Incident investigation·October 17, 2024

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Paula Digerness Today's visit was in response to an LIC624 Incident Report, which licensee self submitted to the CCLD San Diego Regional Office. According to the LIC624: on 10/08/24, Resident 1 (R1) [See LIC 811 Confidential Names List for a description of R1.] was diagnosed with a closed compression fracture of L5.  LPA Domingo reviewed an incident report filed on 10/03/24 by Tamara Movsisyan RN that addressed R1's initial fall.  R1 was sent out to the hospital for an evaluation on 10/1/24 due to the fall.  R1's Primary Care Physician was notified. R1's family members were also notified. When R1 returned to the facility the staff followed up with a fall assessment and an increase in level of care due to the fall.  On 10/8/24 R1's primary care physician provided a status post hospital visit follow up and determined that R1 needed to return to the hospital for further evaluation. The facility has followed up on R1's fall and is following the facility protocol on falls. LPA briefly toured the facility, performed a welfare check on residents in care, interviewed staff, and obtained copies of pertinent facility records. No immediate health or safety risks were observed and no deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22)  were left with the Executive Director, whose signature on this form confirms receipt of these documents.