Facility Evaluation Report

Licensing Program Analyst (LPA) Galarza conducted a Case Management -Deficiencies visit due to observation made while investigating complaint control #: 28-AS-20220128150605 visit. The purpose of the visit was explained to Assistant Administrator Cynthia Flores.

On 1/26/2022, resident (R1) sustained a fall that resulted in a knee fracture. The facility failed to report the incident within reporting requirements time frame. In addition, during the course of the complaint investigation LPA requested a copy of the incident report. The incident report obtained had incorrect date and was missing time of incident. NOTE: The facility has not faxed any incident reports since November 16, 2021.

Ms. Flores presented LPA a copy of a FAX Transmission Verification Report with time stamp 1/31/2022. However, the fax # the incident reports were sent to was incorrect. Ms. Flores acknowledged the fax # on the Transmission report is incorrect. LPA provided Ms. Flores the correct fax number.

Per Title 22, Division 6, Chapter 8, Article 04. Operating Requirements 87211(a)(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...."

Exit interview conducted with Assistant Administrator Cynthia Flores. A copy of the report and Appeal Rights were issued.