Correction check·April 17, 2025

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility to conduct a Plan of Correction (POC) visit. LPA met with Licensee, Angela Zhang who was informed of the purpose of the visit. LPA conducted interviews, records review, and a walk through of the home. The following POCs were met during or before the time of the visit and cleared during the visit: On 3/20/2025, LPA issued a citation for 87202(a) Fire Clearance for bedridden resident which the facility is not approved for. The POC was for the licensee to submit a request for a bedridden fire clearance by the POC due date of 3/21/2025. On 3/21/2025 the regional office received the application for the fire clearance. LPA checked on the bedridden resident during the visit and observed the resident is located in a room with a second exit door. Therefore, the POC has been met and a clearance letter was provided at the time of the visit. On 2/18/2025 LPA issued citation for 87467(a)(3) Resident Participation in Decision making for (1) resident’s whose care plan was signed by the Licensee twice, once for the licensee and once for the resident’s responsible party. Interview and record review revealed the Licensee is not the resident’s responsible party and the Licensee did not send the care plan to the responsible party for review. POC was for the Licensee to send the care plan to the responsible party by POC due date 2/25/2025, On 2/23/2025 the licensee submitted proof to the LPA of submitting the care plan to the resident’s representative for review and signature. Therefore, the POC has been met and the licensee was issued a clearance letter at the time of the visit. 87412(a) Personnel Records was cited for incomplete and unavailable staff files for licensing to review. 87411(c)(6) Personnel Requirements – General was also cited for lack of documented staff training . The POC was for the Licensee to submit the complete staff files to the LPA and appoint a new administrator to audit the staff files for completion. LPA received an email appointing new administrator Victor Otuya. During the visit, LPA reviewed staff training conducted. Therefore, the POC has been met and the deficiency was cleared. On 3/26/2025 LPA received notification appointing VICTOR OTUYA as the new administrator but did not receive a copy of the completed staff files. The LPA needs to review LIC501, Administrator’s Certificate, first aid and CPR training for the Licensee. 40-hour annual training, LIC501, TB test and physical need to be submitted for Staff #1 (S1) and Staff #2 (S2). S2’s medication training also needs to be submitted. During today’s visit LPA conducted file review and reviewed Licensee's, S1, and S2's file and documents listed above. Therefore, the POC has been met and the deficiency was cleared for staff records. 87412(e) Personnel Records was cited for the licensee not having an LIC500 showing staff coverage. 87705(b)(2) Care of Persons with Dementia was also cited as staff interviews revealed there is no awake staff at night despite residents being diagnosed with Dementia in the home. The POC was for the licensee to submit an LIC500 showing staff coverage at all times, and awake staff at night. The licensee submitted a completed LIC500 to the LPA on 3/24/2025. Therefore, the POC has been met and the deficiency was cleared. The following POC was previously agreed upon and the POC due date has passed: On 2/18/2025 LPA conducted an annual visit and cited deficiencies. The POC due date and date for addressing the POC has passed. Therefore, the deficiency is being recited with new POC due date. The following are the previously cited item: 87470(c)(1)(C) Infection Control Requirements was cited for not having an infection control plan for licensing review. The POC was for the licensee to submit their infection control plan. The Licensee also agreed to send a self certified statement appointing a new administrator that will help audit the facility files and ensure all files are complete at the facility by the POC due date. On 3/26/2025 LPA received notification appointing VICTOR OTUYA as the new administrator but did not submit a self certified statement from the Licensee. LPA has also not received the facility’s infection control plan. On today’s visit LPA spoke with Licensee who showed the LPA the infection control plan they had on file. The plan was not filed out. The licensee stated they could fill out and send to LPA by POC due date. Therefore, the facility still does not have an infection control plan for licensing to review. The deficiencies is being recited and a new POC due date was issued. An exit interview was conducted where a copy of this report, deficiency pages, and clearance letters were reviewed and provided.