Follow-up·October 23, 2025

On 10/22/2025, Licensing Program Analyst (LPA) Renee Campbell received an incident report regarding Resident 1's (R1's) back brace and a missing bolt. Per the report, a friend of the responsible party came and provided a temporary solution with a replacement bolt. LPA Campbell contacted the responsible party (P1) and interviewed staff at the facility on 10/23/2025. LPA Campbell contacted the responsible party (P1) on 10/23/2025 regarding the incident. Per P1, the facility had not initially made sure that R1 was using the back brace. When staff notified P1 that a bolt had gone missing, a family friend came to the facility and provided a temporary replacement bolt. The combination of the missing bolt and because staff not hot initially provided support for usage of the back brace, P1 concluded that facility staff were not taking responsibility for R1 using the back brace correctly and they were not keeping track of the brace to avoid losing parts. When staff was interviewed on 10/23/2025, S1 stated that the facility had not known that staff needed to support R1's use of the back brace because they had not received doctor's orders regarding the back brace. Instead, S1 stated that P1 had "just shown up with it." and given it to staff. S1 then requested that P1 obtain doctor's orders so that staff could be properly trained and informed on how to properly assist R1 in using the brace. Once received staff then assisted R1 in putting on the brace in the mornings and taking it off in the evening. S1 had notified P1 on 10/22/2025 that staff noticed the bolt was missing from R1's back brace when they were assisting R1 with putting the brace on that morning. To avoid further miscommunication, the facility has taken steps to educate staff and document any issues that may arise when assisting with the back brace. Training has been conducted with 19 staff on the parts of the back brace and how to take it on and off (10/01, 10/18, 10/25) In the future, staff will scan for any missing parts or other issues when assisting R1 into or out of the back brace and document any changes in R1's notes. P1 will also be notified of additional resources in regards to regulations for Residential Care Facilities for the Elderly (RCFE) to familiarize themselves with procedures and what the facilities can and cannot do. Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited. An exit interview was held, and a copy of the report was provided to Dawn Pero, Care Coordinator.