Non-compliance follow-up·May 22, 2023

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced required annual visit. Along with the required annual visit, the purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. The LPA met with Terri Weitzman and Kaitlyn Smith and explained the reason for the visit. The last legal/non-compliance visit was conducted on 2/1/2023. Today, the LPA conducted a file review for five (5) residents and five (5) staff. A file review of five (5) resident files was conducted from 12:30 p.m. – 1:30 p.m. Files were reviewed for, but not limited to: admissions agreements, medical assessment, updated appraisals, consent forms. Resident records were in order. A file review of five (5) staff files was conducted from 1:30 p.m. – 2:30 p.m. Files were reviewed for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid certification. Out of the five files reviewed, the following was observed: Staff #1 and Staff #2 did not have a completed job application, medical assessment, or criminal record statement on file, and Staff #3 did not have tuberculosis results on file. LEGAL: As it pertains to the Stipulation and Waiver, and Order, the following was noted: · Career Smart conducting quarterly audits: The last audit took place in March 2023; recommendations were made around organization of staff training and the availability of care plans · Compliance audit was conducted by a member of the licensee’s governing board on 02/27/2023 · Facility continues to monitor staffing levels as it relates to resident care needs and census. · Staff support group was conducted on 4/28/2023; staff encouraged to obtain the total attendance · Resident care needs are assessed monthly Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.