Facility Evaluation Report

Licensing Program Analyst (LPA) A. Canela conducted an unannounced Case Management- Incident visit and met with Administrator, Grace Sandoval.

LPA went over several incident reports that were submitted by the facility as required.

LPA had previously went over several incident reports for resident R1 who had falls on 4/12, 4/13, and 4/14 and resident and their family had refused medical attention. Facility placed R1 on 72 hour checks after R1 was found on the floor but did not complain of any pain. On 5/21/23 R1 was found on the floor, did not complain of pain and refused medical attention. On 5/22/23 facility reported they found R1 on the floor again and their left ankle was swollen and R1 complained of hip pain. 911 was called by facility and R1 was sent to the hospital and diagnosed with a left ankle fracture and given a soft cast. R1 returned the same day. It was also reported by facility that on 4/29/2023 at 9:04pm, the facility received a call from R1's daughter to report R1 was outside. Staff went out and R1 was found at the end of the street sitting down on the floor. A man that was walking by saw R1 on the floor and helped to call R1's daughter, who then notified facility. No visible injuries were noted, but facility was unaware R1 had left the premises.

On 5/7/2023 it was also reported staff went to R1's room at 8:00am to bring them to the dining area for breakfast and staff could not locate R1. Staff began searching and after 5 minutes, saw R1 outside walking searching for their sister. Resident became verbally abusive but agreed to return to the facility.

Facility explained, resident is not diagnosed with Dementia on their LIC602 Physicians report and went out the back door. LPA explained the facility is responsible for knowing if a resident has left the premises and should be exiting the main entrance. LPA also requested facility to get resident assessed and submit a new Physicians report to Community Care Licensing.