Non-compliance follow-up·May 22, 2024

On 5/22/2024, 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 reviewed facility's stipulation binder and reviewed the orders of the stipulation. LPA observed facility audits of emergency call responses, care records and incident reports. LPA observed E-call testings to be completed for residents in care for month of April 2024. LPA observed last reporting of response call exceeding 10 minutes to be sent to Licensing on 5/17/2024. LPA observed in-service training regarding PHB, Valve Shut off- to be conducted on 5/9/2024. LPA observed the signatures of staff present. LPA observed the facility to be clean, safe, sanitary and in good repair at all times. LPA observed the stipulation to be posted in a conspicuous space. LPA and Executive Director discussed the upcoming end of facility's probation term. LPA informed Executive Director once probation has ended, a new facility license will be generated and mailed to the facility. 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 was provided.