complaint·March 8, 2024

Continued from LIC 9099 It was alleged that the facility did not have a certified Administrator. A review of the facility Organizational Chart reflected the Administrator/Director of Resident Care reports to the facility Executive Director (ED). The primary role of the ED is the day-to-day operations of the facility which includes budgeting and all matters related to finances. The facility Administrator/Director of Resident Care handles all matters related to resident care and staffing. Per interviews, staff will bring forth any concerns to the Administrator prior to going to the ED. However, staff and residents are able to discuss any concerns with either party. Moreover, interviews reflected that the ED is assigned by corporate to sign any communication letters to the residents and family. The current Administrator of the facility Joyce Aquino holds a valid Administrator Certificate along with the required training and experience to fulfill this role. Based on information gathered, the Department does not have sufficient evidence to determine that the facility does not have a certified Administrator; therefore, the above allegation is deemed UNSUBSTANTIATED at this time. It was alleged that facility staff does not have a Tuberculosis (TB) clearance. During today’s visit, LPA reviewed a random sample of staff records and observed all fourteen (14) staff to have the appropriate TB clearances. LPA was informed that the files for the ED and the Sales/Marketing Director are stored offsite and the administrator was unable to access the online copy. However, at approximately 3:08, administrator provided LPA with proof of TB clearances for the ED and Sales/Marketing Director. Moreover, Administrator stated that during the hiring phase all employees are sent to WellnessMart an off-site clinic where TB Testing, finger printing and a physical will be conducted prior to starting employment. Based on the information gathered, the Department does not have sufficient evidence to determine that staff does not have the appropriate TB clearance; therefore, the above allegation is deemed UNSUBSTANTIATED at this time. No citations issued. A copy of this report was provided. Continued from LIC 9099 It was also alleged that staff do not have fingerprint clearances and are not associated to the facility. Information gathered during the course of the investigation reflected that Staff #1 (S1), and Staff #2 (S2) are all fingerprint cleared but not associated to the facility. Moreover, a review of the Guardian System reflected that Staff #3 (S3) has been employed at the facility since 09/01/2021 however, was associated at today, 03/08/2024 at 11:35 a.m. Based on the information gathered, the Department has sufficient evidence to determine that facility staff are not associated to the facility. Therefore, the above allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D) Exit interview conducted. Citations issued. A Copy of report and appeal rights provided.