Facility Evaluation Report

On this day, Licensing Program Analyst (LPA) Edward Kim conducted a case management visit to document a deficiency observed during the investigation of complaint 22-AS-20250820085829 but unrelated to the allegation investigated.

During the visit at the facility, LPA reviewed R1’s Facility’s Progress Notes and observed the following falls were listed in the Progress Notes, but no incident reports were received by the department: February 12, 2025, February 26, 2025, February 28, 2025, June 8, 2025, June 10, 2025, July 2, 2025, around 1:30 AM, July 2, 2025, around 8:20 AM, July 4, 2025, July 6, 2025, July 11, 2025, July 14, 2025, July 19, 2025, July 25, 2025, July 30, 2025, and August 3, 2025.

A deficiency was cited during the visit according to Title 22 Division 6 Chapter 8. The facility did not send incident reports of when R1 had falls on February 12, 2025, February 26, 2025, February 28, 2025, June 8, 2025, June 10, 2025, July 2, 2025, around 1:30 AM, July 2, 2025, around 8:20 AM, July 4, 2025, July 6, 2025, July 11, 2025, July 14, 2025, July 19, 2025, July 25, 2025, July 30, 2025, and August 3, 2025.

An exit interview was conducted, and a copy of this report, LIC811, and appeal rights were provided to Executive Director Enrique Ledesma.