complaint·January 4, 2023

On the allegation that facility ‘Staff did not report incidents to the department in a timely manner’, the complainant’s concern is that the facility staff are not submitting Special Incidents Report(SIR’s) to reporting agencies or to residents’ responsible parties in a timely manner, and sometimes staff do not report incidents at all. To investigate this allegation, on 09/30/2020, LPA Basili interviewed Staff #1(S1). Per the interview, S1 stated, ‘That sometimes they have had a difficult time faxing / emailing any documents to numerous agencies. They have had to sit by the fax or wait by the computer while on the phone with any individual to confirm they have received the document. They would not be surprised if there is someone that is missing documents, that they believed they had sent out; however, they do keep all the hard copies on file’. On 01/03/2023, LPA Urena conducted a record review. The record review revealed that the licensee had three Incident Reports (SIR’s) drafted regarding incidents, which occurred on the following dates: 9/17/2020 for Seizure; 09/23/2020 for Psych Evaluation, and 09/24/2020 for Psych Evaluation. However, the licensee did not submit the drafted incident reports to CCLD as verified on the CCLD’s electronic filing system by LPA Urena on 01/03/2023. During today's visit the LPAs spoke with S2 about two current positive cases of COVID at the facility which occurred on 12/25/2022, and 12/28/2022. According to the administrator, and the receptionist both cases were reported to the CCLD, however, only one case was received at the CCLD office via fax on 12/29/2022. Based on the information obtained, there is sufficient evidence to support the claim that ‘Staff did not report incidents to the department in a timely manner’. Therefore, this allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Citations were issued. Exit interview conducted. A copy of the report and appeal rights were provided.