Follow-up on corrections·June 18, 2024

Licensing Program Analyst (LPA) Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240611160853. LPA met with Staff #1 (S1) who granted access to facility. The Administrator Designee was contacted and LPA explained the reason for the visit. During the visit, LPA was informed that on 03/30/2024, R1 had inflammation of the skin around the right foot toenails and R1 was taken to the hospital. On 04/29/2024, R1 was taken to the hospital again for the inflammation of the skin around the right foot toenails. Additionally, on 05/09/2024, R1 was taken to the hospital for the inflammation of the toenail not getting better and R1 being in pain. However, no incident reports were submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe any Incident Reports regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. LPA informed the Administrator to submit an incident reports that occurred on or before : 03/30/24, 04/29/2024, and 05/09/2024 (three incidents) Per the California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered.