Office review·April 22, 2021

Licensing Program Analyst (LPA) Mary Flores, Licensing Program Manager(LPM) Rebecca Orendain, Regional Manager (RM) Araceli Ramirez, and Pasadena Public Health Department Nurse (PPHD - HEFN) Whitney Frame conducted an office visit regarding documentation provided to PPHD on a timely manner. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today's visit was conducted via Microsoft Teams meeting with Virginia Garcia Administrator and Lori Lackey Assistant Administrator. The following was discuss during the meeting: RM Ramirez discussed concern regarding documentation for new admissions not being submitted to PPHD timely and consistently. Facility is currently allowed to have new admission from Assistant Living Waiver (ALW) program. Facility has been moved to surveillance testing - testing staff once a week and 50% of residents once a week. Per PPHD-HEFN Frame facility is consistent with submitting lab test for all testing. Per PPHD- HEFN Frame facility is to submit 2 out of 3 documents currently required for admission; ALW Verification of Approval, Vaccination Card, and/or Declination of Vaccination before admission, the day of, or 24 hours after admission. PPHD - HEFN Frame stated that the facility is responsible for submitting the documents to the department upon any new admissions. RM Ramirez follow up with reminding Administrator that due to history and previous citations for not submitting documentation, subsequent citations will be assess if facility does not comply with submitting documents. Exit interview was conducted with Virginia Garcia Administrator telephonically, and a copy of the report was email for signature.