Facility Evaluation Report

On 10/26/2023 Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit to follow up on an incident report submitted to the Department. LPA was allowed entry into the facility, met with the executive director, and explained the purpose of today’s visit.

During the course of the department’s investigation, Interviews were conducted, and records reviewed. Interviews and records review conclude, The Licensee failed to ensure a sufficient provision to aid in fall prevention of R1 after R1 sustained multiple falls over a seven month period which led to injury of R1. On October 19 th, 2023, the Department concluded the investigation and substantiated the findings.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties.

Exit interview conducted and appeal rights provided.