Routine inspection (multi-day)·January 17, 2024

At approximately 12:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Residential Relations Director, Arlene Samonte, Assisted Living Director, Mary Ann De Lara , and Administrator /Executive Director, Shawn Mooney. LPA reviewed resident medication records. Medication was found to be centrally stored and secure. LPA also followed up on an incident report that was submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 12/04/2023. Report states that on 11/26/2023, Resident 1 (R1) was administered a medication that they did not have a prescription for. Resident was observed to not have any adverse effects. Facility made all appropriate notifications per regulation (this deficiency has been cited, see LIC809D, Regulation 87465 (a)(4)). Facility conducted a in-service training covering Medication Related Errors and The Five Rights of Residents. LPA was provided with a copy of training documentation. LPA cleared deficiency cited today during visit. LPA also cleared the previous deficiency cited conducted on 12/20/2023 for Health and Safety Code 1569.625(b)(2) during visit. LPA was informed that the facility has a new Executive Director, Shawn Mooney. LPA and Executive Director discussed submitting Administrator paperwork to the Regional Office so they can be established as the Administrator on file. Until paperwork has been submitted, facility understands that Donna Daniel-Herr will continue to be the Administrator on file until paperwork has been reviewed and processed. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Continued on LIC809C Continued from LIC809 LPA also requested for the following documents to be submitted: Administrator Documents · LIC 308 (Designation of Facility Responsibility) · Active and Current Administrator Certificate · First Aid Certificate · Administrator Resume · LIC 500 (Personnel Report) · LIC 501 (Personnel Record) · LIC 503 (Health Screening Report - personnel) · Proof of TB test · LIC 9182 (Criminal Record Exemption Transfer Request) · LIC 508 (Criminal Record Statement) · Copy of Driver's License or Passport that is not expired · Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations) Administrator documents to be submitted for Shawn Mooney by 02/01/2024. Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 02/16/2024. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Plan of Corrections reviewed and developed with Executive Director. Copy of report, LIC809D, Plan of Corrections, Plan of Correction Letters, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.