Incident investigation·September 20, 2024

On 9/20/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of following with case management regarding complaint investigation and incident involving resident (R1) and was greeted by Executive Director, Cleitus Jones. On 8/22/2024, R1 had been assisted onto the facility van for an appointment by staff (S1). It was found that the facility van wheelchair lift was not in proper electronic functioning order but is also equipped with a manual hand crank lever located inside the vehicle, that still provides lifting function in case of electronic failure. S1 stated that they assist residents into the wheelchair lift based on transportation practices for wheelchair assistance by placing residents facing forwards and outside the vehicle. During the event, S1 had properly loaded R1, facing forwards towards the outside of the vehicle while S1 had operated the manual lift from the inside of the vehicle. During the lifting process it was identified that R1 had sustained minor injury from falling forward from the wheelchair but not due to intent or neglect. During LPA observation of wheelchair lift, it appeared that the manual crank causes a jerking motion which was a potential factor in R1 moving forward and sustaining a fall from the lift with minor injury Based on interviews with staff, R1 was not equipped with a standard wheelchair device with larger rear wheels but instead equipped with a foldable wheelchair with a set of smaller swiveling wheels, with less or no leverage towards the back of the wheelchair. Although not due to intent or neglect, staff did not ensure that R1 was provided safe accommodations and equipment or additional support to prevent R1 from sustained injury. Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.