Incident investigation·July 11, 2022

On 07/11/22 at 10:18 AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving self-reported incident dated 06/08/22 submitted to CCLD regarding resident sustained injury while was transporting to a designation on the community bus. LPA explained the purpose of the visit with administrator (ADM). ADM admitted the incident was occurred by a staff member careless. The investigation was determined that the wheelchair strap to the right-side wheel was not properly secured, the buckle fell off when bus driver made a turn, which caused wheelchair to tip over left side resulting resident to fall. Resident was transported to John Muir hospital and diagnosed injury of left shoulder and strain of neck muscle. LPA obtained resident physician's report, care notes, and in-services training record during visit. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809 D. Failure to submit proofs of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in additional civil penalties . Immediately Civil Penalties $500 is assessed today. Exit interview conducted with ADM. Appeal Rights and a copy of this report provided.