Incident investigation·July 19, 2022

On July 19, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that was reported to CCLD. LPA met with Interim Administrator, Robert Snee and Director of Resident and Family Services, Kate Rickard and explained the purpose of the visit. The Licensee reported on July 15, 2022, Resident #1 (R1) was observed by a caregiver laying besides Resident #2 (R2), who was fully clothed and sleeping during the time. Caregiver immediately redirected R1 and called for additional help. During the case management visit, LPA observed R1 eating lunch in the dining room with his/her private caregiver. In addition, during the visit, LPA interviewed staff and reviewed R1's file. According to R1's file reviewed, R1 has a diagnosis of dementia. Interviewed staff indicated that a private caregiver was assigned to R1, and R1 will have a full work up conducted on 7/20/22 by R1's primary care physician. It was also indicated that R1's medications will be adjusted. This is the second unusual behavior involving R1, as the other incident occurred on 5/26/22, where R1 was found in a female resident's room. (see LIC809 dated 6/16/2022). Due to staff's lack of supervision, R1 a dementia resident, was able to walk into R2's room and lay besides him/her. Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. Report is reviewed with Interim Administrator, Robert Snee and a copy is provided with the appeals rights.