Facility Evaluation Report

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Health and Wellness Director (HWD) Alex Alvarado and Business Office Manager Michelle Greenberg and explained the reason for the inspection.

On 02/21/2023, Community Care Licensing (CCL) received an Unusual Incident/Injury Report (LIC 624) pertaining to Resident #1 (R1) and Staff #1 (S1). Please note, the Administrator Joey Alvarado submitted the written report to CCL on 02/19/2023, but due to the report being received over the weekend, and Holiday on Monday, the report was not reviewed until 02/21/2023. The report stated on 02/19/2023, Staff #2 (S2) observed R1 to have superficial peeling of the skin on their right upper back. S2 reported this to the med-tech on duty who then reported to HDW Alex Alvarado who then investigated the incident. Interviews revealed that on 02/12/2023, S1 used a bucket of hot water from the kitchen to bathe R1 due to R1 not having any hot water in their shower and failed to test the water prior to using on the resident. S1 noticed redness on R1's right upper back but failed to report to a supervisor. The HWD notified R1's physician of the incident. R1 was taken to urgent care by the request of R1's family member and returned back the same day with a topical prescriptions to be applied to the area.

On 02/23/2023, the LPA spoke with Administrator Joey Alvarado regarding the incident. She stated R1 was sent to the urgent care on 02/19/2023 and was diagnosed with a burn of unspecified degree of upper back and was prescribed prescription medication to be applied to the injury. The Administrator emailed this document to the LPA. The Administrator stated when S1 was interviewed they conveyed the incident was an accident and they had no ill intent. The Administrator stated S1 was placed on leave initially when they were aware of the incident and then terminated on 02/22/2023. The Administrator stated R1's room does have an issue with maintaining hot water temperature which maintenance is currently working on. The Administrator stated the part needed to fix the issue is currently on order. In the interim, R1 was moved to another room until the repair can be made. Report continued on LIC 809-C.