Office review·April 4, 2024

An Non-Compliance conference was conducted on 04/04/24 at Sacramento North Regional Office, located at 9835 Goethe Road, Suite 100. Present in the meeting were facility’s representatives- Stephen MacDonald-Executive Director, Courtney Lane- Regional Director of Operations, Dan Williams-Regional Director of Health, Denise Munoz- Corporate Director of Administration, Joel Goldman- MBK Counsel and CCLD staff, Regional Manager (RM), Alycia Berryman, Licensing Program Manager (LPM), Laura Munoz, and Licensing Program Analyst (LPA), Talwinder Bains. This Non-Compliance conference has been scheduled today as the Department has identified some substantial compliance issues with the facility. It is the goal of today’s meeting to discuss the noncompliance and develop a plan in assisting to get the facility back into compliance. This conference does not in any manner excuse past problems or resolve the Department’s case against the licensee if the problems are not corrected. The Non-Compliance Conference may be the last step prior to initiating administrative action following unsuccessful attempts by the Department to gain compliance. The following topics were discussed during today's meeting: · Staffing · Record keeping · Reporting responsibilities · Lack of Care and supervision (falls and AWOLs) · The facility has had 4 residents AWOL from the facility. · Severity of the falls (multiple falls reports) · Staff aware of care plans · Medication administration · Overall leadership and accountability · Internal audits and quality assurance **Report continued on 809-C.... The facility has stated they will do the following to achieve continued and substantial compliance: · The facility shall send in monthly staff schedules to the Department for 6 months to ensure the facility is meeting staffing requirements. · The facility shall develop and implement a quality assurance plan to ensure resident and facility staff records are complete and updated. The plan shall be sent to the Department for approval. · The facility shall develop and implement a plan on how the facility will ensure staff that care for residents are knowledgeable of the resident’s needs and limitations. The plan shall be sent to the Department for approval. Once approved, the facility shall train staff in plan and document training. · The facility shall develop and implement training for staff who administer medications that include but not limited to ensuring correct medications are dispensed to the correct resident and documenting any medication errors. Training shall be conducted quarterly and documented. · Facility shall develop and implement a plan addressing facility’s reporting requirement responsibility. The facility shall designate a member of staff whose responsibility it is to ensure all reportable items are reported to the Department based on Title 22 regulations. · Facility will develop and implement a plan on how facility staff will assist residents who are documented fall risks and how staff will mitigate falls for residents in care. The facility shall obtain an outside agency to train all facility staff on fall mitigation. · Facility shall train staff on recognizing if a resident AWOLs the facility who is unable to leave unassisted. Facility leadership shall have a communication process developed for staff to report resident AWOLs. The Compliance Plan is a demonstration of the licensee’s intention to make a good faith effort to comply and remain in substantial compliance with licensing regulations and statutes. If the licensee fails to maintain compliance with the conditions established in the plan, revocation action may be pursued. A follow up meeting will be scheduled between facility and department. The Department may increase monitoring at your facility. In an effort to assist you with coming into compliance, the Department would like to request the above documents by 05/04/24. An exit interview was conducted, and a copy of this report was provided.