Incident investigation·July 6, 2023

At approximately 1:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit and met with Administrator/Executive Director, Corrine Tanchoco. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 05/11/2023. Report states that on 05/10/2023, Resident 1 (R1) was found on the floor by Care Staff. R1 was observed to have a bump on their head and was bleeding. Facility contacted Emergency Personnel and R1 was transported to the hospital to be evaluated. Facility made all appropriate notifications per regulation. LPA and Executive Director discussed R1. LPA was informed that R1 was sent to stay at a Skilled Nursing Facility for Physical/Occupational Therapy due to their fall. Facility was in communication with R1, R1's Responsible Party, and Physician during R1's stay at the Skilled Nursing Facility. While R1 was at the Skilled Nursing Facility, R1's Responsible Party decided to relocate them to a Board and Care. As of today, 07/06/2023, R1 has been moved out. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC 811 (Confidential Names), discussed and provided to Administrator. Signature on form confirms receipt of documents.