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25 | Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the complaint findings received on 12/22/2021 and 01/04/2022. LPA met with Administrator in training, Tammy Lu.
During the complaint investigations, multiple deficiencies were found that were not part of the complaint allegations.
In December 2021, a resident (R1) was admitted to the facility. Based on record review, R1 was accepted into the facility without a physician’s report and updated needs and services plan. R1’s needs and services plan was dated on 06/28/2018 and was written from the previous facility. Based on interview and record review, Licensee did not develop a needs and services plan for R1 to determine if the facility can meet the needs of the client and obtain a physician’s report to determine medical assessment, prior to being accepted to the facility.
In December 2021, R1 was restrained by staff on two separate occasions. On 12/16/2021, it was noted on the San Andreas Regional Center corrective action plan that R1 was put on restraint for one hour. On 02/21/2021, it was noted that R1 was put on restraint for one and a half hours. Based on multiple visit notes provided from crisis counselors, facility staff stated to have placed R1 in a restraint for one to two hours at a time or until R1 was calm. Based on record review, the facility’s Emergency Intervention plan states manual restraints are not considered an intervention and will not be used.
The Department received two incident reports on 12/16/2021 and 12/21/2021, which did not report the use of restraint or use of the emergency intervention plan, on both occasions.
Deficiencies are being cited today per California Code of Regulation, Title 22. See LIC809D. Exit interview conducted with Administrator in training, Tammy Lu. A copy of this report, along with the facility's appeals rights were provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
06/03/2022
Section Cited
CCR
85068.1(c)(2
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7 | (c) Prior to accepting a client for care and supervision, the person responsible for admissions shall: (2) Develop a Needs and Services Plan as specified in Sections 80068.2 and 85068.2. This requirement was not met as evidenced by: | 1
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7 | Licensee will submit a statement of understanding on section 86068.1 and 86068.2. Going forward, the licensee will ensure to only accept clients whom they can meet the needs by developing a thorough needs and services plan and to obtain all necessary documents prior to admission. Licensee will develop a care plan prior to admitting new residents. Licensee will send a statement of understanding by POC due date. |
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14 | Based on record review, prior to admission the Licensee did not develop R1’s needs and services plan to determine if R1’s needs can be met at the facility which poses an immediate health, safety, and personal rights risk to persons in care. | 8
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Type A
06/03/2022
Section Cited
CCR85102(b)(7)
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7 | (b) Manual restraint or seclusion shall not be used: (7) If it is prohibited by the facility's Emergency Intervention Plan or the client's Individual Emergency Intervention Plan; This requirement was not met as evidenced by: | 1
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7 | Licensee will review section 85102 and will never use manual restraint or seclusion on any resident until an Emergency Intervention plan is developed and approved by the Department. Licensee will send a statement of understanding to LPA by POC due date. |
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14 | Based on record review, the facility’s Emergency Intervention plan stated manual restraints are not considered an intervention plan and will not be used yet staff used manual restraint on R1 which poses an immediate health, safety, and personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
06/03/2022
Section Cited
CCR
85122(e)(6)
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7 | (e) If staff will use, or it is reasonably foreseeable staff will use, manual restraint or seclusion or both, the licensee shall include and ensure the following time limitations are adhered to in the Emergency Intervention Plan. The Emergency Intervention Plan shall include procedures for ensuring: (6) Unless discontinued sooner, at 15 consecutive minutes after the initiation of a manual restraint or seclusion, staff shall discontinue the manual restraint or seclusion. This requirement was not met as evidenced by: | 1
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7 | Licensee will ensure adherence to the Emergency Intervention plan and never use manual restraint on a resident. Licensee will send a statement of understanding to LPA by POC due date. |
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14 | Based on record review, the licensee did not adhere to the facility’s Emergency Intervention Plan and used manual restraint on R1 for 1 – 1.5 hours which poses an immediate health, safety, and personal rights to persons in care. | 8
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Type A
06/03/2022
Section Cited
CCR85161(b)
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7 | (a) Each use of manual restraint or seclusion shall be reported to the Department in writing no later than the next business day. This time frame shall supersede the reporting time frame required by Section 80061(b). This requirement was not met as evidenced by: | 1
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7 | Licensee will review section 85161 and will adhere to the Emergency Intervention plan and never use manual restraint on a resident. If, for any reason, the facility uses manual restraint on a resident, the licensee will report the incident to the Department in writing no later than the next business day. Licensee will send a statement of understanding to LPA by POC due date. |
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14 | Based on record review, the licensee did not report the manual restraint to the Department in writing which poses an immediate health, safety, and person rights risk to persons in care. | 8
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