Incident investigation·August 30, 2024

On 08/30/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident visit. LPA met with business office manager Jovy Castro and explained the purpose of today's investigation. During today's visit LPA toured chemical storage areas, observed the custodial cleaning cart, and conducted interviews. It was verbally reported to the Department's regional office in San Bruno on 08/29/2024 that a resident was found with a bottle of cleaning solution in her room. A staff person passing by the room during a resident activity observed the resident holding the spray bottle of Windex with the top spray nozzle/cap off, holding the bottle of cleaning solution and the spray nozzle in each hand. The staff person immediately retrieved the bottle from the resident and reported observations and the situation to management. Per examination of the Windex bottle it was found that there was Fabuloso cleaning solution inside the bottle, not Windex. Management staff called 911 and the resident was evaluated on site. Based on emergency responders evaluation, they recommended to not send the resident to the emergency department as the resident appeared normal and baseline. The facility contacted the power of attorney for the resident and they too agreed to not send the resident to the emergency department. Resident is on increased supervision for 72 hours as a safety precaution due to health concerns. Per interviews conducted today the resident has been eating normally and acting normally since the incident with no indications of distress. Based on interviews conducted today, cleaning staff at the facility forgot the cleaning solution in the room after cleaning and the resident was able to access the cleaning solution forgotten in their room. Staff observed the solution on the face of the resident around or near the lips, on the cheek, and on the glasses of the resident, the facility failed to keep cleaning solutions inaccessible to residents in care which poses an immediate health and safety risk. Deficiencies are cited in accordance with California Code of Regulations Title 22 and is noted on attached LIC809D. Additional citations or penalties may be issued. LPA reviewed the report with business office manager Jovy Castro and a copy is provided.