Most inspections found no deficiencies, including the annual inspection on December 1, 2023, and a complaint investigation on September 1, 2023, both of which were clean. However, some complaint investigations in 2024 found serious issues, including failure to document and report a resident’s fall and failure to provide immediate medical care after the fall, resulting in a substantiated injury and a $500 fine with additional penalties pending. The most recent report from October 28, 2024, cited a deficiency for obstructed passageways due to construction debris, posing an immediate health and safety risk. Several other complaint investigations were unsubstantiated, and the facility generally maintained adequate safety equipment and environment. While there have been some serious findings, the facility showed compliance in earlier inspections and no clear pattern of worsening conditions.
The visit was an unannounced 1-year Annual Inspection conducted by the Licensing Program Analyst to assess compliance with regulatory requirements.
Findings
The facility was generally well maintained with adequate lighting, good repair, sufficient food supplies, and operational safety equipment. However, a deficiency was cited due to obstructed outdoor and indoor passageways caused by mattresses in the hallway, wooden boards, black metal fencing, paint, and debris from construction in the backyard, posing an immediate health and safety risk.
Deficiencies (1)
Description
Obstruction of all outdoor and indoor passageways and stairways by mattresses in the hallway, wooden boards in the backyard, black metal fencing, paint, and debris from construction, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Capacity: 8Census: 7Hot water temperature: 110.1Facility temperature: 69Fire extinguisher last inspection date: Apr 22, 2024Emergency disaster drill last conducted: 202407
Employees Mentioned
Name
Title
Context
Meina Wu
Administrator
Met during inspection and named in exit interview
Lisha Holmes
Licensing Program Analyst
Conducted the inspection and signed the report
Yvonne Flores-Larios
Licensing Program Manager
Supervisor and Licensing Program Manager named in report
The inspection was conducted as an unannounced case management visit to investigate complaint 15-AS-20230831144512 regarding undocumented resident fall and failure to report the incident.
Findings
The investigation found that neither the administrator nor staff documented Resident R1's fall in early February 2022, nor submitted the required unusual incident report to the Department. Two Type-A deficiencies were cited related to observation and reporting requirements.
Complaint Details
Investigation of complaint 15-AS-20230831144512 revealed failures in documentation and reporting of Resident R1's fall and injury. The deficiencies were substantiated with two Type-A citations.
Severity Breakdown
Type A: 2
Deficiencies (2)
Description
Severity
Failure to document Resident R1's fall in early February 2022, posing an immediate health, safety, or personal rights risk.
Type A
Failure to report the injury sustained from Resident R1's fall to the Department within the required timeframe.
Type A
Report Facts
Deficiencies cited: 2Capacity: 8Census: 7
Employees Mentioned
Name
Title
Context
Meina Wu
Administrator/Director
Named in relation to failure to document and report Resident R1's fall.
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident sustained a fracture due to insufficient care by staff and a stage 4 pressure injury due to lack of care by staff.
Findings
The complaint that resident R1 sustained a fracture due to insufficient care was substantiated, with evidence showing staff negligence in not securing immediate medical care after a fall. The allegation that R1 sustained a stage 4 pressure injury due to lack of care was unsubstantiated, as evidence showed facility staff followed care instructions and the injury worsened due to the resident's declining health.
Complaint Details
The complaint investigation was substantiated for the allegation that resident R1 sustained a fracture due to insufficient care by staff. The allegation that resident R1 sustained a stage 4 pressure injury due to lack of care was unsubstantiated. A $500 immediate civil penalty was assessed with additional penalties pending.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Failure to provide immediate medical care for resident R1 after a fall despite known risk of falling.
Type A
Report Facts
Capacity: 8Census: 7Immediate civil penalty: 500
Employees Mentioned
Name
Title
Context
Meina Wu
Administrator
Named in relation to findings on resident care and investigation interviews
James Sampair
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
An unannounced 1-Year Required inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies cited. All staff and resident files reviewed were complete and current. The facility environment and safety equipment were adequate and properly maintained.
Report Facts
Staff records reviewed: 5Resident files reviewed: 7Fire extinguisher last serviced: Jun 26, 2023Fire drill last conducted: Oct 1, 2023Hot water temperature: 112.6
Employees Mentioned
Name
Title
Context
Meina Wu
Administrator
Facility Administrator present during inspection
Maria Martinez
Caregiver
Caregiver met with Licensing Program Analyst during inspection
The inspection was conducted as a result of a Priority 1 complaint to perform a health check at the facility.
Findings
The Licensing Program Analyst toured the facility and found that the temperature was maintained properly, food supplies were sufficient, medications were securely stored, safety detectors were functional, and fire safety equipment was up to date. No citations were issued.
Complaint Details
The visit was triggered by a Priority 1 complaint. No citations or deficiencies were issued, indicating no substantiated violations.
The visit was an unannounced annual Infection Control Inspection conducted to evaluate the facility's compliance with infection control and COVID-19 mitigation protocols.
Findings
The facility had a COVID-19 mitigation plan on file, adequate supplies, and posted signage for infection control. The fire extinguisher, smoke/carbon monoxide detectors, and first aid kit were observed to be operational and complete. Several forms were required to be updated and submitted by 10/25/2022.
Report Facts
Hot water temperature: 106.3Facility temperature: 71Fire extinguisher last inspection date: Mar 28, 2022Capacity: 6
Employees Mentioned
Name
Title
Context
Meina Wu
Administrator
Named as facility administrator, not present during inspection
Miesha Cooper
Care Staff
Present during inspection and assisted Licensing Program Analyst
Lisha Holmes
Licensing Program Analyst
Conducted the inspection
Yvonne Flores-Larios
Licensing Program Manager
Named in report header
Alis Luna
Care Staff who received copy of report at exit interview
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