Incident investigation·November 8, 2022

Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting a case management and met with facility Administrator, Charito Santos. LPA is following up on a self-incident report filed by the facility Administrator to CCL on 11/1/22. Per incident report, On 10/26/22 around 12:50pm resident (R1) went to the bathroom sat down in the toilet bowl and couldn't get up informing roommate that had a back pain. Staff called 911 immediately and transported R1 to Sutter Hospital. R1 was discharged same day with a diagnosed of closed wedge compression fracture of T12 vertebra after a fall. During today's visit, LPA reviewed R1's records including their care plan, Physician's Report (LIC602) and discharge documents dated 10/26/22 indicating that R1 sustained a fracture and follow up appointment on 11/7/22 with R1's Physician were it was determined that R1 does not need surgery and has another follow up appointment on 12/16/22. LPA also made observations to residents in care and conducted interviews with facility staff and residents that concluded R1 had an un-witnessed fall while using the restroom. Based on Physician's report (LIC602) dated 9/22/15 and R1's care plan dated 7/18/18 R1 is able to perform ADL's independently. LPA advised Administrator to update R1's records. Administrator agreed to update resident's records. No deficiencies cited during today's visit.