Incident investigation·December 6, 2024

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a follow-up case management – incident visit that was initiated on 05/29/2024. LPA met with Health Services Director, Jocelyne Bailon. On 05/25/2024, resident (R1) passed away at the facility and the cause of death was an accident. R1 had ligature strangulation in the setting of ethanol use. Based on R1’s evaluation report dated 11/30/2023, R1 had a history of substance use which may cause some interpersonal and/or health problems but does not significantly impair overall independent functioning. However, staff still had concerns about R1’s alcohol consumption and overall safety after drinking alcohol. Based on R1’s progress notes, R1 had multiple fall incidents from 2021 – 2024 resulting in injuries. Staff interviewed were aware that R1 was a fall risk, had multiple fall incidents and liked to drink alcohol. The review of R1’s assessment shows R1 was last re-assessed on 11/30/2023, even though R1 continued to be a fall risk and had multiple falls resulting in injuries after 11/30/2023. There was no reassessment completed after 11/30/2024. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty of $1000 is being assessed today for a repeat violation within 12 months. See LIC421IM. Failure to correct the deficiency may result in additional civil penalties. An additional Civil Penalty for a violation resulting in serious bodily injury of a resident is pending review. This report was reviewed with Health Services Director, Jocelyne Bailon and a copy of the report along with the appeal rights were provided.