Complaint·August 30, 2023

Licensing Program Analyst (LPA) Katie Brown arrived at the facility to deliver complaint investigation findings. LPA met with Administrator (AD) Heidi Setty. Resident (R1) fell resulting in a fracture requiring surgery on 5/1/23. Based on interview, it was confirmed that the facility did not conduct an assessment or obtain required updated documentation of R1’s changes in condition or care needs prior to return to the facility on 5/6/23. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents.