Facility Evaluation Report

On 9/7/2022 at around 10:10AM Licensing Program Analyst (LPA) L. Ibo conducted an unannounced Case Management visit regarding an incident report that was received on 9/6/2022 . LPA met with S2 and explained the reason for the visit. LPA called Administrator Kavitha Pramod and explained the purpose of the visit. Administrator arrived at the facility around 11:15AM.

The incident that was submitted for R1 occurred on 8/16/2022 where R1 was found by Police officers couple of blocks away from the facility. Based on the interview with staff, on 8/16/2022 the police officers went to the facility at around 2:30PM and informed the staff that R1 was found walking around the street. Skin tear on R1’s face was observed during the incident that prompted the Police officers call 9-1-1 and R1 was taken to the hospital.

The Physician's Report indicated that R1 has dementia and that she is unable to leave the facility unassisted. Staff interviewed indicated R1 has history of wandering behavior.

Medical records further revealed R1 had a fall with uncertain cause, based on interview with staff, R1 sustained skin tear on the left side of her face. Staff admitted that R1 did not have the skin tear while she was at the facility and was only observed when Police officers found her at the street.

Deficiency are cited from Title 22 California Code of Regulations (see 9099D). A $500.00 civil penalty is assessed. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Licensee will be called for a meeting at a later time.

Deficiency, plan and proof of correction and civil penalty were discussed with Kavitha Pramod.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided