Facility Evaluation Report

On 4/29/2025, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to the facility to address a deficiency discovered during a complaint investigation involving Resident 1 (R1). LPA met with Administrator, Rance Leth who was informed of the purpose of the visit.

On 5/1/2023 from approximately 12:50 p.m. to 2:30 p.m., the Department conducted the initial complaint visit to obtain pertinent records regarding complaint control number 18-AS-20230428143402. Records obtained included three (3) Unusual Incident/Injury Reports (UI/IRs) documenting a total of three (3) falls on 1/25/2023, 3/30/2023, and 4/5/2023 that R1 experienced while residing in the facility. The UI/IRs are not signed and the “REPORT SUBMITTED BY:” and "REPORT REVIEWED/APPROVED BY:" date sections are blank in all three (3) UI/IRs. The UI/IRs have a date and time on the bottom left corner stating “5/1/2023 1:42:24 PM”, “5/1/2023 1:43:35 PM” and “5/1/2023 1:44:23 PM”. LPA reviewed the Community Care Licensing (CCL), Riverside Regional Office’s incident report/duty log and there is no record the facility submitted any UI/IRs for R1 while they resided in the facility from December 2022 to April 2023. In addition, during an interview conducted with Staff 1 (S1) they reported staff write incident reports and they only report to CCL if the resident experienced a head injury or went to the hospital. S1 added it depends on the circumstances whether or not they report the incident to the State. Based on the totality of the circumstances, the facility will be cited for not meeting the reporting requirements pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, Regulation 87211. An exit interview was conducted and a copy of this report Confidential Names list (LIC 811), LIC 809-D, Appeal Rights were reviewed and provided to Administrator Leth.