Health check·February 10, 2023

Licensing Program Analyst (LPA) Renee Campbell arrived unannounced on 02/10/23 at approximately 9:00 am and was greeted by Caregiver Chudean Roper. LPA entered the facility and was led into a clean unobstructed area where one resident was sitting on the couch and four residents were in the dining room eating breakfast. Caregiver Ken Morris was present as well. R1 was sitting at the head of the table eating. A catheter bag could be seen beside her ankle. LPA confirmed with caregiver Roper that this was the new resident and that she had a catheter. No exception request has been approved as of this date however nurses had trained staff in R1’s care over a period of three days. Citation issued. LPA spoke to Administrator, who was out of the country, by phone. Administrator continued to assert that no exception was needed and that she did not know how to write the exception request. LPA reminded her that she could refer to the regulations. LPA had also provided a redacted exception letter as a basic guide. Before leaving, an exception letter was provided that will require review. LPA inquired as to who was the designated authority for the facility. Neither staff member was aware and were unfamiliar with the Designation of Facility Responsibility form when shown. Administrator stated she had designated R2 as the responsible person but the form could not be found and the administrator did not know where it could be. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 ,and California Health and Safety Code. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.