Post-licensing visit·November 21, 2023

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 11/21/23 to conduct a Post Licensing Inspection utilizing the CARE inspection tool. LPA met with a caregiver and explained the purpose of the visit. Licensee and Admin arrived for review. LPA and caregiver toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, 1 resident bedroom, kitchen and dining. In the areas toured no immediate health, safety, or personal rights violations were observed. R1's room needs the exit door to be cleared of furniture or R1 agrees to move to a different room. LPA reviewed resident files. R3 needs an updated LIC 602 and Services Plan. R1 needs an order to use a recliner vs a bed and licensee to submit an exception request. Staff files were reviewed. 3 of 3 staff do not have required training on file. LPA requested resident roster and LIC 500 be submitted and liability insurance certificate (certificate to be submitted by 11/27/23). As a result of this inspection, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Exit interview conducted. Report copy and appeal rights provided.