Complaint Investigation Report

The investigation also determined that the facility failed to notify the Community Care Licensing Division of R1’s hospitalization, as required by regulations. As a result of these failures, R1’s medical care was delayed, leading to their hospitalization for conditions that could have been addressed sooner with timely intervention. R1 remained in the hospital until December 2, 2023, after which they were discharged to a skilled nursing facility. The facility has a meal log that documents the approximate amount of food eaten per meal. It shows a decline in the amount of food the resident was consuming three days prior to the resident being sent out to the hospital. Facility also did not report to Community Care Licensing Division that the resident was sent to the hospital due to decline. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met that the facility failed to seek timely medical care, notify the physician, and the Department that resident’s health was in decline. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency and civil penalty are being issued

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. Staff did not seek medical attention for resident in care in a timely manner.