Follow-up on corrections·April 25, 2023

Licensing Program Analyst (LPA) Rebecca Ruiz conducted a complaint investigation visit where an unrelated deficiency was discovered. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Stefanie Ancheta. During the unrelated complaint investigation, LPA Ruiz conducted interviews and records review, which revealed that an incident report was not submitted to the Department regarding an incident that occurred in January 2023, where Resident 1 (R1) had fallen resulting in no injuries and 911 was contacted to assess R1's condition. Review of the facility's incident reports submitted to the Department did not show an incident report for the fall in January 2023. Interviews with the Executive Director confirmed that any incidents, including falls, that do not result in an injury are not reported to the Department. Per California Code of Regulations Title 22, the following deficiency is cited on the attached LIC809-D page. An exit interview was conducted with Executive Director Stefanie Ancheta, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.