Facility Evaluation Report

At approximately 11:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Deficiencies Visit and met with Executive Director, Jeff Gollihar.

During the course of the Complaint Investigation dated for April 1, 2022, LPA reviewed documents. LPA learned that Resident 1 (R1) had sustained a black eye from an unknown source. This incident was not reported to Community Care Licensing (CCL) and was not documented on an LIC 624/Unusual Incident Report Form ( See LIC-809D ). LPA and Executive Director discussed the importance of reporting incidents in a timely manner.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.