Facility Evaluation Report

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Emily Pascua and explained the purpose of the visit.

Upon arrival, LPAs Moleski and Williams observed a resident (R1) sitting in a chair with large amounts of dark-colored bruising covering their face. LPAs Moleski and Williams asked Pascua about the cause of these injuries, and she said R1 had fallen on 10/21/24. LPA Moleski reviewed an incident report submitted to the Community Care Licensing Division on that same date. According to the incident report, R1 went to the bathroom around 2:30 p.m. and fell, hitting their head and right forearm. Immediately after the fall, R1 exhibited redness to their left eye and forehead, and had a wound on their upper nose. R1's right forearm had an open wound, a skin tear, and bruising, according to the incident report. The report further stated that first aid was provided to R1, including antibiotic ointment and gauze for R1's wounds, and R1's responsible party was notified.

In an interview, Pascua said that 911 was not called. She said that R1's responsible party was texted immediately after the incident and asked whether or not R1 should be sent to the hospital, but R1's responsible party did not respond to her inquiry until the next day. Pascua said that R1's responsible party told her that R1 did not need to be sent to the hospital.

22 CCR Section 87465(g) states that " the licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health ." Pascua admitted that 911 should have been called after the incident described above.