Incident investigation·June 13, 2024

On 6/13/24, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit regarding an incident report the Department received on 6/6/24. LPA met with Administrator Glenda Molinyawe and explained the purpose of the visit. The purpose of this case management visit is to follow up on an incident that occurred on 6/2/24. Per incident report, resident R1 started screaming after lunch and throwing everything R1 can get a hold of at staff. R1 was completely out of control; therefore, staff called the paramedic to bring R1 into Kaiser ER for evaluation. Incident report revealed that R1 is declining both mentally and physically. Staff reported R1 could no longer turns on their bed. The facility declined to accept R1 back from the hospital as R1 could no longer turns and is considered bedridden. During today’s visit, LPA Truong review records and interviewed staff. It was learned that staff noticed R1 was having a change in condition a week prior to hospitalization. R1 would scream day and night causing disturbance to other residents and to the neighbors. When staff asked why R1 was screaming, R1 said, they don’t know. Staff stated R1 is unable to turn or move on their own and mentally not cooperating with staff. The facility refused to accept R1 back to the facility due to change in R1’s mental condition and R1 is determined to be bedridden. Staff believes R1 needs a higher level of care and the facility doesn't have a fire clearance to retain a bedridden resident. No deficiencies were cited during today’s visit pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted and a copy of this report was left at the facility.