Facility Evaluation Report

Licensing Program Analysts (LPAs) Mariana Agban and Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20231009085600 . LPAs met with the Administrator and explained the reason for the visit.

During the visit, LPAs observed two (2) incidents for 2 residents that were not submitted to the Community Care Licensing Department (CCLD) in a timely manner. Moreover, Administrator informed LPAs that R1 was hospitalized on 10/03/2023. LPAs reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting.

LPAs informed the Administrator to submit the following two (2) incidents that occurred on:

In addition, review of R1's record revealed that the facility file is incomplete/missing documents.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D.

Exit interview conducted, appeal rights and copy of report signed and delivered.