Facility Evaluation Report

On 10/20/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced to conduct a case management visit regarding the incidents reports the Department received on Tuesday October 17, 2023. LPAs met with Executive Director (ED), Kim Hagen, and explained the purpose of the visit.

LPAs and ED discussed the serious/unusual incident report (SIR) submitted for an incident occurring on 9/10/2023 regarding R1’s emotional distress. LPAs discussed the importance of submitting SIRs in a timely manner as Title 22 mandates written reports to be submitting within seven days of occurrence. ED explained the dated of occurrence was inputted incorrectly as the incident occurred on 10/15/2023 not 9/10/2023.

Additionally, LPAs and ED discussed the SIR submitted for an incident occurring on 10/16/2023 regarding the incident with medications in R2’s room. LPAs discussed the importance of informing family members that medications are to be locked and secured if resident is able to store own medications. ED informed LPAs R2 is a new resident in care, and is in the Med Program, meaning facility assist with medication administration. ED stated the medications found in the room where over the counter medications which was removed during time of observation. ED informed LPAs the facility notified family members immediately to remind them of facility's protocols. ED also stated primary care physician was notified as all medications need a doctor's order.

LPAs and ED then discussed the LIC 624A Death Report received for R3. ED informed LPAs R3 was hospitalized beginning of the month due to a concern home health nurse observed. ED stated R3 was then discharged to a skilled nursing facility and then hospitalized again for the original concerns when R3 was at the facility. ED stated cause of death is unknown as R3 has not been at the facility for a few weeks.