Facility Evaluation Report

On 1-31-23 at 10:34am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit. Case management was conducted in regards to an incident which originally occurred on 2-14-2021 and a recent investigation based on complaint #27-AS-20220913143824. LPA met with Administrator Kimberly Camello and explained the purpose of the visit. LPA reviewed incident report dated 2-14-2021 , information face sheet, and recently completed investigation. Based on interviews and record reviews conducted, it was determined that resident1 (R1) experienced a choking episode on 2-14-21 while eating a meal at the dining table. R1 was observed by staff to be coughing with mucus and saliva exiting R1’s mouth and nose. R1 went to the bathroom and water was heard running. It was further determined that staff member was instructed to take remaining residents on an outing while Administrator remained on duty to supervise R1. A review of information face sheet states, as result of a swallow evaluation on 4-2-2019, R1 has a “delay in her swallow due to her food/drink going into a sinus pocket before going down.” Based on interviews and record reviews, it was determined that Administrator, who is also the Licensee of facility did not adhere to appropriate levels of care and supervision in that R1 was not assessed for safety and medical attention between a period of 7-9 minutes after an initial inquiry by staff with no response from R1. 911 was notified and R1 was taken to a local hospital where R1 was pronounced deceased.

As a result of this case management, a citation is issued under Title 22, Division 6. An exit interview was conducted with Kimberly Camello and a copy of this report was left with Kimberly. Appeal rights provided.