Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Diana Weinstein.

CCR 87466 states, “The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning…” Per Licensee’s “Fall Management Protocol” written policy, all falls, witnessed or unwitnessed, “will require completion of an Unusual Occurrence Report and an investigation of the circumstances leading to the fall,” and “any resident sustaining a fall will also be placed on Alert charting status.” The policy further states that an “internal Incident Report (Form 406a) is completed every time a resident falls,” and the “the [resident's] healthcare practitioner will be notified using Form 213a, Physician Fax Report of Fall.”

Review of records and interviews of staff and outside sources showed: Resident #1 (R1) fell just outside the facility’s main entrance door on 03/22/2025. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The responding facility staff, Staff #1 (S1) and Staff #2 (S2), did not timely inform any medication tech, nurse, or manager about this fall. No internal Incident Report (Form 406a) was completed for this fall around when it occurred. Also, Licensee did not timely submit an LIC624 Unusual Incident/Injury Report to CCLD for this fall (this latter element was already addressed/cited in a separate complaint report). R1’s primary care physician (i.e., the pertinent healthcare provider) was also not timely notified of R1’s fall via a Form 213a, or by any other means. [CONTINUED ON LIC 809-C, 1 of 2]