Incident investigation·November 1, 2022

Licensing Program Analyst (LPA) Jamie Ivey Canady and Licensing Program Manager (LPM) Stephen Richardson arrived to the facility unannounced and met with Deborah Gagle and explained the reason for the visit. On 10/25/2022, Community Care Licensing (CCL) received a SOC341 regarding possible neglect. LPA Ivey Canady requested and received a copy of Resident 1 (R1) resident file. R1 has been at the facility for 4 weeks. According to Staff 1 (S1), R1 had a seizure due to low magnesium and was sent to the hospital. When R1 was returned to the facility, it was determined by R1 family and facility LVN that R1 needs a higher level of care. Based on that decision, the facility is working with Star Agency in regards to facilitating a new placement facility for R1. S1 stated R1 placement was represented at a lower level of care that R1 actually needs. Therefore the need for R1 replacement to a different facility is justified. According to further investigation, R1 suffered a seizure on 10/18/2022. CCL was not notified via incident report of the occurrence. LPA Ivey Canady received a copy of the incident report during this unannounced visit on 11/1/2022. During facility visit it was discovered current designated person in charge of the facility is fingerprint cleared but not associated to this facility. The identification number was provided to human resources at the time of hire. Based on this discovery current person in charge was removed from staff schedule as of 11/01/2022 and deficiencies cited. Civil penalties will be assessed. Per California Code of Regulations, Title 22, Division 6, Chapter 8, . An exit interview was held, and due to printer malfunction a copy of the report and appeal rights were emailed to Deborah Gagle.