Follow-up on corrections·January 28, 2025

On 1/28/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with caregiver. LPA and caregiver notified administrator Jae Kim, who arrived to assist. LPA had completed previous visits, on 1/2/25 and 1/8/25, regarding R1’s unexpected passing. On 12/1/24, the department received a death notification for R1's passing on 12/1/24. LPA conducted records reviews and interviews, the department and the county coroner, has concluded that R1 passed due to natural caused related to existing health conditions. During the review of this incident, the department observed the following deficiencies: On 12/1/24, S1 responded to R1’s fall. S1 allowed residents to physically move R1 to R1’s bed before emergency services assessed R1. S1 did not follow facility policy or 1 st aid training for a resident who had an unwitnessed fall. 87411(a) Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met bases on interviews and records that showed S1 did not demonstrate competency in performing 1 st aid to R1. This posed a potential risk to the resident. During the investigation of this incident it was found that Administrator destroyed R1’s unused medication without recording the medication destruction. An advisory was issued for this deficiency. R1’s family arrived when notified that R1 had died. The family member observed S1 take a photograph or R1 and send the photo to a staff who had previously worked at the facility and knew R1 well. 87468.2 (a)(1) Additional Personal Rights of Residents in Privately Operated Facilities (a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations… This requirement was not met based on statements that S1 photographed and shared a photo of R1 without consent. This posed a potential risk to R1’s personal rights. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights provided.