Office review·May 29, 2024

Licensing Program Manager Victoria Bertozzi and Licensing Program Analyst Christi Coppo conducted an informal office meeting, and met with Administrator, Patrick Seawright and John O'Brien District Manager (DM) for licensee and Michelle Mainez COO of licensee. Informal meeting to address concerns identified by the Department during a recent Complaint Investigation. DM indicated they had lots of meetings about this incident and agree that the course of action taken by Admin was not appropriate and they have addressed it with Admin. Going forward, the staff have all been retrained about communicating about residents' care needs in order to prevent residents from experiencing pain unaddressed. Admin wants it noted that there was not any malice or purposeful neglect to not get the medical attention for R1. The complaint investigation revealed that a client was observed on with a “heat blister” on 2/12/2024 by facility staff. Staff documented the blister on the facility’s internal system and per interviews, Administrator was notified of the blister the same day. The Administrator did not seek medical treatment via the emergency room despite client presenting with a raised blister. Staff noted that on the NOC shift the client was “whining” during repositioning. On 2/13/2024, staff noted that they observed the blister had grown bigger, was red, and filled with liquid. Interviews conducted during investigation revealed that the blister ruptured on 2/14/2024. Administrator did not seek medical treatment via the emergency room when blister ruptured. LPM Bertozzi spoke with Administrator on 2/15/2024 around 2:00pm. Administrator told LPM that they had emailed the client’s doctor between 9:00am and 11:00am but was unsure if the doctor had responded. CCL staff advised the Administrator to seek emergency medical treatment for the client, but Administrator indicated that they were going to wait for the doctor to respond. Continued on LIC809C Continued from LIC809 LPM directed Administrator to call the doctor and notify the office staff to assist in expedited guidance from the doctor. Eventually, the client’s doctor directed the Administrator to seek emergency medical treatment, which they did on 2/15/2024 at approximately 4:54pm. LPM spoke directly with Administrator regarding a perceived refusal on the part of the Administrator to seek medical attention for the client. Administrator disagreed that they refused and indicated that they were unsure how to proceed as the injury was not something that they have previously encountered. Parties discussed the changes that facility has made to their protocols to ensure residents' needs are met timely as well as the interaction between the Administrator and CCL staff. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.