Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit regarding an Death Report (LIC624A) received by Community Care Licensing (CCL). LPA met with Susie Sarria Business Office Manager (BOM) an stated the purpose of the visit on 7/14/22 at 9:15am.

LPA reviewed the death report indicating that resident #1 (R1) passed away on 7/1/22 in the hospital. The facility was notified by family on 6/28/22 that R1 was on comfort care. The facility was made aware that R1 was deceased on 7/1/22 and the Death Report was received by CCL 11 days later on 7/11/22.

In addition, upon a file review, LPA did not observe an Special Incident Report (LIC624)(SIR) submitted to CCL indicating that R1 was sent to the hospital on 6/24/22 for a fall that occurred at the facility.

CCL received another Death Report (LIC624A) for R2 which indicated R2 passed away on 7/9/22. The Death Report was received by CCL 2 days later on 7/11/22.

Based on the documentation, reviewed with BOM during this visit the investigation revealed that the facility did not report to CCL timely.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The BOM was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.