Follow-up on corrections·May 16, 2022

Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management- Deficiencies visit in conjunction with complaint control # 29-AS-20210125142107. At 9:35 a.m., the LPA met with Administrator Dion Gallarza, and explained the reason for the visit. During the investigation of complaint control # 29-AS-20210125142107, LPA Walker spoke with the Administrator. The administrator informed the LPA that Resident #1 (R1) passed away. The LPA advised the administrator that CDSS does not have record of R1’s death report, and inquired as to whether the facility submitted the Death Report to Licensing or the previous assigned LPA. The administrator stated that R1 passed away in a Hospital, and not in the facility. The LPA advised the administrator that a written report shall be submitted to the licensing agency within seven days of any Death of any resident from any cause regardless of where the death occurred, including a hospital. During the investigation, the LPA conducted a record review. Record review revealed, that the facility staff often did not respond in a timely manner when Resident #1 (R1) called or pressed their pendant during fall(s), and/or for different purposes requesting service. On 12/24/2020 at 10:51:33 a.m., R1 pressed their pendant “Announced” 8 times, staff responded at 11:30 a.m. 39 mins after. On 12/22/2020 at 10:43:59 a.m., R1 pressed their pendant “Announced” 5 times, staff responded at 11:05 a.m. 22 mins after. On 1/20/2021 at 10:56:48 a.m., R1 pressed their pendant “Announced” 6 times, staff responded at 11:22 a.m. 26 mins after. On 1/17/2021 at 9:30:29 a.m., R1 pressed their pendant “Announced” 5 times, staff responded at 9:50 a.m. 20 mins after. On 1/30/2021 at 7:38:17 a.m., R1 pressed their pendant “Announced” 5 times, staff responded at 7:59 a.m. 21 mins after. On 2/18/2021 at 4:42:03 p.m., R1 pressed their pendant “Announced” 4 times, staff responded at 4:59 p.m. 17 mins. On 2/16/2021 at 4:51:10 p.m., R1 pressed their pendant “Announced” 6 times, staff responded at 5:20 p.m. 29 mins after. Continue on LIC 809C.. The LPA advised the Administrator that the facility is responsible for ensuring residents are provided care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The LPA also advised the Administrator facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Pursuant to Title 22 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were provided.