Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a unannounced Case Management Visit-Deficiency on 05/09/2025, stemming from initial complaint investigation (28-AS-2025052102030) visit on 05/09/2025. LPA was greeted by Administrator Toni Santos and explained the purpose of the visit.

On 05/09/2025, LPA Ramirez reviewed (R1) resident file and observed six (6) Unusual Incident/Injury Reports (LIC 624) from 02/01/2025 through 03/19/2025. These reports revealed R1 had multiple falls and sustained a small skin tear on their elbow. Per Title 22, Division 6, chapter 8, Article 04. 87211(a)(1)(D)- Reporting Requirements- ( a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This licensing agency did not receive these reports. Staff interviews revealed staff did not send these reports to licensing. This poses a potential risk to the health, safety, or personal rights of persons in care. LPA Ramirez will issue a deficiency based on this observation and staff interviews.