Office review·October 25, 2023

Sacramento South Regional Office held an office meeting via Microsoft teams on 10/25/23 at 11:00 AM. The purpose of the meeting was to discuss Solvency and Trust Audit Report Findings. Present in today's meeting were Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Maja Jensen, LPA Christina Valerio, Gereral Auditor (GM) Jorge Mojica, and Licensee/Administrator Justice Ehimaiegho. Topics of Discussion: Solvency Audit Report Findings - Based on information received and reviewed, it appears licensee has not established or maintained a financial plan Operating Income: Facility’s operations generated a net profit, during the sampled month. However, reported food costs were below USDA guidelines and must be increased. Reported Food Cost is $2,800 and USDA suggested Food Cost for 14 Residents is $3,437.00 . Cash Reserves: Licensee does not maintain sufficient cash reserves to ensure provision of care and supervision to residents. Recommended amount is to equal the monthly operating cost. Trust Audit Report Findings - Improvement is needed in licensee's procedures when handling and safeguarding of resident monies. Staff is handling resident’s monies but did not notify regional office or obtain a Surety Bond. Licensee safeguards some residents’ debit cards but did not notify the regional office or obtain requisite Surety Bond. In addition, affected persons did not know (or did not recall) that facility staff safeguarded their debit cards. Licensee should make reasonable efforts to safeguard resident property, including implementing a theft and loss program. Continues on LIC 809 - C... Continued from LIC 809 2. Trust Audit Report Findings Continued - Licensee did not provided requested items to auditor, even after multiple requests. Licensee will do the following: Licensee to provide to Audits Section by January 22, 2024 : A balance sheet (LIC 403 or equivalent) reflecting all assets and liabilities, as of December 31,2023, an income statement (LIC 401 or equivalent) for the months of October 2023, November 2023, and December 2023 summarizing all income and expenses, and month end bank statements for all operating and savings accounts used for licensed facility for period of October 1, 2023, thru December 31, 2023. Other information and documentation to be requested, as needed. Licensee to provide to Audits Sectio n by the 3 rd week following each quarterly visit, provide to Audits Section an, income statement (LIC 401 or equivalent) with support, for the last month in the quarter and Bank statements (savings and checking accounts) and Utility vendor’s billings for each month of the previous quarter. Licensee to provide the Regional Office a statement regarding Licensee Business Cash Reserves by November 27th, 2023 Licensee to submit a statement whether they will or will not change their plan of operation regarding handling/safeguarding resident monies by November 11th, 2023 Licensee to submit a copy of in-service training provided to staff regarding Bonding, Safeguard for Resident Cash, Personal Property, and Valuables, and Theft and Loss by November 11th, 2023 The Regional Office will do the following: Continue Quarterly Financial Monitoring for a period of 1 year (to October 31, 2024) RO to determine quarterly status after two quarterly periods Continue to collaborate with Licensee as needed Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, deficiencies are being cited on today's visit. Technical Advisory was provided for Title 22, Section 8755, General Food Service Requirements. An exit interview was held, and a copy of the report was provided via e-mail. Licensee to review, sign, and return signed copy to LPA by COB 10/272023.