Follow-up on corrections·April 17, 2025

Licensing Program Analysts (LPAs) Kimberly Viarella and Sommer Hayes arrived on 04/17/25 for an unannounced inspection to follow up on a substantiated complaint investigation. LPA Viarella met with facility administrator Danielle Barry and explained the purpose of the visit. On July 1, 2024, the Department concluded a complaint investigation regarding the following allegations: resident fell sustaining fractures due to staff neglect, staff did not seek medical attention for resident, staff did not notify resident’s authorized representative of incident, and staff are not meeting a resident’s hygiene needs. The licensee was cited for California Code of Regulations (CCR) 87468.1(a)(2) Personal Rights of Residents in All Facilities, 87465(g) Incidental Medical and Dental Care, and 87211(a)(1)(B) Reporting Requirements, and 87464(f)(4) Basic Services. At the time of the complaint visit on July 1, 2024, substantiated findings were delivered to the facility.  On September 5, 2024, this report was amended to include issuance of an immediate civil penalty in the amount of $500 and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code Section 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or a mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”  This is evidenced by the administrator not providing R1 with an updated needs and services plan to address their risk status due to multiple falls, to include increased observation of R1, fall prevention measures and implementing a fall prevention plan. As a result, R1 suffered a fall which resulted in multiple fractures. A subsequent fall occurred where R1 fell and reopened the surgical site and was not sent out for a medical assessment until the following day. Today, April, 17, 2025, the Department will be issuing a civil penalty per Health and Safety Code Section 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously assessed on September 5, 2024, the amount of the civil penalty assessed today will be $9,500. Exit interview conducted. A copy of this report and the LIC 421D were signed and given to Danielle Barry.  Appeal rights were provided. Barry’s signature on this report acknowledges receipt of the appeal rights, which are found on page two of the LIC 421D.