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13 | Licensing Program Analyst (LPA) Cuadra arrived unannounced to deliver findings regarding the allegation listed above and met with Co-licensee, Nick Aquino.
The Department received an allegation of staff do not ensure that resident's incontinence needs are met and staff do not assist resident with ambulating. The reporting party reports that staff are not providing sufficient care for a resident (R1) by not assisting them to toilet and R1 used to get out of bed but now stays in bed all of the time. Based on records review, R1 was ambulatory, not needed incontinence care, but fall risk. However, on 9/16/26, R1 had a significant change of condition, but the facility did not update resident's care plan and did not obtain an updated physician report. Based on interviews conducted with staff, they were aware that R1 needed a higher level of care, requiring two people to assist with their toileting needs. However, the facility failed to obtain an updated physician report after they learned about R1’s fall that resulted in a significant change of condition. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Continued on LIC9099C...
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| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
10/23/2026
Section Cited
CCR
87466 | 1
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7 | 87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning…When changes such as…deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented & brought to the attention of the resident's physician and the resident's responsible person, if any…This requirement has not been met as evidenced by: | 1
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7 | Administrator agrees to submit a written plan describing how the facility will ensure residents’ needs are met including incontinence care and ambulating after a significant change of condition. Written plan will be submitted to CCL by POC due date of 10/23/26. |
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14 | Based on LPA's interviews conducted with facility staff and records reviews of R1’s medical records, the facility staff failed to obtain an updated physician report for R1 after learning of their higher level of care needs, which poses an immediate risk to the health and safety of the residents in care. | 8
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14 | The Department will be scheduling a meeting to discuss areas of concern and non-compliance. |
Type A
10/23/2026
Section Cited
HSC
1569.269(a)(6) | 1
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7 | §1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement has not been met as evidence by: | 1
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7 | The administrator will re-train staff in personal rights describing how to assist residents with hygiene needs after a significant change of condition. The facility will submit date of scheduled training to CCL to clear the deficiency. |
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14 | Based on records review and interviews conducted with staff, it was revealed that the facility did not ensure that R1’s hygiene meets were being met, which poses an immediate risk to the health and safety of residents in care. | 8
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14 | Then, they will follow up with submitting proof of training including subject, persons, date and time to CCL. compliance.
***A civil penalty in the amount of $250 is assessed for repeated citation.
The Department will be scheduling a meeting to discuss areas of concern and non- |