Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct an unannounced case management – deficiencies. LPA met with Licensees Carolyn and James Heinan. On 09/16/2024, LPA Dolores arrived to the facility to open the initial complaint investigations for complaint control numbers 26-AS-20240910121029 and 26-AS-20240912155005. During the complaint investigations, Title 22 violations were observed.

On 09/16/2024, LPA Dolores was informed of a resident (R1) who passed away in March 2024. LPA Dolores reviewed the facility’s file and did not observe an incident report and death report was received by the licensing department. Licensee produced the incident report from R1's file from March 2024 stating R1 was sent to the hospital. Licensee was unable to produce documentation to show the incident report or death report was submitted to the licensing department.

On 09/16/2024, LPA Dolores obtained records for 2 complaint investigations. Based on interview, the Licensee's observed resident (R2) had a change of condition from ambulatory to bedridden. It was stated that the resident also required a two-person assist during transfers. The review of R2’s records show the physician’s report was last updated on 09/16/2022, which does not indicate the change of condition and updated ambulatory status. R2’s appraisal/needs and services plan was last developed during admission on 09/18/2022.