complaint·February 10, 2023

At approximately 08:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegation. LPA met with Executive Nurse Teresa Oliveri, reviewed records and interviewed staff. LPA received copies of documents. Based on a record review, Resident 1, R1, has been declining in health for several months. Records indicate R1 had several falls from December through the end of January and there were no documented changes to the care plan. LPA found documentation showing an alert status for R1 but no further instruction for staff to follow. LPA was not able to associate the falls with a lack of staff, however, there were no updated services plans or appraisals for staff to follow to ensure residents needs were met. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Teresa Oliveri and Appeal rights were given.