Facility Evaluation Report
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Stephanie Santos, Program Administrator (PA). The purpose of the visit was to follow up with three incidents self-reported by the facility to the department.
The first incident was reported on 03/04/2025. The incident occurred on 03/04/2025 and involved resident R1 swallowing a battery from a blood pressure machine that was in R1's bedroom.
The second incident was reported on 03/19/2025 and occurred on 03/19/2025. The second incident involved R1 using a mirror that was in R1's backpack to attempt to cut himself/herself.
The third incident was reported on 04/02/2025 and occurred on 04/02/2025. The third incident involved R1 swallowing R1's bedroom key and kinetic sand.
During visit, LPA Marrufo interviewed PA. PA stated that staff had left the blood pressure machine in R1's bedroom in the morning on the day of the incident. PA stated that the blood pressure machine should have been returned to a cabinet in the facility garage, but staff did not return the blood pressure machine. PA stated that due to personal rights of R1, staff are not able to sweep, or tour, R1's bedroom while R1 is not present in R1's bedroom. PA stated that when R1 returned to R1's bedroom in the evening, R1 rushed to the blood pressure machine, removed a battery, and swallowed a battery.
See LIC809-C page for more information. Page 1 of 2.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction