Facility Evaluation Report

07/22/2024 11:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with house manager Blanca Chavez. LPA contacted licensee Nora Serrano and obtained permission to meet with Ms. Chavez in Ms. Serrano's absence. Today’s visit is regarding an incident that occurred on 04/13/2024 and was reported to licensing on 04/15/2024.

It was reported that on April 13, 2024 8:15am staff discovered Client 1 (C1) on the floor by their recliner in the living room. No staff witnessed the fall, but Client 2 (C2) said that C1 fell and hurt their face on the end table. Staff examined C1's head and did not see any bruising, swelling, or bleeding at the time. Later in the evening staff noticed some bruising and swelling had occurred to C1’s head. Staff applied ice to bring down the swelling, but staff stated it didn't help much. On April 15, 2024 7:00am, assistant administrator arrived on duty and was told what happened to C1. Assistant administrator instructed staff to take C1 to the ER. C1 was transported to ER at 8:30am.

During the course of the investigation, it was learned that staff did not transport C1 to the ER after the fall and waited two days to seek medical attention for C1. C1 did not sustain any injury as a result of the fall.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Nora Chavez.