complaint·August 15, 2025

LIC 9099 C On May 30, 2025, at approximately 5:53 PM, emergency medical services was contacted when staff (S1) found resident (R1) outside on the ground in the courtyard of the facility, R1 was then transported to Mercy Hospital of Folsom Emergency Room for evaluation. According to hospital paperwo rk, it revealed R1 was admitted with temperature of 39.1* C (converting to 102.4* F) and "hot to the touch". R1 was discharged at approximately 9:25 PM on May 30, 2025 with reasons for visit to be "heat exposure" due t o " the patient had a heat exposure incident related to his care home losing track of him during a fire drill" and discharge diagnosis of heat exposure, dementia, dehydration, and acute kidney injury. Statements gathered on June 4, 2025, it revealed a fire drill was conducted at approximately 3:00 PM on May 30, 2025, where all emergency exits where released opened. It was revealed that part of the fire drill protocol is for caregivers to conduct a head count on their assigned residents to ensure all residents are accounted for at the end. Additionally, caregivers are to conduct hourly observations on the residents. Interview conducted with staff (S2) revealed that as a caregiver, S2 is responsible for conducting a head count of the residents, checking to see if the residents are wet and need to be changed, giving the residents showers, participating in activities, transporting the residents to their meals, and getting the residents up for the day or getting them ready to go to bed. Interview indicated a resident head count after the fire drill was not conducted. S2 admitted to losing track of R1 and did not realized R1 was missing until close to dinner time. Staff (S3) then located R1 outside after 5:00 PM. Based on information obtained, the Department finds the allegation to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty in the amount of $500.00 assessed for R1 sustaining injury and/or illness due to staff's neglect. As a result of the resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess an additional civil penalty if warranted. Deficiencies cited on the attached LIC 9099-D. An exit interview was conducted, a copy of the report and appeal rights provided.