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13 | Licensing Program Analysts (LPAs) Angelica Rea and Luis Mora conducted a visit, to issue the final results of the investigation. LPA met with Administrator, Maria Nguyen who assisted with today's visit.
Regarding the allegation that: Staff #1 hit Resident #1 with car causing injuries. The investigation was conducted by the department, and consisted of interviews with Administrator Ivonne Meador, facility staff, facility resident(s), review of facility records including resident #1's facility file, and resident #1's medical records.
The investigation revealed the following : On 4/1/21, Resident #1 was walking with the assistance of a walker on the sidewalk near the facility driveway. Resident #1 was unsupervised. Staff #1 began backing out of the driveway, and struck resident #1. Staff #1 was cited for suspended license, no proof on insurance, and expired registration. Staff #1’s vehicle was towed at the time of the incident. Police report indicated that Staff #1 made an unsafe backing movement. Resident #1 suffered two broken ribs, a broken pelvis, lower left extremity laceration, and hemmorrhagic shock.
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32 | Medical records, Resident #1’s file review, and interviews conducted indicate that Resident #1 was a fall risk. It is documented that Resident #1 had poor vision, required assistance with walking, and required the use of a walker. Resident #1’s physician report dated 8/27/19 states that resident #1 is unable to leave the facility unassisted. Administrator, Ivonne Meador was aware of this and had Resident #1’s family member, sign a waiver of liability and hold harmless agreement dated 10/19/19, because Resident #1 would take daily unsupervised walks. Administrator did not get approval from Community Care Licensing to use a waiver of liability and hold harmless agreement. Staff interviewed stated they were never told not to let Resident #1 go out alone. The facility failed to follow resident #1’s physician’s report, and allowed resident #1 to leave the facility unassisted.
Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.
Immediate Civil Penalty will be issued in the amount of $500.00
The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e) or (f).
Exit interview conducted, and copy of report and appeal rights were provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Request Denied
Type A
11/10/2023
Section Cited
CCR
87458(a)(b)(4) | 1
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7 | (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. (b) The medical assessment shall include, but not be limited to: 4) Identification of physical limitations of the person to determine his/her capability to participate in the programs provided by the licensee, including any medically necessary diet limitations.
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7 | Administrator shall follow Title 22 Regulations and will follow Resident(s) physicians report(s). Administrator shall review Section 87458 and will send LPA a written letter stating that the section has been reviewed and is understood, by POC due date. |
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14 | This requirement was not being met as evidenced by: Administrator did not follow resident #1’s physician’s report, which states that resident #1 cannot leave the facility unassisted. This poses a health and safety risk to residents in care.
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Request Denied
Type A
11/10/2023
Section Cited
CCR
87468.2(a)(4) | 1
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7 | (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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7 | Administrator shall follow Title 22 Regulations and will ensure that the facility has sufficient staff to meet the needs of residents. Administrator shall review section 87468.2 and will send LPA a written letter stating that the section has been reviewed and is understood, by POC due date. |
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14 | This requirement was not being met as evidenced by: Administrator was aware that resident #1 was unable to leave facility unassisted, and did not provide resident #1 with sufficient staff to assist resident #1 on daily walks. This poses a health and safety risk to residents in care.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Request Denied
Type A
11/10/2023
Section Cited
CCR
87208(a) | 1
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7 | Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:
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7 | Administrator shall follow Title 22 regulations and willl not make changes to the facility's plan of operation, without receiving approval from Community Care Licensing. Administrator shal review section 87208 and will send LPA a written letter stating that the section has been reviewed and is understood, by POC due date. |
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14 | This requirement is not met as evidenced by: Administrator altered the facility plan of operation, by creating a waiver of liability and hold harmless agreement for resident #1, without obtaining approval from Community Care Licensing. This poses a health and safety risk to residents in care.
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