Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Deficiencies inspection at the facility regarding deficiencies observed during the investigation of complaint control # 29-AS-20230125125751. The LPA met with Nursing Director Betsy Mccoy and explained the reason for the inspection.

During the investigation of complaint control # 29-AS-20230125125751, it was alleged that staff did not respond to a pendent call for assistance timely pertaining to a choking incident regarding Resident #1 (R1). During the course of the investigation, although there was insufficient evidence to support staff did not respond to a pendent call timely, there was sufficient evidence to support staff did not respond to a stat assistance for help with a choking incident timely as interviews revealed it took approximately seven (7) to eight (8) minutes for the S2 to respond and S2 utilized the elevator from the third floor to the first floor instead of using the stairs which is typically faster. Interviews conducted with witnesses also reflected that S2 did not perform the Heimlich maneuver or provide any type of life-saving procedures/medical interventions on R1 in the dining room.

More information pertaining to this investigation is under the LIC 9099 dated 02/01/2024 under complaint control # 29-AS-20230125125751.

During the course of the investigation, it also revealed S2’s first aid certification expired in February 2022, and S2 did not have a current certificate during the incident on 01/24/2023.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).

Exit interview conducted, civil penalties issued, appeal rights discussed, and a copy of this report issued.