Non-compliance follow-up·March 14, 2024

On 3/14/2024, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a required quarterly case management visit in accordance with the Stipulation and Order, effective date 06/01/2022 to 06/01/2024. LPA met with the Executive Director (ED), Natasha Georges, and explained the purpose of the visit. During today's visit, LPA observed the common areas to be clean, safe, sanitary and in good repair. LPA reviewed facility's stipulation binder and reviewed the orders of the stipulation. LPA observed an audit of total care staff hours and total care task for month of January 2024, February 2024 and partial of March 2024. LPA observed the facility to conduct daily audits of emergency call response and incident reports for residents if call exceeds ten minutes. LPA observed documentation of facility's staff training conducted in month of January 2024. LPA observed the recent report submitted to LPA, between February 20 - March 4, there was a total of 883 calls made, there was three calls exceeding ten minutes. LPA and Executive Director discussed the facility's current standing of nine days with no response call exceeding ten minutes. As a result of today's visit, LPA observed the facility to be in compliance to Stipulation and Waiver and Order. Exit interview conducted and a copy of the report will be emailed to Executive Director.