Incident investigation·January 2, 2025

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on December 24, 2024, regarding Resident #1 (R1). LPA met with Staff #1 (S1) Michelle Kwak and explained the purpose of the inspection. Administrator (AD) Tammy Joo arrived during the inspection. During the inspection, LPA and AD toured the facility. LPA conducted health and safety checks on R1 and the other residents present and confirmed they were doing well and observed no health and safety issues. LPA interviewed AD, R1, and witnesses, and requested and reviewed copies of the resident roster, staff roster, an Incident Report received December 24, 2024, R1’s Physician’s Report dated June 21, 2024, and R1’s Appraisal dated January 02, 2025. The investigation into the incident revealed the following. Per interview with AD and an Incident Report received December 24, 2024, on December 17, 2024, R1 was diagnosed with a fractured clavicle after an unwitnessed fall at the facility. Interviews with AD and a witness and review of R1’s Physician’s Report dated June 21, 2024, revealed that on June 21, 2024, R1 was readmitted to the facility after receiving treatment at a skilled nursing facility for a stroke and had fall risks related to the stroke. Per AD and a witness, the facility and R1’s family created a fall prevention plan around June 21, 2024, to address R1’s fall risks related to the stroke which included moving R1’s room to the first floor and more frequent checks, private one-on-one caregivers, and furniture and equipment in R1’s room to address possible falls. AD and the witness also stated that after R1’s fall on December 17, 2024, the facility and R1’s family updated R1’s fall prevention plan to include additional private one-on-one caregivers and additional alterations to furniture and equipment in R1’s room to address possible falls. Per R1’s Appraisal dated January 02, 2025, the facility properly reassessed R1 after R1’s change in condition relating to the fall on December 17, 2024. However, AD admitted that R1’s Appraisal was not updated in writing after R1’s readmission on June 21, 2024 to document the fall prevention plan put in place to address R1’s change in condition and fall risks related to the stroke. Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.