Follow-up on corrections·April 11, 2023

At approximately 1:50PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Deficiencies visit and met with Executive Director, Susan Edwards, and Health and Wellness Director, Victoria Mozaffari. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). LPA also followed up with the facility regarding incidents that were verbally reported to CCL but not submitted to the Department in a timely manner. Incident Report 1/SOC-341: CCL received an SOC-341 report on 02/16/2023, and an incident report on 02/17/2023. The incident report states that on 02/14/2023, the facility was informed that Resident 1's (R1) Responsible Party reported a possible injury with bruising. Facility spoke with R1 and Responsible Party about the incident and suspended facility staff while an internal investigation was completed. Facility's internal investigation resulted in the facility conducting all staff training. Facility made all appropriate notifications per regulation. LPA discussed R1 with Executive Director. Per conversation with Executive Director, Local Law Enforcement came to investigate the incident, and determined that no criminal act had occurred. LPA received copies of the two in-service training sheets that were conducted for staff. Incident Report 2: CCL received an incident report on 03/20/2023. The report states that on 03/15/2023, Resident 2 (R2) was observed being brought back to the facility by a member of the community. Facility was informed by the individual that R2 was located at a nearby restaurant and that they assisted R2 back to the facility. Facility observed that R2's wander bracelet was removed from their wrist. Facility made all appropriate notifications per regulation. Continued on LIC809 Continued from LIC809 Per review of R2's LIC602/Physician's Report, R2 is not allowed to leave the facility unassisted or without facility supervision. Per conversation with Executive Director, R2 was able to leave the facility due to not having their wander bracelet on, and therefore did not trigger the facility's alarm system. Facility has had their alarm system inspected and has ensured that the system is in operating condition. As of today, 04/11/2023, Facility has relocated the wander bracelet to R2's ankle and they have not left the facility unassisted since. LPA also followed up on two Death Reports and two Incident Reports that were verbally reported to the Department but were not submitted in a timely manner. LPA requested to have the reports submitted on the following dates: 03/07/2023, 04/03/2023, 04/04/2023, and 04/05/2023. On 04/06/2023, LPA received one of the incident reports that had been requested. During today's visit, 04/11/2023, LPA received copies of the death reports and other incident report that had not been submitted. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. ***An immediate civil penalty in the amount of $1,000.00 has been issued for a repeat violation of the California Code of Regulations (CCRs) Section 87211. Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC421IM (Civil Penalty Assessment), LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.