Incident investigation·August 3, 2021

Licensing Program Analyst (LPA) Konnor Leitzell arrived at facility to conduct a Case Management Visit. Community Care Licensing (CCL) received an Incident Report (LIC 624) and Report or Suspected Dependent Adult/Elder Abuse (SOC 341) from facility regarding Resident's recent trip to the ER. Prior to initiating the case manage inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted Admin and completed a facility risk assessment, and was sure to apply hand sanitizer prior to entry. Upon entry, LPA was screened and greeted by Ashley Steele (Admin Assistant). LPA then explained the purpose for the visit to admin. During visit, LPA conducted interviews with Jennifer Scarberry (Admin); Officer Limon (Folsom County Police); Staff 1; Staff 2; Staff 3; and Resident. Interviews documented on LIC812's. LPA toured the dining area, kitchen, and Resident's personal room.LPA is requesting the following documents to be submitted to CCL via email at konnor.leitzell@dss.ca.gov or via fax at (916) 263-4744 by COB 8/13/2021: Residents Admission Agreement; LIC602; Charting Notes from move in to current; and discharge papers from recent hospital visits. No deficiencies are being cited as a result of today’s visit. Exit interview conducted and report left at facility.