Facility Evaluation Report

On 1-24-22 at 12:24pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit during a complaint investigation for complaint #27-AS-20220120131855. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. LPA interviewed Administrator and reviewed incident report dated 12-26-21. Based on interview and record review it was determined that Resident1 (R1) fell on 12-26-21 and sustain injury. Incident report was submitted to regional office in a timely manner. Upon further review and interview, it was determined that 9-1-1 was not called immediately after the fall incident.

LPA's interview with Administrator also revealed that staff1 (S1) was working alone in the facility and interacted with residents in care on 12-26-21 for a period of time and did not receive a criminal record clearance as per regulations. Staffing list did not include S1 and a reference check through regional office internal records did not reveal a clearance or association of S1 to the facility.

Based on today's visit, citations are issued under Title 22 Division 6, Chapter 8. An immediate civil penalty of $100 is issued due to violation of criminal record clearance. An exit interview was conducted with Adetayo Kokumo and a copy of this report was left with Adetayo. Appeal Rights provided.