Incident investigation·August 1, 2024

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Director of Resident Care Services, Dana Malengo. The purpose of the visit is to address incident reports and death reports that are submitted late to the Department from April 1, 2024 – July 25, 2024. The facility file for incident reports was reviewed. Based on review, between April 1, 2024 – July 25, 2024, the facility submitted 15 late incident reports and 4 late death reports to the Department. The incident reports and death reports were reported more than 7 days after the occurrence date. Based on interview, the Executive Director is the only person who is submitting the incident reports and/or death reports to Licensing. The ED states the incident reports and death reports are sometimes late when ED is not in the community. By the time the ED returns to the community is when the incident reports are submitted to Licensing. ED states a plan to ensure incidents and death reports are submitted within Title 22 reporting requirements. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Resident Care Services, Dana Malengo and a copy of the report and appeal right were provided.