Incident investigation·June 30, 2023

On 629/2023 Licensing Program Analyst (LPA) Felisa Shirley conducted a Case Management visit to follow up on an incident report faxed to CCLD on 6/28/2023. LPA was greeted by Robin Owens, Resident Director. LPA spoke with Robin and explained the purpose of the visit was to gather information surrounding the incident with R1. The regional office received a copy of an incident report submitted by the facility on 6/28/2023 reporting that on 6/27/2023 Resident 1 (R1) attempted suicide. The incident report stated that on 6/27/2023 at 5:30pm a caregiver went to deliver resident dinner and found them on the floor of the room. First aid was applied and 911 was called. R1 was responsive and was transported to the hospital. LPA interviewed Administrator, S1 and S2. LPA requested and received copy of list of medications. The following documents were requested and not received during the visit as the forms were not accessible to Staff: ID and Emergency Informat ional Capability Assessment, Pre-Placement Appraisal. LPA did receive copy of list of medications. Please fax or email requested documentation to me asap. Deficiencies are being cited based on records review and interviews conducted in accordance with the California Code of Regulations, Title 22, Divisions 6 chapter 1, see LIC 809D. . An exit interview was conducted, Plans of Corrections were discussed and a copy of this report and appeals rights were and left with Staff, Robin Owens whose signature on this form confirms receipt of these documents.