Facility Evaluation Report

On 10-24-23 at 1:30pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva conducted an unannounced complaint investigation to follow up on a substantiated allegation of lack of care and supervision which led to the death of a resident for a complaint that was received on 9-13-22. LPAs met with the Licensee Kimberly Camello, and explained the reason for the visit.

Based on the investigation, the allegation was substantiated, and the licensee was cited for a violation of California Code of Regulations (CCR) Title 22, Division 6 section 80078(a) Responsibility of Providing Care and Supervision and CCR Title 22, Division 6, section 85064(j)(4) Administrator Qualifications and Duties for not ensuring a provision of safety and supervision.

The investigation revealed that on February 14, 2021, a resident (R1) was served a tri-tip steak sandwich for lunch. During this meal period, staff (S2) observed R1 to be coughing with clear mucus and saliva coming out of R1’s mouth and nose. R1 covered their mouth with a napkin and ran to the bathroom and closed the door. S2 knocked on the door but did not hear anything and observed the door to be locked. An estimated time of five (5) minutes lapsed from when R1 entered the bathroom and S2 knocking on the bathroom door. {Cont. on 809C}