R2-R4. LPA asked resident R2 questions, but R2 did not respond to questions posed by LPA. Residents R3 and R4 stated they doesn't remember R1. Residents R3 and R4 stated they don't remember any instant where they themselves or other residents were physically assaulted by another resident.

The Department reviewed R1's 30 Day Eviction, dated October 22, 2025. The eviction letter states, R1 moved into the facility on October 21, 2025. Furthermore, the letter states R1's behaviors that morning had become very unmanageable. R1 became physically aggressive to the staff and ran into the other residents room and assaulted them. Page 5 Out of 7

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 26-AS-20251024153025

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TRINITY RCF, INC.- WILLIAMS	FACILITY NUMBER: 435202373
	VISIT DATE: 01/02/2026

NARRATIVE

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Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Staff unlawfully evicted a client

On October 24, 2025 the Department received a complaint alleging Staff unlawfully evicted a client

The Department reviewed R1's 30 Day Eviction, dated October 22, 2025. The eviction letter states, R1 moved into the facility on October 21, 2025. Furthermore, the letter states R1's behaviors that morning had become very unmanageable. R1 became physically aggressive to the staff and ran into the other residents room and assaulted them.

On October 30, 2025, LPA Chang interviewed Staff S3. S3 stated the facility (ADM) sent 30 day eviction letter to R1’s Service coordinator on October 22, 2025. S3 stated R1 moved in the facility on October 21, 2025. S3 stated R1 did not want to live in the facility, S3 stated R1 kept trying to exit the facility but staff always stopped him/her.

On December 22, 2025, LPA Manuel Monter interviewed Administrator Ini Uboh. ADM stated because the acts of physical aggression to staff, residents, and law enforcement, the facility concluded that R1 was not compatible with other residents, resulting in the eviction.

ADM stated she did complete a pre admission appraisal for R1 based on R1's IPP. ADM stated the service coordinator brought R1 from the previous home for a visit, and they were able to see R1. ADM stated regarding R1's Behaviors: the previous home staff and service coordinator stated R1 was not doing well at the previous home and that R1 was high functioning. ADM stated R1 came to the facility to visit, prior to R1 moving in, R1 stayed in the car with care staff. ADM stated, the SC told her that R1 was in the car because he was becoming upset. ADM stated she was informed by the service coordinator that R1 will leave without informing staff. ADM stated she was not aware of R1's physical aggression behaviors prior to R1 moving in.

Page 6 Out of 7

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 26-AS-20251024153025

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TRINITY RCF, INC.- WILLIAMS	FACILITY NUMBER: 435202373
	VISIT DATE: 01/02/2026

NARRATIVE

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ADM stated R1 moved into the facility on October 21, 2025. ADM stated there was an incident that occurred on October 22, 2025. ADM stated she was informed by her staff that R1 had hit the staff and pushed a client, R3. ADM stated the same day of the elopement, R1 later that afternoon, was also being physically aggressive. ADM stated when police came to talk to R1, R1 tired to hit the police and took R1 to the hospital. ADM stated SARC was offering a 1 on 1 but decline to accept R1 back due to his aggressive behaviors. ADM stated because of the acts of physical aggression to staff, residents, and law enforcement, the facility concluded that R1 was not compatible with other residents, resulting in the eviction.

On January 2, 2026, LPA Manuel Monter interviewed residents R2-R4. LPA asked resident R2 questions, but R2 did not respond to questions posed by LPA. Residents R3 and R4 stated they doesn't remember R1. Residents R3 and R4 stated they don't remember any instant where they themselves or other residents were physically assaulted by another resident.

On January 2, 2026, LPA interviewed ADM. ADM stated she did not do a re-assessment of resident R1 to determine that R1's needs cannot be met by the facility.

The Department reviewed Resident R1’s Preplacement Appraisal, dated October 21, 2025. The Preplacement appraisal does not indicate that R1 has aggressive behaviors or elopement behaviors.

The Department reviewed R1’s Individual Program Plan, dated October 3, 2025. R1’s IPP states, R1 has a tendency to wander away when not supervised. R1 can also be resistive to being redirected. R1 will slap, push and pull staff’s hair. R1 history also includes walking out of a previous care home at 5am and was lost for approximately 7 hours. R1 was sent to the hospital due to being aggressive / resistive toward police and Residential Care Staff. Due to R1’s behaviors, R1 benefits from a 1:1 or a 2:1.

The Department reviewed Resident R1’s Appraisal/Needs and Services plan, dated October 21, 2025. R1’s Appraisal/Needs and Services plan does not address R1’s aggressive behaviors or elopement / wandering behaviors.

Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Page 7 Out of 7.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 26-AS-20251024153025

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TRINITY RCF, INC.- WILLIAMS	FACILITY NUMBER: 435202373
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/02/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/03/2026 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidence by:	1 2 3 4 5 6 7	ADM stated she will send a letter of understanding regarding the regulation. ADM stated he will submit the plan of correction to LPA by POC due date January 3, 2026.
	8 9 10 11 12 13 14	Based on interviews and records reviewed, on October 24, 2025, Resident R1 left the facility unassisted. Which resulted in R1 wandering from the facility unsupervised. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
Type B 01/09/2026 Section Cited CCR 80061(b)(E)	1 2 3 4 5 6 7	80061 Reporting Requirements (b) (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This Requirement was not met as evidenced by:	1 2 3 4 5 6 7	ADM stated she will send a letter of understanding regarding the regulation. ADM stated he will submit the plan of correction to LPA by POC due date January 9, 2026
	8 9 10 11 12 13 14	Based on interviews and records reviewed, the facility did not submit incident reports documenting the instances where resident R1 exhibited physical aggression, making contact with other residents in the facility. This poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 26-AS-20251024153025

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TRINITY RCF, INC.- WILLIAMS	FACILITY NUMBER: 435202373
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/02/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/09/2026 Section Cited CCR 80068.5(a)(4)(A)	1 2 3 4 5 6 7	80068.5 Eviction Procedures (a)(4)(A) A Needs and Services Plan modification must have been performed… which determined that the client's needs cannot be met by the facility and the client has been given the opportunity to relocate…This Requirement was not met as evidenced by:	1 2 3 4 5 6 7	ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will submit the plan of correction to LPA by POC due date January 9, 2026
	8 9 10 11 12 13 14	Based on interviews and records reviewed, the facility did not update and re-assess resident R1. This poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

Page: 9 of 9