Office review·November 1, 2023

A Non-Compliance Conference (NCC) was conducted on this day, 11/01/2023, by the Sacramento South Regional Office via Teams meeting. The purpose of this Non-Compliance Conference meeting was to follow up with the facility after an initial NCC was held on 10/13/2023. Due to facility staff availability the NCC meeting was rescheduled for today. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, LPM Stephen Richardson, Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA) Jamie Ivey Canady, LPA Pang Lee, facility board member Ryan Williams, facility board member Scott Clawson, Director of Nursing Melina Dearing, Adminstrator Caleb Summerhays and AShawna Pillay, Resident Care Director. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process as well. Since the facility has been re-licensed in 2021, there have been 16 Type A citations and 8 Type B citations. The focus of the concerns at this time were as followed: - Multiple medication violations including Insulin not being provided by a skilled professional - Care and Compliance - Facility resident pressure injuries - Update of Facility staff roles, duties, and responsibilities Continued on 809-C - Pharmacy addition for filling resident prescriptions - Onboard of Clinical Consultant - Wanderguard System Licensee agreed to do the following in order to bring the facility into compliance: Please provide the following to LPA by 11/7/23. - Provide the Department with an updated LIC500 - Licensee shall provide updated Plan of Operation that includes new staff department head personnel roles, responsibilities and duty statement - Licensee shall provide the Department with a plan of how the facility will assess and monitor resident skin issues. - Licensee shall create a plan and policy on residents with dementia - Licensee will provide the Department a plan for proof of staff, staff training and monitoring required staff training to include updated staff training documents for CPR/First Aid of facility staff - Licensee shall provide the Department with proof of staff certified to assist residents with insulin and a plan regarding how the facility handles insulin assistance when certified staff is not on site. Licensee has accepted the offer of Technical Support Program (TSP) offered by the Department Exit Interview Licensee/Administrator signature on file.