Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 01/28/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Incident report dated 01/25/2025 indicated Resident 1 (R1) had been served shrimp for lunch while having a seafood allergy. LPA observed facility protocol for resident allergies which consists of documentation in the kitchen as well as name cards in the dining room with resident allergies/ food preferences. Facility investigation revealed a new server had mistakenly served the shrimp to R1. Another caregiver realized what had happened and removed the shrimp but not before the resident had taken a bite. Side effects for resident consumption of shrimp include diarrhea. Resident was noted to have no side effects from the shrimp. Resident has since moved out of the facility.

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Sara Modugno, Administrator and a copy of this report was given to the facility along with a copy of the LIC 809-D and Appeal Rights.