Facility Evaluation Report

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a case management related to the recent cluster of falls. LPA met with administrator Ryan Hust, to explain the purpose of the visit. Covenant Living of Turlock is a 377 bed facility where 167 of the beds have clients in a condition of being provided care.

LPA toured several rooms and apartments of the facility, asked for SI reports related to falls for the past 2 weeks, asked for a copy of Plan of OP selections related to employee training including any specific related issue to falls including reporting requirements, and Shift schedules for a period of days. The toured locations of the falls for the past two weeks(aspen, sequoia, redwood), LPA identified no environmental risks for increased falls (torn rugs/trip hazards, unsecured bannisters/grab bars). LPA notes the Plan of Op was last updated in 2015, and is requesting any updates of the past 11 years be sent along in a revised plan of OP to the LPA's email by March 10th 2026. (noel.wolfpetersen@dss.ca.gov) .

Per the facilities Policy training on Medical Emergencies, "the community summons 911 when the resident exhibits signs and symptoms of distress and/or emergency condition: ...to include fall with deformity, severe pain or head injury...". Does not designate seperate policy for witnessed or unwitnessed falls, nor situations where behavioral expression or pathology prevents an expression of pain. 3 of 5 falls in SI reports from the past 6 weeks included a phonecall to 911, responsible party, and a physician.

the remaining 2 of 5 falls in SI reports from the past 6 weeks fell outside of the plan of op's stated reporting criteria, asserted to have been determined by the facilities reporting parties. One SI report of these two included bruising on the hands and knees. One client of these two was inclined to be interviewed, and denied feeling as though there was a shortfall in the care and supervision by the staff related to the fall.