Facility Evaluation Report

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Deficiencies inspection at the facility due to a deficiency observed during complaint investigation control number 29-AS-20211102115349 . The LPA met with Administrator Joey Alvarado who became the Administrator of the facility as of 11/08/2021.

On 10/21/2021, an incident occurred between Resident #1 (R1) and Resident #2 (R2) where R1 accused R2 of pushing R1. R1 was observed on the ground by staff after the incident occurred and later complained of shoulder pain. On 11/04/2021, the Suspected Dependent Adult/Elder Abuse form (SOC 341) only, was completed by Operations Specialist Walter Cline and faxed to the ombudsman and CCL regarding the 10/21/2021 incident. LPA Lopez discussed the issue of the facility not completing the licensing report and issuing the report timely. An Unusual Incident/Injury Report (LIC 624) was completed today and a copy was given to the LPA.

Based on the information obtained, the licensee failed to submit a written report of the incident to licensing within seven days, therefore a citation is being issued.

Exit interview and report reviewed with Administrator Joey Alvarado. A copy of the report and appeal rights was emailed.