Follow-up on corrections·December 8, 2022

At 2:45 p.m. on 12/08/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the Administrator and disclosed the reason for the visit. On 09/28/2022 LPA investigated complaint #31-AS-20220923175322 and substantiated the allegation of resident records not maintained at the facility. A Proof of Correction due date was set for 10/28/2022. At 12:15 p.m. on 12/08/2022 LPA reviewed resident records at the facility as part of complaint investigation #31-AS-20221202164248. LPA observed the following deficiency: The facility did not maintain records for Resident #1 (R1), Resident #2 (R2), nor Resident #3 (R3). Due to the failure to correct the deficiency cited on 09/29/2022, a civil penalty of $100 per day is hereby assessed for the period of 10/29/2022 – 12/08/2022 in the amount of $2,900 (29 days x $100/day). Daily civil penalties will continue to accrue until the deficiency is corrected. The civil penalty is issued on the attached LIC 421FC page. At 4:00 p.m. on 10/27/2022 LPA conducted a case management visit. LPA requested to view staff records. No staff records were available for audit. A deficiency was issued with a Plan of Correction date of 11/25/2022. At 12:15 p.m. on 12/08/2022 LPA requested staff records. The Administrator noted the facility did not maintain staff records for previous or current staff. Staff records were not available for audit. Due to the failure to correct the deficiency cited on 10/27/2022, a civil penalty of $100 per day is hereby assessed for the period of 11/26/2022 – 12/08/2022 in the amount of $1,300 (13 days x $100/day). Daily civil penalties will continue to accrue until the deficiency is corrected. The civil penalty is issued on the attached LIC 421FC page. Additionally, Staff #1 (S1) and Staff #2 (S2) did not maintain criminal background clearances and were not associated to the facility. The Administrator noted S1 began employment on 11/21/2022 and S2 began on 12/07/2022. An additional civil penalty is assessed due to a repeated violation of the same regulation within 12 months. The deficiency are cited on the attached LIC 809-D page. Civil penalties are issued on the attached LIC 421BG page and LIC 421FC page Exit interview conducted. Copy of report, appeal rights, and citation(s) issued.