Facility Evaluation Report

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver findings on complaint number 56-AS-20251107091354. This case management visit is in response to complaint number 56-AS-20251107091354. LPA met with Health Services Director Brandy Herrera and explained the purpose of the visit. LPA explained to Brandy that a deficiency will be issued to the facility in relation to complaint control number 56-AS-20251107091354. During the review of records LPA observed that Resident #2 had sustained multiple falls on different occasions. During further review LPA discovered that the only report reported to CCL was the fall that involved Resident #1 and Resident # 2, sustaining a fall in the shower that resulted in Resident #1 with an elbow fracture. During interview with Facility Health Services Director LPA was informed that falls pertaining to Resident #2 were not reported to CCL because Resident #2 did not need medical attention. During review of records LPA discovered that Resident #2 was a fall risk. In addition, LPA found that Resident #2 had count of notes that were made regarding Resident #2 sustaining falls which were not reported to CCL. LPA informed Facility Health Services Director that all incidents involving residents whether they were transported to the hospital or just administered first aid, that the facility must report. LPA will be issuing a deficiency for reporting requirements in relation to complaint control number 56-AS-20251107091354.