Follow-up·December 26, 2024

On December 26, 2024, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced visit for the purpose of discussing incident reporting. On December 21, 2024, Community Care Licensing received an incident report from AAA Residential Elderly Retreat. The report was regarding an incident with a resident (R1) who had an episode at the day program and was sent to the ER on 12/10/2024. The report indicates that it was called into the CCL phone line on 12/11/2024 providing an initial notification to be followed up with a submitted physical report. LPA discussed with Administrator, Alexis Bell (AB) , the need to submit reports within seven day per regulation. AB indicated that she faxed the report in as usual and on time however she did not notice until four days later that she did not get a confirmation notice and the report was now late. AB indicated that she will pay closer attention to the confirmation notice and ensure that reports are sent in timely. No citation issued at today's visit. Below is the regulation regarding reporting requirements: 80061 Reporting Requirements (a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section. (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following (D) Any injury to any client which requires medical treatment.