Facility Evaluation Report

On 12/16/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management-deficiencies inspection. LPA contacted Director, Jose Marquez via telephone, introduced self, stated the purpose of the visit. Director gave verbal permission for LPA to meet with Administrator, Gladys Hernandez.

During the course of the investigation for Complaint #24-AS-20231221081404, the Department reviewed records and conducted interviews and found that the facility failed to seek timely medical attention for R1. R1 had a history of a chronic constipation, fecal impaction removal, and use of enemas or suppositories. Staff failed to recognize signs/symptoms (including but not limited to leaking, abdominal pain/discomfort, not eating) of possible fecal impaction and the facility did not inform R1’s PCP.

On 12/14/23 at 5:30 a.m. staff checked R1 and noted that he had mottled, darkening skin and his vitals were low. Staff did not immediately call 911, instead cleaned him up, and waited approximately 1 hour for another staff member to come to the facility to start their shift. Upon arrival to the hospital, it was determined that R1 had including but not limited to a severe fecal impaction, fractured ribs, and approximately 45 minutes after arrival to the hospital, R1 passed away.

Based on the interviews conducted and records reviewed, the resident had a change of condition beginning on 12/12/23. The resident remained in his room and was not his normal self. The resident continued to decline and no medical treatment was given until 12/14 when staff noted that the resident appeared to have darkening of the skin and low vitals.

Deficiencies are being cited in accordance with California Code of Regulations. An immediate Civil Penalty in the amount of $500 is being assessed for care and supervision. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any. Exit interview conducted. A copy of this report and appeal rights were discussed and provided to Administrator, Gladys Hernandez, whose signature on this form confirms receipt of this document.