Incident investigation·September 13, 2022

Licensing Program Analyst (LPA) A. Canela arrived unannounced to conduct a Case-Management - Incident visit, and met with assistant Administrator, Maria Buna. The purpose of the visit was to follow up on a self-reported incidents submitted to Community Care Licensing (CCL). CCL received a call from Licensee and several self-reported incident reports regarding resident R1. Reports submitted include incident dated 7/27/2022 where resident R1 went to an area of the yard that is not paved using their motorized wheelchair and sustained a fall. R1 was sent to emergency Kaiser Vallejo for a skin tear. Facility expressed the area where R1 fell, is a dirt area where the facility has some trees planted and the residents have the entire surrounding wooden deck and paved area to use. Facility placed a wood board to prevent R1 in going to that area of the yard. On 8/17/2022 R1 sustained another fall, fire department assisted and R1 refused to go to the hospital. On 8/22/2022 R1 sustained another fall, fire department assisted in lifting and R1 refused medical treatment. On 8/26/22 and additional incident report was submitted, reporting R1 used their electric chair and was in the inside of the facility by the front gate, when their chair got stuck, staff S1 stated to LPA, R1 got up and attempted to walk and fell. Staff S1 rushed out to help but when S1 got there, R1 was already on the floor. R1 complained of right pain, facility called 911, fire department and ambulance arrived and R1 was sent to the hospital. It was reported R1 sustained a hip fractured and required surgery. R1 was sent to a skilled nursing facility and facility expressed they will not be able to meet the current needs of the resident as they have changed and R1 requires a higher level of care and a 30 day eviction is in the process. LPA will review information, no citations issued at this time.