Facility Evaluation Report

Licensing Program Analyst (LPA) Tobola, Licensing Program Manager, Victoria Bertozzi and Regional Manager, Carla Nuti-Martinez held an announced office meeting to follow up on a substantiated complaint investigation and met with Administrator, Mantu Sandhu.

On April 23, 2021, the Department concluded a complaint investigation and substantiated the following allegations: Facility failed to provide adequate care resulting in the injury of a resident; Facility failed to report a change in residents condition as required by Title 22; and Resident has stage three pressure injuries.

The licensee was cited for violation of California Code of Regulations (CCR) Title 22: §87465 (a)(1) Incidental Medical and Dental Care for failing to obtain appropriate medical care for (R1); § 87211(a)(1) Reporting Requirements for failing to notify the Department that a resident (R1) sustained an injury while in care; and §87616(a)(1) Prohibited Health Conditions for retaining R1 with a stage 3 to 4 wound while R1 was not on hospice.

The investigation revealed that a R1 was admitted to the facility on July 2, 2020. R1’s physician report dated June 30, 2020, stated R1 has a diagnosis of hypertension and diabetes mellitus-type 2. R1 requires assistance with bathing, dressing , and toileting. R1 has a history of skin breakdown on bilateral heels and coccyx and is non ambulatory based on physical condition.

According to medical records, R1 was referred for services post operation of the left femur starting July 23, 2020. On July 23, 2020, it was noted that R1 did not have any pressure injuries and was considered a high risk for developing a pressure injury due to decreased mobility and diabetes. Facility staff were advised to provide frequent incontinence care. It was noted that R1 is fully dependent for mobility, transfers, toileting, bathing, and dressing. On July 31, 2020, during a home visit, R1 was noted to have mild redness on the buttocks.