Follow-up·October 18, 2023

On October 18, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on a substantiated complaint number: 14-AS-20190327094949, regarding an allegation that staff failed to provide care, supervision, and services to meet the needs of Resident 1(R1) resulting in R1 sustaining multiple injuries. LPA met with Administrator, Scott Evans and explained the purpose of the visit. On November 26, 2019, the Department concluded a complaint investigation and the allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § “87468.2(a)(4)” Additional Personal Rights of Residents in Privately Operated Facilities for facility failing to provide care, supervision and services that met R1's needs that resulted in R1 sustaining serious bodily injury. The investigation revealed that the plan of care for R1 was not individualized to tailor fit R1’s needs. Furthermore, R1’s hospitalization dated January 16, 2018, indicated R1 has a diagnosis of gait disorder and the physical therapist (PT) assessment notes dated March 1, 2018, identified R1 as high-risk for falls. The facility did not reassess the resident to develop a plan of care to meet R1’s needs. R1 had three separate incidents at the facility. On April 26, 2018, R1 was found on the floor and sustained a large skin tear to the left arm. On August 9, 2018, R1 stood up, fell on the floor, and sustained a fracture to the right hip. R1 was hospitalized and had surgery for a right hip fracture. Per document review and Administrator interview, there was insufficient staffing with only one staff on duty and that staff was assisting another client when R1 had the first two falls. The third incident was discovered when R1 was noted with back and leg pain on October 4, 2018. R1 continued to report pain during the night and continued to the next day. On October 5, 2018, around 2:00 p.m., R1 was reported to be in severe pain, and staff called R1’s family member and informed them the facility would call an ambulance to transfer R1 to the ER for evaluation. Two hours later at 4:00 p.m., the facility called an ambulance to transfer R1 to the ER. R1 was taken to the ER and R1 was diagnosed with a compression fracture in their back and a left hip fracture. (CONT. TO 809C) Based on interviews and record review, the facility was aware of R1’s risk for falls. However, the facility did not reassess R1 to update R1’s plan of care. The facility failed to reassess R1’s plan of care after the falls on April 26, 2018, and August 9, 2018. At the time of the complaint visit, on November 26, 2019, an immediate civil penalty of $500 was issued. The licensee was informed that an additional civil penalty was being determined and might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that an additional civil penalty is warranted for a violation that resulted in R1 sustaining serious bodily injuries while under the care of this facility. Welfare and Institutions Code § 15610.67, defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the licensee failing to provide proper care, supervision and services, which resulted in R1 sustaining multiple falls and injuries, that included a left hip fracture and a right hip fracture, which are serious bodily injuries. Today, October 18, 2023, the Department is issuing a civil penalty per Health and Safety Code 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000.00. However, since an immediate civil penalty of $500.00 was previously issued on November 26, 2019, the amount of the civil penalty issued today will be $9,500.00. A copy of the LIC 421D was given to Administrator, Scott Evans and originals were signed. Exit interview conducted with Administrator. A copy of the report issued. Appeal Rights provided. Administrator, Scott Evans signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.