197605954-9-5-2024-31-AS-ERIS-D8TSFZ-20240905135111

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197605954
Report Date: 09/05/2024
Date Signed: 09/05/2024 01:51:15 PM

Document Has Been Signed on 09/05/2024 01:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WATKINS RCFE		FACILITY NUMBER:	197605954
ADMINISTRATOR:	DAISY HAILEY		FACILITY TYPE:	740
ADDRESS:	42849 SACHS DRIVE		TELEPHONE:	(661) 718-8411
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	0	CENSUS: 3	DATE:	09/05/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	01:36 PM
MET WITH:	Edna Watkins		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/05/2024, Licensing Program Analysts (LPAs) Evelin Rios and Mariana Agban met with Edna Watkins for a Case Management visit to follow up on a substantiated allegation on lack of care and supervision which resulted in a resident’s (R1) death. On September 12, 2023, the Department concluded a complaint investigation which alleged that Lack of care and supervision resulted in resident death. The allegation was substantiated, and the licensee was cited under California Code of Regulations, Title 22, Chapter 8, Section 87464(f)(1) Basic Services. The investigation revealed that on the evening of May 14, 2023, R1 was left sitting on the toilet seat with grab bars while the licensee walked out of the bathroom to grab an item in the adjacent room. The licensee heard R1 call for help. The licensee returned to the bathroom and found R1 on the floor, lying on their left side. According to the licensee, R1 had stated they fell backward. R1 was hospitalized and passed away the following day due to intracranial hemorrhage and blunt head trauma. Based on interviews and records review, Licensee is aware that R1 was a high fall risk and should not be left alone on the bathroom. Prior to R1’s admission to the facility on September 1, 2020, R1’s family informed Licensee that R1 had a history of falling backwards. Licensee admitted that R1 was still a fall risk even when seated and they should not have left R1 alone in the restroom. At the time of visit on September 12, 2023, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49(e). (Continued on LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WATKINS RCFE	FACILITY NUMBER: 197605954
	VISIT DATE: 09/05/2024

NARRATIVE

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(Continued from LIC809)

The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that resulted in the death of R1. This is evidenced by the licensee leaving a high fall risk resident unattended in the bathroom. As a result, R1 fell and suffered blunt head trauma and an intracranial hemorrhage that attributed to the death of R1.

Today, 09/05/2024, the Department is issuing a civil penalty per Health and Safety Code §1569.49(e) in the amount of $15,000 for a violation that the Department determines to have resulted in the death of R1. However, since an immediate civil penalty of $500 was previously issued on September 12, 2023, the amount of the civil penalty issued today is $14,500.

A copy of the LIC 421D was given to Edna Watkins and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Edna Watkins signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

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