Follow-up on corrections·June 26, 2023

Licensing Program Analyst (LPA), Tihesha Smith conducted a Case Management visit in conjunction with complaint (31-AS-20230622091845) and met with staff. LPA Smith observed staff setting up/preparing meals in courtyard. LPA discussing with staff #1 and staff #2 revealed that kitchen plumbing was repaired. LPA interview with Administrator revealed that the incident was not reported to the Community Care Licensing Department (CCLD). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. Occurrences, such as epidemic outbreaks, poisonings, catastrophes, or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours. LPA informed the Administrator that all staff members are mandated reporters and are all responsible for reporting. During today’s visit, the Administrator provided a copy of the written Incident Report. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report given .