Facility Evaluation Report

On August 23, 2021 Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management visit to the facility today to follow up on the substantiated allegation of neglect/lack of care and supervision. The LPA met with Executive Director Taylor Giunto and informed them of the reason for the visit.

On July 3, 2018, the Department received a complaint which contained the allegations: Facility staff failed to provide proper care and supervision to Resident #1 (R1) which contributed to R1’s death; and, facility staff failed to seek timely medical attention for R1.

The above allegations were substantiated, on January 31, 2019, the licensee was cited for violating California Code of Regulations (CCR) Title 22, 87464(f)(1) Basic Services due to failure to provide R1 with proper care and supervision relating to assistance with activities of daily living. Citations were also issued under 87465(g) Incidental Medical and Dental Care for failure to obtain timely medical attention for R1 by failing to call 9-1-1 immediately upon finding R1 in an unresponsive state. The licensee was further cited under section 87411(a) Personnel Requirements – General for not having competent staff to ensure R1 was monitored and ate after receiving insulin, and subsequently failing to contact emergency services for R1 in a timely manner. Lastly, the licensee was issued a citation under section 87405(d)(1)(2) Administrator – Qualifications and Duties for the administrator not providing staff with appropriate training to ensure R1 was afforded appropriate care and supervision, which ultimately contributed to the death of R1. On January 31, 2019, an immediate civil penalty of $500 was also assessed for the violation of CCR Title 22, Section 87464(f)(1) Basic Services.

R1’s physician report dated June 27, 2018, revealed that R1 had a primary diagnosis of vascular dementia and Type I diabetes and was confused with times and dates. R1 had a continuous glucose monitor implanted on R1’s arm which transmitted glucose levels to a bedside monitor every five (5) minutes. The display unit was programmed to sound an alarm when R1’s glucose levels dropped below 80 milligrams per deciliter (mg/dl).