Follow-up·March 6, 2024

On March 6, 2024, Licensing Program Analysts (LPA) Bethany Mirlohi and Talwinder Bains conducted a case management visit to follow up on a case management visit conducted at the facility on February 2, 2023. LPA Bethany Mirlohi and Talwinder Bains met with Tricia Diaz and explained the purpose of the visit. On February 2, 2023, the Department concluded an investigation from a self-reported incident that occurred where R1 sustained a fall at the facility on June 6, 2022, which resulted in R1s death at the hospital on the same day. R1’s death certificate indicates R1’s “Cause of Death” as Acute Subdural Hematoma with Shift, Mechanical Fall, Acute Respiratory Failure, and Acute Cardiac Arrest; and states R1 suffered an unwitnessed, ground level fall. The licensee was cited for California Code of Regulations (CCR), Title 22 Division 6, Chapter 8, § 87464(f)(1) states in part, “Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). At the time of the Case Management visit on February 2, 2023, an immediate civil penalty in the amount of $500 was issued, and the license was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49. Continuation on 809-C. The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced as facility management’s failure to reappraise R1 after R1 suffered five unwitnessed falls in a two-month period, the final fall resulting in R1’s death. The facility should have implemented enhanced care and supervision to mitigate the resident's risk of falls. Today, March 6, 2024, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(d) in the amount of $15,000 for a violation that the Department determines resulted in the death of a resident. However, since an immediate civil penalty of $500 was previously issued on February 2, 2023, the amount of the civil penalty issued today will be $14,500. A copy of the LIC 421D was given to the facility representative. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Tricia Diaz signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.