Follow-up on corrections·June 1, 2023

06/01/02023 9:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Administrator Amber Farmer. Today’s visit is regarding an incident that occurred on 05/26/2023 and was reported to licensing on 05/26/2023. It was reported that during staff rounds, a resident was found with a cup of laundry detergent and laundry detergent around their mouth. 911 was called immediately, the resident was transported to the hospital and subsequently hospitalized for observation. Resident is now back in the facility and doing well. Staff have increased observation of the resident. During the course of the investigation, it was learned that the laundry room is located in the “upper” portion of the facility. The laundry room door has an auto lock, and locks when shut. Staff do not know how the resident gained access to the detergent. All employees who were on duty stated the laundry room door was shut. There were no witnesses. As a result of the incident the facility has installed a spring hinge on the laundry room door and plans to additionally install locks on the cabinets in the locked laundry room where laundry detergent will be stored. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Amber Farmer.