Facility Evaluation Report

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of citing deficiencies observed during the investigation of complaint 22-AS-20230628144300 and not related to the allegations investigated.

There are six residents in care at the time of the present visit. LPA conducted a tour of the physical plant and requested resident records for all six residents in care. Per the review of records, one resident has been assessed to be bedridden, however the facility only has a fire clearance for six non-ambulatory residents. Type A citation issued and immediate civil penalty assessed.

During the investigation of the complaint mentioned above, staff member May Kwok was referred to on multiple occasions as the acting administrator (AA) for the facility. A review of background clearance and staff associations in Guardian demonstrates that AA Kwok criminal record clearance was not associated with the facility’. Type A citation and civil penalty assessed.

During the investigation, the death of a resident 1 dated December 24, 2022, and a fall incident resulting in fracture and hip replacement of resident 2 dated October 6, 2022, failed to be reported to licensing staff as required by regulations. Type B deficiency cited.

Additionally, it was confirmed that facility staff failed to implement adequate fall prevention planning and measures while providing care for facility resident R2. Type A citation issued.