Facility Evaluation Report

On February 16, 2024, Licensing Program Analyst (LPA) Komal Charitra met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero for a Case Management visit to follow up on a substantiated complaint allegation of neglect and lack of supervision resulting in serious bodily injuries.

On October 10, 2019, the Department concluded a complaint investigation which alleged that the facility did not provide proper care and supervision which resulted in a resident (R1) sustaining multiple falls including a serious bodily injury. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87464(f) Basic Services.

The investigation revealed the facility failed to do an accurate fall risk assessment after R1 experienced multiple fall incidents at the facility on June 17, 2018, July 15, 2018, October 11, 2018, October 17, 2018, and December 19, 2018. As a result, the facility failed to identify and implement measures and or plan of care changes to minimize further fall incidents for R1. Based on documentation reviewed, according to the facility’s assessment, it was not identified that R1 was a high risk for falls.

On March 1, 2019, R1 had another unwitnessed fall and was hospitalized. Based on the investigation, it was revealed that there are three small buildings on this property. There were no caregivers present in R1’s building before or at the time R1 fell. Two caregivers were in another building and a licensed vocational nurse (LVN) was in a med room, but the LVN was not answering their phone. As a result of the improper risk assessment and facility’s failure to identify and implement a proper plan of care to address R1’s fall risk; R1 sustained a right intertrochanteric femur fracture and needed to undergo an operation called femur intramedullary rodding. (Continue to 809C)