Correction check·January 30, 2024

Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 01/30/2024 at 10:10 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee was greeted by direct care staff Theodore Patterson and explained the purpose of today’s visit. The current census is 8 with 2 staff present in the facility. A brief telephone call was made to administrator Mark Labella in regard to POC. The purpose of this visit is to follow-up on two plan of corrections that was due on 01/12/2024 and 01/23/2024. LPA Lee toured and inspected the facility to ensure the deficiencies previously cited on 01/09/2024 has been corrected. It was learned that resident 1 (R1) who is non-ambulatory is still residing in bedroom #5, which is licensed for 2 ambulatory residents only. Direct care staff, Theodore informed LPA Lee that the facility cannot moved (R1) to a different bedroom since all the residents in the other bedrooms are also non-ambulatory. During today’s visit, LPA Lee recited the facility due to POC not being corrected or an POC extension was not communicated to LPA Lee. During today’s phone call with administrator Mark, he explained that he is currently working on getting resident replace through Master Care and that he is also working with Metro Fire to get bedroom #5 clear for non-ambulatory. During 01/09/2024 annual visit, LPA Lee had explained to both administrator Mark Labella via telephone and to direct care staff Theodore what the options are in regard to the citations 87202(a)(1). Again, during today’s visit LPA Lee advised administrator Mark Labella and direct care staff Theodore what those options are. LPA Lee advised that administrator need to 1. Change the fire clearance, 2. Have resident moved to a non-ambulatory bedroom and 3. Find a new placement. POC was due on 01/12/2024; however, LPA Lee did not receive any communications from the administrator in regard to POC needing to be extended. Today, LPA Lee observed and learned that the census is 8 with only 1 ambulatory resident who is already in bedroom #5 with (R1); therefore, the administrator won’t be able to move any of the other residents to bedroom #5. On 01/09/2024 and today’s visit, LPA Lee observed two facilities sketches displaced on top of a piano. Continued on LIC 809-C The first facility sketch showed resident bedroom #5 as an ambulatory room and the second facility sketch, which was behind the first facility sketch showed that resident bedroom #5 as a non-ambulatory bedroom. During today’s visit LPA Lee also advised administrator Mark that if for any reason he needs an extension on his POC it is his responsibility to notify the department. Based upon this inspection, LPA Lee observed the following: 1. Deficiency cited under Title 22 Regulation 87465(a)(4) has been cleared. The license did comply with the terms of the POC during today’s visit. During today’s visit administrator Mark asked LPA Lee to give him 10 minutes to send POC to LPA Lee email address. 2. Deficiency cited under Title 22 Regulation 87465(a)(4) has not been cleared. The license did comply with the terms of the POC and POC due date 01/12/2024 during today’s visit. As a result of this POCl visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC-809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.