Facility Evaluation Report

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into a self-reported incident report received in the Orange County Regional Office (OCRO) on January 18, 2024, regarding Resident #1 (R1). LPA met with Health Services Director (HSD) Nathan Solares and explained the reason for today’s inspection. Administrator (AD) Judith Torres appeared via telephone.

During the course of the investigation, Department staff inspected the facility, interviewed residents and staff, and obtained and reviewed copies of the resident roster, staff roster, an Incident Report received January 18, 2024, Facility Incident Reports regarding R1, R1’s Physician’s Report dated October 3, 2023, R1’s Resident Service Plan dated November 27, 2023, R1’s Resident Service Plan dated February 18, 2024, R1’s Admission Agreement, R1’s X-Ray Report dated January 5, 2024, R1’s Power of Attorney Paperwork, and R1’s Hoag Memorial Hospital Medical Records dated January 13, 2024.

Per the Incident Report received January 18, 2024, R1 suffered a fall on January 4, 2024, was diagnosed with a hip fracture on January 10, 2024, and was noted to have discoloration at the fracture site and transferred to Hoag Memorial Hospital on January 13, 2024. Interviews with AD and Staff #1 (S1) revealed that R1 is diagnosed with dementia, is a known fall risk with a history of falls, and engages in wandering around the facility. Per Facility Incident Reports regarding R1, prior to R1’s fall on January 4, 2024, R1 suffered falls on June 10, 2023, and July 26, 2023. AD and S1 reported that there have been multiple instances of R1 being found in other residents’ rooms on the floor or otherwise falling, including incidents not resulting in injuries.