Complaint Investigation Report

306004779-11-16-2023-22-AS-MSTC-CXT4S6-20231121182102

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 770 THE CITY DR., SUITE 7100

This is an official report of an unannounced visit/investigation of a complaint received in our office on

11/08/2023 and conducted by Evaluator Jerome Haley

COMPLAINT CONTROL NUMBER: 22-AS-20231108125250

Facility failed to report resident’s fall and injury.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received November 8, 2023. LPA Haley was greeted by staff and explained the reason for the visit upon entry. Director Maricel Lindsy was contacted via telephone and arrived shortly after and was present for the remainder of the visit.

Regarding the allegation: Facility failed to report resident’s fall and injury.

During an interview with Director Lindsy it was confirmed no incident report was sent to the Region Office regarding Resident 1's fall and injury. Interviews with Director Lindsy, facility staff, Resident 1's son-in-law, R1's physician, and hospice provider confirmed R1 had an unwitnessed fall and sustained an injury to the hip. A review of Angels Hospice RN/LVN Communication Flow Sheet revealed R1 fell on October 18, 2023.

Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6.

An exit interview was conducted and a copy of this report and appeal rights were provided.