Facility Evaluation Report

On August 2, 2022, Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced and met with Administrator, Bill Phelps, and explained the purpose of inspection. Prior to initiating today’s inspection, LPAs completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive COVID-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. Additionally, LPA was screened per COVID-19 precautionary measures upon entering the community. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask.

On February 16, 2021, the Department concluded a complaint investigation which alleged the following: Facility staff failed to provide adequate supervision which resulted in resident (R1) sustaining a fracture, resulting in death.

The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87705(c)(3)(C): § 87466 Observation of the Resident which states; “The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.”

Two additional citations were issued following the investigation pertaining to; 1) Violating CCR Title 22 § 87705 ( c )(4) Care of Persons with Dementia which states; “(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional safety and health care needs as identified in his/her current appraisal.”;