Office review·June 16, 2025

On June 16, 2025, an office meeting was held to discuss an incident that occurred on April 24, 2024, and the results of the subsequent Investigations Bureau (IB) investigation. In attendance were Regional Manager Alycia Rayner, Licensing Program Manager Troy Ordonez, Licensing Program Analyst Kayla Adkison, Licensee/Administrator Kristine Abejo, and Michael Goryan, Licensee's Consultant. On April 24, 2024, at approximately 0400 hours, a resident (R1) experienced a "slide" while in the presence of staff. Based on the Unusual Incident Report (UIR) , and the Department's interviews with staff and day program personnel, the resident reported pain and was observed with swelling, but emergency medical assistance was not sought immediately. On April 25, 2025, at approximately 0940 hours, the resident was sent to the medical clinic were x-rays were taken. As a result, at approximately 1146 hours the resident was transferred from the medical clinic, via ambulance, to the emergency room. Medical attention was delayed for nearly 29 hours, and the resident was ultimately diagnosed with fractures that required emergency surgery, physical therapy, and the resident suffered prolonged pain. This delay in care constitutes a failure to meet the requirements under Title 22, Section 87465(g), which mandates that 9-1-1 be called immediately when there is an imminent threat to a resident’s health . As a result of the resident’s injury and the facility’s failure to seek medical attention in a timely manner, the violation warrants an immediate civil penalty in the amount of $500, which is being issued today. At this time, the issuance of an additional civil penalty is still being determined and the Administrator has been informed that an additional civil penalty may be assessed, at a later date, based on Health and Safety Code §1569.49. CONTINUED ON LIC-809C. The licensee was encouraged to: -Review regulations on Restricted Healthcare Plans -Review regulations on Prohibited Healthcare Plans -Review when to call 9-1-1 -Update the facility’s policies and procedures for seeking timely medical attention. Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Signature on this report acknowledges receipt of these reports