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Inspection visit

complaint

MAMA ANGELINA COCONOCHOLicense 331880980
Clean visit · 0 citations

Inspector’s narrative

What the inspector wrote

These additional interviews/hospital records additionally confirm that R1 had left the facility through their bedroom window. Since evidence supports the Administrator's recollection of the event, the circumstances surrounding the elopement do not suggest a lack of supervision by staff, as R1 exited through a window (which is low in the wall and is feasible for R1 to have exited from) in their bedroom during a brief period of time where staff did not have line of sight on R1, and it was normal for R1 to be in their private bedroom at this time. Additionally, R1 had no prior elopements from the facility in the last two years since admission. R1's elopement from the facility was unusual in R1's established behavior at the facility as well as the method used to exit the premises. Therefore, based on interviews, observations, and hospital records, the allegation " Lack of supervision resulting in resident leaving the facility" is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Administrator Maria Gonzalez and a copy of this report was provided.

Citations

6 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87203Type A

    Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above regulation with at least one area of the facility. LPA Colvin observed that the front door was locked with a deadbolt that is only able to be unlocked with a key. This is an immediate safety risk to residents in care.

  • 87211(a)(1)(D)Type A

    Reporting Requirements: (a) Each licensee shall furnish...reports...including... the following: (1) A written report shall be submitted ...within seven days of...(D) Any incident which threatens the welfare, safety or health of any resident, such as... unexplained absence of any resident. This was not met by: Based on record review, the Licensee did not comply with the above regulation with at least one occurance. LPA Colvin confirmed that no report was submitted for R1's elopment from the facility on 7/4/22. This is an immediate safety risk of all residents, as the facility has never submitted a report to Licensing.

  • 87307(a)(3)(B)Type B

    Personal Accommodations and Services: (a) Living accommodations...shall be related to the facility's function...The following provisions shall apply: (3) Equipment and supplies necessary...licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident...a lamp, or lights sufficient for reading... This requirement was not met by: Based on observation, the License did not comply with the above regulation with one resident. LPA Colvin observed no operational light source in R1's room other than the bedroom window. This is a potential personal rights violation of R1.

  • 87468.1(a)(11)Type B

    Personal Rights of Residents in All Facilities: (a) Residents...have all of the following personal rights: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours... This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above regulation. LPA Colvin observed Visitor Hours posted outside the facility which were unreasonably restrictive. Additionally, the posted hours are not what is reflected in the facility's Admissions Agreement. This is a potential personal rights violation of all residents.

  • 87705(c)(5)Type B

    Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with at least on resident. LPA Colvin observed that R1's most recent Physician's Report is dated 6/11/21. R1 is diagnosed with Dementia. This is a potential health and safety risk to R1.

  • 87705(j)Type A

    Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based on observation, the Licensee did not comply with the above regulation with two exit doors. LPA Colvin observed both the front door and back door of the facility to have their auditory alarms turned off. LPA Colvin also tested the doors to confirm. This is an immediate safety risk to Dementia residents.

FAQ · About this visit

Common questions about this visit

What happened during the July 22, 2022 inspection of MAMA ANGELINA COCONOCHO?

This was a complaint inspection of MAMA ANGELINA COCONOCHO on July 22, 2022. The inspection found no deficiencies and no citations were issued.

Were any citations issued to MAMA ANGELINA COCONOCHO on July 22, 2022?

No citations were issued during this inspection. The facility was found to be in compliance with all applicable regulations.

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.