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25 | Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit today at 11:55 AM for the purpose of following up regarding a self-reported incident report received at the Regional Office on 9/17/2021. LPA met with Martha Berard, the facility Administrator. Entrance interview conducted.
On 09/14/2021, Administrator contacted LPA Dulek and informed LPA that Resident #1 (R1) disclosed information to a third party while out of the facility and Administrator inquired about the proper reporting protocol. Subsequently, on 09/16/2021, a confidential SOC 341 document was received via fax at the Woodland Hills Regional Office (RO). LPA KaSandra Lopez then called Administrator and requested additional documentation. On 09/17/2021, the self-reported incident report was received at the RO via fax.
During today's visit, LPA and Administrator discussed R1 and the documents received. LPA and Administrator conducted a facility tour at 12:20PM. R1 was observed and interviewed at that time. LPA also conducted staff interviews from 12:31PM to 1:25PM. LPA requested additional documentation be emailed to the LPA.
LPA determined that further investigation is needed. LPA will follow up at a later date to continue the investigation.
Exit interview was conducted with Brenda Reyes and a copy of the report was issued via email. |