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25 | On 08/20/2024 at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility to conduct a case management. LPA Martinez met with Jonathan Aguilar and explained the purpose of today’s visit.
The purpose of this visit is to follow up on learned deficiencies.
Resident 1(R1) had multiple falls that entailed Emergency Room (ER) visits. Additionally, the facility did not implement a fall plan. In addition, R1's assessments were not updated after falls. Service plans were dated June 28, 2023 and February 07, 2024.
12/30/2023-Fall with head laceration and staples
01/22/2024-Un-witnessed fall with head incision
03/19/2024-Un-witnessed fall with head injury
As a result, the facility did not complete full reappraisals that included a fall prevention plan. Deficiency can be found on 9099D page.
Because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87463 (a)), a civil penalty in the amount of $1,000.00 shall be assessed 08/20/2024. Please refer to LIC 421IM form for additional information.
Due to R1 sustaining serious bodily injuries and death, the violations warrant civil penalty assessments. At this time, the civil penalty assessments are under review, and civil penalty determinations are pending by the Department. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties. An exit interview was conducted, and a copy of this 809 report, appeals rights, and LIC 421IM were provided to the facility. |