Follow-up on corrections·June 1, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit to cite a deficiency. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Kimberly Finch-Dominy and Administrator Brooke Harris. Today's visit was in response to three (3) LIC624 Incident Reports which licensee self-submitted to the CCLD San Diego Regional Office (RO). During today’s visit, LPA briefly toured the facility, collected copies of records, and interviewed staff. Per the first LIC624: On 03/29/2023, Resident #1 (R1) fell at the facility. [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] Licensee sent R1 to the emergency room via 911, where R1 was diagnosed with an “avulsion fracture” on their left elbow. However, Licensee did not send a written report of the incident to CCLD until 05/04/2023. Per the second LIC624: On 03/30/2023, Licensee sent Resident #2 (R2) to the emergency room for a change in condition involving vomiting, diarrhea, fever, and decreased fluid intake. However, Licensee did not send a written report of the incident to CCLD until 05/04/2023. Per the third LIC624: On 04/02/2023, Licensee sent Resident #3 (R3) to the emergency room for a change in condition involving severe/pronounced weakness. R3 was subsequently diagnosed with “CHF exacerbation,” pneumonia, and sepsis, requiring antibiotic treatment and twenty-two (22) days of skilled nursing care. However, Licensee did not send a written report of the incident to CCLD until 05/04/2023. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] A preponderance of evidence exists to show that Licensee did not meet reporting requirements. A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Finch-Dominy and Harris, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.