Facility Evaluation Report

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management Deficiencies inspection due at the facility today. The LPA met with Interim Administrator Julius Osorio and explained the reason for the inspection.

During an investigation under complaint control # 29-AS-20220322104533 , interviews and the service plan for Resident #1 (R1) revealed R1 is a two person assist with transfers and is wheelchair bound. During the complaint investigation, it was revealed that S1 reported when they were transferring R1 to the shower bench, R1 lost their balance and S1 assisted the resident down to the floor. R1 sustained a skin tear and paramedics were called. Interviews with S2 revealed they were not present or assisting R1 with showering at the time of the incident and only arrived after there was a call for assistance due to the resident being injured. Interviews with Individual #1 (I1) also revealed they have also observed only one staff responding to assist R1 with transferring.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code.

Exit interview and report reviewed with Interim Administrator. A copy of the report was provided.