Facility Evaluation Report

Licensing Program Analyst (LPA), Juliana Barfield arrived on April 8, 2025 for an unannounced inspection to follow up on an incident investigation reported by the facility. LPA met with Tracy Knepple.

On March 28, 2025, the Department concluded an incident investigation regarding a self-reported incident involving delayed medical care to resident (R1).

The licensee was cited for California Code of Regulations (CCR) § 87465(g) Incidental Medical and Dental Care.

At the time of the case management visit on March 28, 2025, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49(f).

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the licensee did not immediately telephone 9-1-1 for R1, who had fallen, was expressing pain, and could not get out of bed due to experiencing extreme physical pain.

Today, April 8, 2025 the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes a serious bodily injury to R1 in the amount of $10,000.00.

Exit interview conducted. A copy of the report issued. Appeal rights provided to Tracy Knepple and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.