Facility Evaluation Report

At approximately 9:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Deficiencies Visit and met with Executive Director, Pari Manouchehri.

During the course of the Complaint Investigation 21-AS-20241204092912, it was revealed that the Facility did not submit an incident report to Community Care Licensing (CCL) regarding R1's observed change in condition. During the investigation, R1 was observed to have a swollen shoulder by facility staff on 10/29/2024. R1 received an x-ray where it was found that they had a shoulder fracture. This incident was not reported to CCL and was not documented on an LIC 624/Unusual Incident Report Form (deficiency cited, see LIC809D, regulation 87211(a)(1)(D)).

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.