Facility Evaluation Report

On May 4, 2023 at approximately 11:25 am, Licensing Program Analyst (LPA) Luisa Fontanilla conducted an unannounced Case Management visit. LPA met with Robert Roby and explained the purpose of the visit.

On August 30, 2017, the Department concluded a complaint investigation on a substantiated allegation that the facility did not seek timely medical attention resulting in amputation of a resident’s (R1) right pinky toe .

The licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87465(a)(1) – Incidental Medical and Dental Care. The facility failed to seek timely medical attention for R1’s toe condition which resulted in amputation. Failing to seek timely medical attention posed an immediate health and safety risk to R1. R1 was taken to the hospital and was diagnosed with gangrene of the toe with cellulitis of the foot. According to the Mayo Clinic, “gangrene refers to the death of body tissue due to either a lack of blood flow or a serious bacterial infection. Gangrene commonly affects the extremities, including your toes, fingers, and limbs, but it can also occur in your muscles and internal organs. Your chances of developing gangrene are higher if you an underlying condition that can damage your blood vessels and affect blood flow, such as diabetes or hardened arteries (atherosclerosis).”