Facility Evaluation Report

Licensing Program Analyst (LPA) Brian Balisi conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20250515145455). The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation unrelated to the complaint. Upon arrival, LPA met with Executive Director Kellie Smith and explained the reason for the visit.

During the investigation between 07/07/25 and 09/15/25, The Department reviewed Resident #1(R1s) charting notes covering the period from 01/28/25 through 07/06/25. Charting notes revealed that since 01/28/25, R1 experienced a total of four (4) unwitnessed falls on 03/11/2025 at 11:00 a.m., and 01:59 p.m., on 04/12/2025 at 01:25 p.m., on 04/27/2025 at 04:42 p.m. On 05/01/25, Home Health recommended that R1 receive assistance with all upright activities due to fall risk. After Home health’s recommendation R1 experienced additional falls on 06/05/2025 at 04:22 a.m. and on 06/10/2025 at 04:10 p.m.

LPA’s records review of incident reports (LIC 624) revealed the Regional Office (RO) only received an incident report for the fall on 06/10/2025. LPA’s records review of R1’s file revealed there was no reappraisal on file after home health’s recommendation that R1 receive assistance with all upright activities due to fall risk on 05/01/2025.

The following deficiencies were cited from the Title 22 California Code of Regulations. (See LIC 809-D). The Executive Director was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report was provided