Incident investigation·January 17, 2023

On 1/17/2023 Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced case management visit to the above facility. LPA met with Manager, Ilana Yazdi and Administrator Lida Zarafshan and explained the purpose of today’s visit was to conduct case management for the incident that occurred on 1/15/2023. LPA and Manager, Ilana Yazdi toured the physical plant to ensure no health and safety risks were present. The following documents were requested: Facility Roster, Staff Roster Public Health Inspection Report and R#1-R#6; Identification and Emergency Information, Admission Agreement, Physician Report for Community Care Facilities, Appraisal/Needs and Services Plan and Unusual Incident/Injury Reports. LPA observed room #226 had fire damaged other rooms were not effected by the fire. Resident in room #226 was relocated due to fire damage in room. Residents in rooms #206, #216, #222, #222, #216 and #228 were relocated (vacant rooms) for one(1) night to remove water delivered by automatic sprinklers in the facility. Resident in room #210 was relocated due to health assessment. No deficiencies cited, exit interview was conducted, a copy of this report is being provided to Administrator, Lida Zarafshan.