Office review·October 26, 2023

A Non-Compliance Conference (NCC) was conducted on this day, 10/26/2023, 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 9/30/2022. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, LPM Stephen Richardson, Licensing Program Analyst (LPA) Tung Truong, LPA Christina Valerio, facility Regional RCFE Stephen Sarine, VP of Operation Michelle Baker and facility staff Barb Rose and Kayleen August. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process as well. Since the last meeting on 9/30/2022, six new complaints have been filed against the facility and four Type A deficiencies have been cited. The facility was cited for the following issues: Personal Rights of Residents in All Facilities, Administrator Qualifications and Duties, Basic services care and supervision and Plan of Operation. The focus of the concerns at this time were as followed: - Designated Facility Administrator-Qualifications/Duties - Maintaining continued compliance - Oversight of facility staff for proper care and supervision - Facility staff roles, duties, and responsibilities - Plan of Operation regarding outside agency Continued on 809-C - Plan of Operation regarding resident with behaviors - Adhering to the Plan of Operation - Outside staff fingerprint clearance and facility association Licensee agreed to do the following in order to bring the facility into compliance: Please provide the following to LPA by 11/3/23. - Provide updated Plan of Operation regarding admitting resident with behaviors - Provide updated policies and procedures regarding using outside agency staff - All staff including administrator shall receive training on Resident Intervention and Redirecting - All staff and administrator shall receive in-service training on Reporting Requirements Exit Interview Licensee/Administrator signature on file.