Non-compliance follow-up·August 23, 2023

On 8/23/2023, Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced at the facility to conduct an unannounced quarterly on-site visit regarding the Stipulation and Waiver and Order adopted on 05/23/2022. LPA and LPM met with Lacy Berry, Administrator, and explained the purpose of the visit. LPA was provided the Compliance Binder, and observed a copy of the Stipulation in the binder and at a conspicuous space by the front desk. During today's inspection, LPA observed two (2) missed weekly calls, week of 06/19/2023 and 06/26/2023, with Alan Flores Consulting Group, due to vacation from 6/21/2023-6/29/2023. LPA and Administrator discussed rescheduling the required calls to fulfill the condition of the Stipulation. LPA observed monthly staff needs review to last be conducted on 8/4/2023 with notation of hiring more caregiver and housekeepers. Administrator informed LPA there are no staffing concerns but would like to be overstaffed. LPA observed the recent quarterly clinical audit was conducted on 8/17/2023. LPA and Administrator discussed the details of documentation for End of Shift Report, and charting notes. As a result of today's visit, no deficiencies cited. Exit interview conducted. Copy of report provided to Administrator.