Incident investigation·March 9, 2022

On 03/09/2022 at 12:00 PM, Licensing Program Analyst (LPA) Jaclyn Avila and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced to conduct a case manager related to a self reported incident. LPA and LPM met with Executive Director Eric Perry and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA Avila and LPM Munoz were screened by care staff upon entrance to the facility. On 2/24/2022, LPA Avila received a call from Administrator Eric Perry, notifying Community Care Licensing (CCL). Eric self reported an incident that occurred on 2/20/2022. Eric said a resident ate a "Mop Pod." Eric said a newly hired staff was cleaning and left his cart unattended while cleaning. Staff realized a resident was chewing on something and went to the Med Tech. The Med Tech called EMS who responded. Eric said he has already ordered new carts with a locking mechanism to prevent this incident from happening again. Eric later submitted the LIC 624 ( unusual incident report), LIC 602 (Physicians report), and hospital discharge paperwork. At time of visit, LPA reviewed the discharge paperwork from the hospital which stated ingestion of foreign substance. LPA requested to see the "Mop Pod." The cleaner is from Sysco called Reliance Floor Cleaner. The warning on the container under Warning states "dangerous gases (chlorine)." The pods are pink in color and approximately 1 by 1 inch. The following deficiencies were cited per Title 22 of the California Code of Regulation (See LIC 9099D or 809D). Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.