Office review·June 8, 2022

An informal conference was conducted today via Microsoft Teams Platform. The purpose of this informal conference meeting is to discuss the inability to remain in substantial compliance with the regulations. Present in the meeting is Regional Manager Alycia Berryman, Licensing Program Manager Laura Munoz, Licensing Program Analyst Jaclyn Avila, Licensee Raj Rao, Chief of Operations Stephen Ratliff, Audre Smith, Dave Curtis interim CEO of Peer Services and Administrator Samantha Guarino. The informal conference process was explained during this meeting. The facility has been cited 11 times in the last year. The facility was cited for the following issues: personal rights, staffing, incontinence care, activities, dementia care, etc. The facility was cited for 8 Type A citations, and 3 Type B citations. Three complaints were filed against the facility. Issues discussed during the meeting were: · Staffing issues and training · Food Service · Housekeeping · Activities Cont'd on LIC 809-C · Activities · Medications · Providing ADLs · Licensee/Administrator accountability · Transition as Peer Services separates as Licensee/Management · Ensuring all staff regardless of position are fingerprint cleared and associated The facility has stated they will do the following to achieve continued and substantial compliance: · Increase the amount of training each staff receives · Create policies and procedures to ensure staff are meeting needs of residents · Maintain at least two direct care staff one of which is also a med tech · Increase oversite of facility operations The following Forms are due by June 10th, 2022 and are to be submitted to LPA LIC 308 The following Forms are due by June 30 th , 2022 and are to be submitted to LPA Infection Control Plan The following Forms are due by July 8th, 2022 and are to be submitted to LPA LIC 500 Personnel report Resident Roster LIC 9020 Activities Schedule Medication Policy and Auditing System LIC 309 and Organizational flow chart Copy of this report will be e-mailed to the Licensee for Signature and a signed copy will be returned same day to LPA.