Facility Evaluation Report

On 01/04/2024 at 12:00PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an incident that was reported to Community Care Licensing (CCL) on 12/24/2023. LPA met with both General Manager, Linda Fisher and Care Director, Yelba Havelhorst and explained the purpose of the visit. General Manager informed LPA that Health Services Director, Maria Collado, LVN was phoned and will be arriving shortly to assist with the reported incident.

CCL received an Unusual Incident /Injury Report on 12/24/2023 that reported that Resident 1 (R1) was visited by nurse from home health agency and informed Staff 1 (S1) that R1's wound located on buttocks was not getting better and have spread. The report further stated that R1 was unable to get out of their bed and was having difficulty turning and repositioning. S1 completed an assessment and noted that R1's wound located on buttocks had redness on surrounding areas and also have increased in size.

S1 stated that she went to Stanford Hospital in Palo Alto, CA on 03/06/2022 to conduct an Individualized Service Assessment (pre-appraisal) on R1 prior to admission to the facility. S1 stated that R1 was assessed for potential skin breakdown due to R1's paraplegic medical condition and urinary catheter.