Correction check·March 7, 2024

On 3/7/24 at 10:30am, Licensing Program Analysts (LPA) Arvin Villanueva arrived at this facility to conduct an unannounced Plan of Correction (POC) visit. LPA initially met with the staff on duty and explained the purpose of the visit. Chukwudi Isikeh, administrator, was notified of the visit by the staff. Staff on duty was given permission to sign this report. The purpose of this visit was to verify the plan of correction that was required to be completed on ____ for deficiencies that were previously cited on a prior visit conducted on 11/27/2023. Present during this visit are 3 residents in care with 1 staff on duty. During this visit, LPA attempted to conduct file reviews of the 4 staff noted on the LIC 500 dated 11/25/23. Staff on duty was only able to retrieve 2 staff files for review at this time. Per staff on duty, the files for the administrators are not present at this facility. Additionally, per interview of staff on duty, staff_1 (S1)noted on the LIC 500 dated 11/25/23 is no longer employed at this facility. LPA also requested S1's files for review but staff on duty is unable to retrieve and stated it is not at this facility at this time. LPA also reviewed resident files and found that resident_1(R1) is using a catheter. Per interview with R1 and staff on duty, it was revealed that R1 is unable to care for their catheter and requires staff assistance at this time. Per interview with Chukwudi Isikeh, a request for an exception for R1's catheter has not been submitted to the Department for approval. Further resident file review revealed that R1 does not have Needs and Services Plan (LIC 625) in their file. LPA requested from the facility to submit an updated LIC 500 to the Department. Con't to LIC 809-C... ...Con't from LIC 809 Based upon this inspection, LPA Villanueva observed the following: The deficiency cited under Health and Safety Code 1569.618(c)(3) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. The deficiency cited under Title 22 Regulation 87411(c)(1) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. The deficiency cited under Health and Safety Code 1569.695(c) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. The deficiency cited under Title 22 Regulation 87606(c) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. The deficiency cited under Health and Safety Code 1569.618(b)(3) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. The deficiency cited under Title 22 Regulation 87412(g) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. The deficiency cited under Title 22 Regulation 87412(a)(6)(A) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. The deficiency cited under Title 22 Regulation 87412(a)(12) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. The deficiency cited under Health and Safety Code 1569.625(b)(2) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. The deficiency cited under Health and Safety Code 87219(a)(1) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. Immediate civil penalties are being assessed due to repeat violations. The facility was informed that the civil penalty will continue to accrue $100 per day per violation until the deficiency is corrected. As a result of this case management, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted with Shyniel Brown, staff on duty, and a copy of the LIC 809 reports, LIC 809-D pages, and Appeals rights were provided to the facility.