Office review·January 27, 2025

On 1/27/25 an Informal Meeting was conducted at the Regional Office. Present were: CCL Staff: Licensing Program Manager (LPM), See Moua, LPM, Alexandria Walton, Licensing Program Analyst (LPA), Mary Garza, Licensee, Rajat Roychoudhury, Administrator, Minakshi Roychoudhury and Designee, Shailesh "Steve" Patel. The purpose of the office meeting is to discuss concerns regarding the Facilities. Facility was licensed 10/18/23. The Department has completed the annual inspection on 10/22/24. Facility was offered and declined Technical Support (TSP) on 10/30/24. A case management visit was completed on 01/08/25. Deficiencies were issued during both of visits. During the meeting discussions of concerns and operations of the facility. Meeting covered the deficiencies cited. 1) Personal Accommodations and Services: storage area accessible through bedroom 2) Oxygen Administration -Gas and Liquid: signs posting and reporting to Fire Department 3) Resident Records: pre-admission, reappraisals, medical assessments, TB, etc. 4) Personal Accommodations and Services: Open patio area without railing/lighting The following were also discussed and explained: - Compliance does not mean just completing POCs after the Department issue citations. The facility should aim and be proactive in making sure its operation meets Title 22 regulations. The Department is transparent that the regulations and CARE Tools are available. CONT... - The Licensee has declined TSP services. TSP is not mandatory. By declining, the licensee communicates that it can be compliant. Although the LPA has a consultative role, the Administrator by maintaining an active certificate, understands all the laws, regulations, and Title 22 to operate. - Clearing Proof of Corrections – Clearing the POC is the responsibility of the LPA. The LPA was there during the inspection. The facility should communicate with the LPA when there are questions regarding the POC. - Administrative Actions - Continued non-compliance means the Department may take Administrative Action. This includes any of the following: revocation of the licensee, exclusion of staff, Administrator certificate de-cert, etc. The inimical conduct of any staff, administrator and licensee, including false statements to the LPA or Department, falsifying records and jeopardizing the health and safety of the residents, may result in Administrative Actions. - ALW Program and Hospice – residents being in the ALW Program, on Hospice, or Home Health does not negate the facility and its staff of the responsibility for providing care and supervision. Licensee was informed that deficiencies can affect the facility/residents and their license. Enforcement laws and regulation for licensed facilities were covered. The following POCs were not cleared and a new date of 2/7/25 was provided to submit the POC: 1) Open patio is without hand railing/lighting. The following deficiency was cited during today’s office meeting: Resident Records Exit interview completed with Licensee, Rajat and Administrator, Minakshi. A copy of this report, deficiency and appeal rights given.