Incident investigation·March 6, 2025

Licensing Program Analyst (LPA) Fred Arias made an unannounced case management visit to follow-up on an Unusual/ Special Incident Report (SIR) received in our Regional Office on February 20, 2025. LPA was greeted and granted entry by staff. LPA met with Health Services Director (HSD) Deisi Lujan-Ramirez, Executive Director (ED) Selene Lopez and Assistant Executive Director Maggie Pantaleon and explained the purpose of the visit. LPA obtained the following for review: Appraisal dated 2/1/2025, Service Agreement, and Needs and Services plan for Resident 1 (R1). Facility had already provided a physician's report and additional appraisals dated 1/9/2025 and 2/18/2025 prior to the visit. HSD explained the details of the incident and reviewed the facility protocols for high fall risk residents. R1 had been placed in hospice care on 1/31/2025, prior to the incident and was reported to our Regional Office by fax. LPA interviewed three staff members who were familiar with the resident. Staff members stated that resident was checked on approximately every two hours or more often in cases when R1 pressed their pendant. Pendant activation is logged into the facility's internal online systems. During the month of the incident, the resident was checked on at an average of 10-15 times per day. At the time of the incident, the resident's pendant was pressed and a staff member was at their unit in less than 3 minutes. Based on the observations, record review and interviews made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted and a copy of this report was given to the facility representative.