Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Michael Gastelum.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 05/05/2023), involving Client #1 (C1) falling at the facility on 04/29/2023. [See LIC 811 Confidential Names List for a description of C1].

During today’s visit, LPA performed a facility tour and welfare check on C1, finding they were safe. LPA interviewed C1 and relevant staff. LPA also reviewed pertinent care and hospital records.

Records, corroborated by interviews, showed: On 04/29/2023, C1 tripped over a piece of carpet tape which had peeled up over time. Licensee had placed the carpet tape in this spot to cover a seam/transition line, where two sections of the facility’s carpet flooring joined together. During the incident, Licensee timely arranged emergency medical care for C1 and met reporting requirements. Following the incident, Licensee replaced the peeling piece of carpet tape with a new piece of tape that laid flatter/smoother to the floor surface (as corroborated by LPA observation).

A preponderance of evidence exits to show that during the above incident, Licensee did not ensure that C1 was protected from a visible trip hazard associated with the facility’s flooring, which contributed to C1’s fall and subsequent injuries. One (1) deficiency was thus cited per California Code of Regulations, Title 22 (see attached LIC 809-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Gastelum, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.