Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the complaint findings received on 12/22/2021 and 01/04/2022. LPA met with Administrator in training, Tammy Lu.

During the complaint investigations, multiple deficiencies were found that were not part of the complaint allegations.

In December 2021, a resident (R1) was admitted to the facility. Based on record review, R1 was accepted into the facility without a physician’s report and updated needs and services plan. R1’s needs and services plan was dated on 06/28/2018 and was written from the previous facility. Based on interview and record review, Licensee did not develop a needs and services plan for R1 to determine if the facility can meet the needs of the client and obtain a physician’s report to determine medical assessment, prior to being accepted to the facility.

In December 2021, R1 was restrained by staff on two separate occasions. On 12/16/2021, it was noted on the San Andreas Regional Center corrective action plan that R1 was put on restraint for one hour. On 02/21/2021, it was noted that R1 was put on restraint for one and a half hours. Based on multiple visit notes provided from crisis counselors, facility staff stated to have placed R1 in a restraint for one to two hours at a time or until R1 was calm. Based on record review, the facility’s Emergency Intervention plan states manual restraints are not considered an intervention and will not be used.

The Department received two incident reports on 12/16/2021 and 12/21/2021, which did not report the use of restraint or use of the emergency intervention plan, on both occasions.

Deficiencies are being cited today per California Code of Regulation, Title 22. See LIC809D. Exit interview conducted with Administrator in training, Tammy Lu . A copy of this report, along with the facility's appeals rights were provided.