Incident investigation·February 9, 2023

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit to follow up on various incident reports received. LPA met with facility staff, and explained the purpose of the visit. Resident 1 (R1) had a fall, which results in R1 landing on R1's back. R1 was sent out to Sutter Amador Hospital. According to staff, R1 returned with no major injuries. Facility records show follow up care was provided and R1 was monitored. The Regional Office received a death report for Resident 3(R3). The death report did not include cause of death or conditions related to death. LPA reviewed resident records and interviewed staff. LPA discussed with ADM Fleta regarding the completion of a death report. LPA to provide TA to assistant administrator Karly. An incident occurred wit Resident 4 (R4) and Resident 5 (R5). R4 was walking down the hall and walked by R5. R5 used an elbow and forearm to push R4, which resulted in R4 falling on the ground hitting R4's head. All responsible parties were contacted, in addition to the non-emergency and local PD. R4 sustained an injury of head; laceration of forehead. R4 was made a follow up appointment to have sutures removed. According to staff, Per California Code of Regulations (CCR), Title 22, deficiencies are being cited on LIC 809-D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview held, and a report was provided to facility staff. LPA also discussed information with Administrator Fleta Herndon via cell phone.