Facility Evaluation Report

Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced case management visit to the facility on 11/03/23 to follow up on an incident that occurred on 10/16/23. LPA Campbell met with Celerina Belen, Caregiver and explained the purpose of the visit.

LPA Campbell reviewed a special incident report stating that R1 and R2 were involved in an altercation on 10/16/23, a Monday. The incident report was sent to licensing on 10/19/23, on Thursday. R2 had to be treated at the hospital for a laceration on his head before returning to the facility the next morning. Both residents apologized to each other with no further action taken.

LPA Campbell discussed with caregiver that reporting requirements are required for incidents that involve an injury which requires medical treatment. Incident Reports must then be submitted to licensing by the next business day.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The Facility Designee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.