Routine inspection (multi-day)·February 14, 2024

At approximately 9:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Annual Continuation visit and met with Executive Director/Administrator, Susan Edwards. Upon arrival, LPA was informed that there were 49 Residents in care and 26 staff members on-site. At approximately 10:00AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA reviewed 6 resident files and 4 resident medication records. Resident files were all found to be well organized, thorough and contained the required documentation. 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 a incident report on 02/12/2024. Report stated that on 02/09/2024, Resident 1 (R1) was found by facility staff at the end of the facility's driveway. Report stated that the facility's front door has delay egress and was alarmed. Facility made all appropriate notifications per regulation. (This deficiency has been cited, see LIC809D, Regulation 87705(b)(2). 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 Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 03/14/2024. Continued on LIC809C Continued from LIC809 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. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.