Facility Evaluation Report

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced case management visit at the facility. LPA was greeted at the front entrance by Caregiver Rojas, identified herself, and was granted entry into the facility. Administrator Cynthia Grape arrived during the visit.

During the visit, LPA discussed Title 22 reporting requirements with the Administrator, specifically the requirement to report unusual incidents involving residents, including changes in condition requiring medical evaluation or treatment, and other incidents required under California Code of Regulations, Title 22, Section 87211, Reporting Requirements. LPA also discussed the facility's responsibility under Section 87466, Observation of the Resident, to monitor residents for changes in physical, mental, emotional, and social functioning and to ensure appropriate medical evaluation and follow-up when warranted.

During the discussion, the Administrator informed LPA that the facility had not been reporting incidents involving residents who experienced changes in condition requiring medical evaluation, including residents exhibiting behaviors that were later determined to be associated with urinary tract infections (UTIs). The Administrator stated that the facility did not believe these incidents were required to be reported because they were not considered medical emergencies.

LPA explained that Section 87211 requires the reporting of unusual incidents affecting the health, safety, or welfare of residents, including significant changes in condition requiring medical evaluation, regardless of whether the incident constitutes a medical emergency.