Office review·May 29, 2025

On 05/29/25 at 03:00PM, an informal conference was conducted via Microsoft teams (virtual). The purpose of this informal conference meeting is to discuss issues which were identified during facility’s annual visit on 05/01/25 and case management visit on 05/28/25 and within last 3 years. Present in the meeting; Licensing Program Manager (LPM) Laura Munoz; Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan; Licensee - Kevin Broomfield, and Administrator Irene Nepomuceno. The purpose of the informal conference is to have an open discussion related to the current issues at the facility. During this meeting the licensee was made aware that this Informal conference is a part of the Administrative Action process. The informal conference process was explained during this meeting. Issues discussed during the meeting were: · Issues related to Fire Clearance, uncleared staff working at the facility and medication accessibility, repeat deficiencies and other citations · Residents and staff Record not available for audits and incomplete record · Administrator’s qualifications To support the facility maintaining substantial compliance with Health and Safety Statute and Title 22 regulations, the Department is developing a plan with the licensee to address causes for concerns. Plan to address compliance concerns by 06/10/25: Submission of new LIC308, updated LIC500, Completing the pending POC requirements issued on 05/01/25, 05/28/25, plan to address how facility will be complying per Title 22 Regulations. Licensee/ Administrator was notified that the Department will provide additional case management visits and complete a referral to TSP (Technical Support Program). An exit interview was conducted. Copy of this report was provided via email and should be returned to department with signature within 24 hours.