Incident investigation·August 10, 2023

Citations

2 citations recorded^*CCLD

• 87411(a)Type A

  Facility personnel sufficiency and competence

  Personnel Requirements - 22 CCR Section 87411(a): "Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. ... The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services."This requirement was not met as evidenced by: Based on interviews and document review, R1 and R2 were permitted to leave the facility without assistance, which poses an immediate health and safety risk.

• 87211(a)(1)(D)Type B

  Reporting Requirements 22 CCR Section 87211(a)(1)(D): "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident."This requirement was not met as evidenced by: Based on interviews and record review conducted during a complaint investigation, no incident reports were sent for R1 and R2's unauthorized absences, which poses a potential health and safety risk.

  Read full inspector narrative