Complaint·May 17, 2023

Regarding allegation, “Facility ceiling has water damage” through interviews and observation, LPA found that there are spots in the ceiling of one of the residents rooms that appears to be water damage. Regarding allegation, “Staff did not provide a care plan for resident upon admission”, LPA obtained information that resident #1 (R1) and/or R1’s Responsible Party signed documents that were incomplete upon admission. Administrator stated that an assessment would be put into place after getting to know the resident. LPA observed the Admission Agreement that shows areas highlighted for signatures and initials, all of which are completed and signed by Licensee and Responsible Party on 2/5/23. However, the Identification and Emergency Information form (LIC601) was not completed, dated or signed. Additionally, Appraisal/Needs and Services Plan (LIC625) was observed to be incomplete but signed and dated which confirms the allegation. Regarding allegation, “Facility kitchen floor is in disrepair”, through interviews and observation, Administrator and staff all confirmed that the kitchen floor was not leveled, and the laminate tiles were not properly attached to the floor which was a tripping hazard. Based on interviews, and documentation the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. Additionally, Based on fire clearance deficiency not corrected prior to resident relocating, you are hereby assessed an Immediate civil penalty in the amount of $150.00. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview conducted and report provided.