Follow-up·June 26, 2024

Licensing Program Analyst, Natasha Persaud arrived on June 26, 2024 for an unannounced case management visit to follow-up on a substantiated case management investigation. LPA met with Rocio Granda , Administrator and reviewed the report. On November 12, 2020, the Department concluded a case management investigation into the questionable death of a resident in care. The licensee was found culpable of negligence for not providing needed care and supervision to R1 and was cited for a Type A deficiency under California Code of Regulations Title 22 (22 CCR), § 87705(c)(5)(A) Care of Persons with Dementia, which states in part, “When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident." The investigation revealed that on April 6, 2020, a resident (R1) returned to the facility from a skilled nursing facility after hip surgery due to a fall. R1’s physician’s report dated March 9, 2019, evaluated R1 with a primary diagnosis of a major neurocognitive disorder characterized as “dementia with agitation.” Medical records dated April 6, 2020, documented R1 as a fall risk with a history of repeated falls, and indicated R1 now required a higher level of supervision and care. Multiple staff interview statements confirmed they were aware of R1’s increased weakness and nausea, and an unwitnessed fall that had occurred earlier the same day. Staff (S1) acknowledged they read a communication log that documented R1’s need for increased supervision and contact guard, touching and steadying assistance during toileting. However, S1 admitted that they left R1 alone and unattended on the toilet, then returned several minutes later and found R1 lying on the bathroom floor unresponsive and pale. R1’s head and upper body were in the shower area, while their legs were near the base of the toilet. Staff called 911 and paramedics pronounced R1’s death at the scene. The death certificate documented the immediate cause of death as traumatic brain injury due to R1 striking their head during a fall. Continued on an LIC 809C. At the time of the case management visit on November 12, 2020, the licensee was informed that a civil penalty might be assessed based on Health and Safety (HSC) §1569.49. The Department has concluded an analysis and has determined that a civil penalty per HSC §1569.49(e) in the amount of $15,000 is warranted for a violation that resulted in the death of R1 while under the care of this facility. This is evidenced by the facility’s neglect and lack of supervision which led to R1’s fall, directly resulting in the resident’s death. Today June, 26, 202 4 , the Department will be issuing a civil penalty per Health and Safety Code 1569.49(e) in the amount of $15,000 for a violation that resulted in the death of a resident. A copy of the LIC 421D form was given to Administrator, Rocio Granda and originals were signed. An exit interview was conducted, a copy of this report was issued, and appeal rights were provided. Administrator, Rocio Granda signature on this report acknowledges receipt of the appeal rights, found on page two of the LIC 421D.