Facility Evaluation Report

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced Case Management- Deficiencies visit regarding a complaint reported on 08/14/25 about a client sustaining a fracture. LPA Gonzalez met with Bilikisu Jinadu, DSP and explained the reason for the visit.

During the course of the investigation related to Complaint Control Number: 28-AS-20250814095323, the Department interviews revealed facility staff were neglectful as they failed to report C1’s fall sustained that was on 02/12/25. As a result, there was no change to C1’s care plan by a medical professional. Per C1’s Primary Care Physician (PCP), they did not receive any report from the facility for the fall C1 sustained on 02/12/25. Per C1’s PCP, any fall or accident is classified as a change of condition. If there is a change of condition, the PCP must be made aware. PCP added had the facility reported C1’s fall on 02/12/25, it was possible that an adjustment to C1’s care plan may have prevented C1’s fall on 08/08/25 that caused a nasal fracture. The Department interview with S4 revealed that S4 admitted to staff not reporting C1’s fall on 02/12/25. S4 added there was no change in C1’s care plan by a medical professional for any fall prevention between the fall on 02/12/25 or the fall on 08/08/25. LPA Gonzalez reviewed facility file for special incident reports submitted to CCL and confirmed no SIR was submitted for the 02/12/25 fall of C1.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed is indicated on the LIC809D page. Additionally, an immediate $500 civil penalty is being assessed today, due to client sustained a fracture while in care. (Refer to LIC421IM)

Exit interview held, and a copy of the report along with appeal rights were provided to Bilikisu Jinadu, DSP