Facility Evaluation Report

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of following up on a Special Incident Report (SIR) that was obtained from Inland Regional Center (IRC). LPA Colvin met with Facility Manager Mitzi Ambrosio and advised them of the purpose of today's inspection.

LPA Colvin observed that Community Care Licensing (CCL) has not received any SIRs from the facility since 2017. LPA Colvin reviewed facility records and observed that multiple incidents that are subject to reporting to CCL have occurred since 2017, including two AWOLs (5/15/21 & 11/14/19) and 2 hospital visits (9/22/18 & 7/18/18) for Resident One (R1), 1 hospital visit (7/24/23) and one medication error (2/14/24) for Resident Two (R2), and 1 injury (2/23/22) for Resident Three (R3). While these incidents have been reported to IRC, the facility has not submitted these reports to CCL, as is required. LPA Colvin asked Facility Manager Mitzi Ambrosio (who is the one who completes the reports) why these reports are not being submitted to CCL. Mitzi Ambrosio stated that they submit the reports online to IRC and assumed that the reports were being sent to CCL as well. LPA Colvin informed Mitzi Ambrosio that the reports must be faxed or mailed to the CCL office as well in order to fulfill the reporting requirements. LPA Colvin will be issuing a Technical Violation instead of a deficiency as it appears to be an honest mistake, and the facility was still submitting reports to IRC.

An exit interview was conducted with Facility Manager Mitzi Ambrosio and a copy of this report and LIC9102-TV were provided.