Routine inspection (multi-day)·September 4, 2024

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual continuation visit. LPA Valerio met with facility staff, and explained the purpose of the visit. LPA Valerio conducted the initial annual inspection on 08/12/2024. No deficiencies were cited during the visit. LPA Valerio toured the facility to ensure compliance with Title 22 regulations. No health, safety, or personal rights risk were observed. LPA Valerio reviewed six (6) resident files and three (3) staff files. Resident files were observed to be complete with required annual documentation and assessments. Staff files were observed to have required dementia, first aid, and annual training. During file review, LPA observed medication documentation showing that Resident 1 (R1) sustained a fall on 09/01/2024. The facility reported the fall to CCL on 09/04/2024 at 6:04 AM via fax. LPA obtained a copy of the fax transmission receipt. R1 fell at the dinning room after moving the wheelchair and leaning forward. R1 fell on face, resulting in a laceration, which required stitches. According to an interview with Administrator Elaine, Administrator and Facility Staff were on shift. Two residents were eating dinner at the dinning table. Administrator was walking back from getting a plate from Room 1 and facility staff was feeding resident in their room. Administrator was walking back and observed that resident moved the wheelchair and R1 was falling forward to the floor. Administrator tried to catch R1 but it was too late. Staff immediately contacted 911 and responsible party while Administrator assessed R1. Resident was transferred to the emergency department and returned the same evening. Technical Assistance was provided to Administrator Elaine. Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited. An exit interview was held, and a copy of the report was provided.