Shalom House

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties: (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...This requirement is not met as evidenced by: Licensee did not comply with the section cited above. Licensee did not ensure that they have an active Administrator Certificate which posed/poses a potential health, safety or personal rights risk to persons in care.

Certified administrator requirements and substitute coverage

Based on observations made and interview conducted, Licensee did not comply with the section cited above. Licensee did not ensure that they have an active Administrator Certificate. Licensee’s last administrator certification was December 2021. This poses a potential health, safety or personal rights risk to residents in care.

Certified administrator requirements and substitute coverage

Based on observations made and interview conducted, Licensee did not comply with the section cited above. Licensee did not ensure that they submitted an application to renew their Administrator’s Certification with the Department. Licensee’s last administrator certification was December 2021. This regulation poses a potential health, safety or personal rights risk to residents in care.

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency...:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(A) Death of any resident from any cause regardless of where the death occurred... This requirement is not met as evidenced by:Based on interview conducted and record review, the Licensee did not comply with the section cited above, and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.

Certified administrator requirements and substitute coverage

Based on observation and interview the administrator did not comply with this section above due to Licensee's Administrators Certificate expired December, 2022. This regulation poses a potential health, safety or personal rights risk to persons in care.

Health screening and fitness requirements

Based on interview with Administrator and record review, the licensee did not comply with the section cited above in 2 out of 4 staff files do not contain required health screening report or TB test verification, which poses/posed a potential health, safety or personal rights risk to persons in care.

Submit and maintain current mailing address

Based on LPA's review of staff associations list from Departments LIS Data Base, and review of DOJ Fingerprint Lists/Clearance Information in the Guardian website. Licensee stated to the LPA that she did not follow-up on Leticia Reye's fingerprinting documentation and/or ensure she had fingerprint clearance & has worked in the facility since 9/1/2023. This is a personal rights/Health and Safety violation and risk to all residents in care. An immediate Civil Penalty will be assessed in the amount of $500-see LIC421BG.

Based on record review, the administrator did not comply with the section cited above in 3 out of 3 staff do not initial training required and or on going training which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview, the administrator did not comply with the section cited above in 1 out of 1 facilty quarterly disaster drills were not conducted which poses/posed a potential health, safety or personal rights risk to persons in care. Administrator stated that there is no proof of drill, we have not been doing.

Based on observation, interview and record review, the licensee did not comply with the section cited above by not having or aware that the facdility needs an Infection Control Plan which poses a potential health and safety risk to persons in care.