Facility Evaluation Report

At 9:30am, Licensing Program Analyst (LPA) Angela Panushkina conducted a Case Management Visit in conjunction with the complaint #31-AS-20230630161933. LPA met with the Administrator explained the reason for the visit, and requested resident and staff roster.

R1 was admitted to this facility on August 2nd, 2022 and passed away on May 5th, 2023. LPA was informed that several incidents took place between 08/02/2022 to 05/05/2023 (R1 was in and out of the Hospital due to medical condition/diagnoses), and were not submitted to the Community Care Licensing Department (CCLD) in a timely manner. Based on Title 22 Regulation: a written Unusual Incident / Injury Report / Death Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed Administrator that all staff members are mandated reporters and they are all responsible for reporting.

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