Follow-up·March 29, 2022

On 3/29/2022, Licensing Program Analysts (LPA) Murial Han conducted an unannounced case management visit to follow-up on a complaint investigation. LPA Han met and explained the purpose of the visit with the assistant administrator, Siobhan Surracao while the administrator, Freddie Fullon was busy at the moment then the administrator took over and assisted with the rest of the visit. The Department investigated allegations under complaint # 14-AS-20210913142555, regarding a resident sustaining a fracture while in care; facility refusing to accept resident back to the facility; and facility failing to report/provide information to the injured resident’s family. During the course of investigating the allegation of the resident sustaining a fracture while in care, there was a caregiver (identified as S1 in complaint 14-AS-20210913142555) who was with the resident #1 (R1) prior to the resident being removed by emergency personnel. Upon arrival to the hospital, R1 was found to be suffering of a right shoulder fracture, spleen laceration, and left buttocks bruising consistent with traumatic injuries. S1 has failed to cooperate with the Department investigation. During the course of investigating the allegation, the department asked the administrator to provide camera footage to the Department to determine who was with the resident when the paramedics arrived, and who could had been present before removal of the resident by the paramedics. The administrator failed to provide the actual footage despite numerous requests to do so. A resident went to the hospital early in the morning of 8/31/2021. After a stay at the hospital for couple of weeks, the resident was discharged back to the facility on 9/9/2021. According to the administrator and the resident service director, R1 was readmitted with health conditions and needs that were not previously required and the facility was not capable of caring for R1 under these new health conditions. Therefore, the administrator gave R1, as only options, to stay as long as R1’s responsible party hire a personal skill professional to care for the resident, or to have R1 transferred back via ambulance to the hospital. The administrator illegally evicted a resident when failing to follow Section 87224. The licensee failed to reappraise a resident before admitting him/her back from a hospital stay; then, upon readmission, the resident was cursorily deemed beyond the level of care (without a formal appraisal) and sent back to the hospital. The facility has been cited on a LIC 9099D under complaint number 14-AS-20210913142555. A resident had a change of condition during the night of 8/30/2021 and early hours of 8/31/2021. The facility had failed to update the resident’s emergency card, so the notification of the resident’s condition went to a contact person out of State, and who unable to respond to the resident’s situation and in so doing violating Section 87468.1 (a) (8) Personal Rights of Residents in All Facilities. The facility has been cited on a LIC 9099D under complaint number 14-AS-20210913142555. Given the above information the facility is cited under: · 87755 (b) Inspection Authority of the Licensing Agency - The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility. · 87755 (c) Inspection Authority of the Licensing Agency - The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed, if necessary, for copying. · 87405 (d) (2) Administrator - Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to the applicable laws, rules and regulations. · 87411 (a) Personnel Requirements – General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs . In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. Based on interviews and record reviews during the investigation, deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the administrator. A copy is provided.