Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Bilger conducted an unannounced case management visit on 3-29-23 at 2:19pm to follow up on a substantiated complaint received on April 4, 2022. LPA Bilger met with the Licensee Anthony Limbrick via phone. LPA explained the reason for the visit. Licensee gave permission for staff member (W1) to sign on his behalf.

On June 3, 2022, the Department concluded a complaint investigation and substantiated an allegation that Staff (S1) failed to secure Resident (R1) in a vehicle. R1 sustained fractures to their feet and S1 failed to obtain medical attention for R1.

The allegations were substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Tile 22, Division 6 § 80078(a) Responsibility of Providing Care and Supervision and (CCR) Tile 22, Division 6 80075(a) Health Related Services for failure to obtain timely medical treatment.

The investigation revealed that, on March 27, 2022, S1 drove R1 and R2 to a nearby park. The residents played basketball at the park. According to an interview, S1 reported that they usually assist R1 into the vehicle, but on this day did not. S1 reported, they started the car and “didn’t look back.” R2 stated, “the car began to move and there was a scrapping sound.” {Cont. on 9099C}