Facility Evaluation Report

At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit to investigate the reduction of Unusual incident reports (SIR's) submitted by the facility. LPA met with Executive Director Zenia Shah, interviewed staff and reviewed records. Based on records reviewed, this facility generally submits an average of 8-10 SIR's per month until May, 2025, when the number dropped to 3-4. LPA reviewed records at the facility from July 31 to August 6, and observed at least 4 incidents where emergency personnel were contacted and came to the facility to address resident needs. These incidents were not reported to CCLD. LPA provided regulation 87211, Reporting Requirements for review. LPA pointed out subsection (D): Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. LPA received copies of past incidents during this visit.

During this visit LPA was informed of a recent elopement from the facility. Resident was located safe approximately 15 minutes from when resident was noted being missing. LPA reviewed resident records and observed facility staff have observed a change in behavior with resident and was working on an updated care plan. LPA reviewed regulation with staff and provided guidance on methods of keeping residents safe.

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.

This report was reviewed with Zenia Shah and Appeal rights were given.