Follow-up on corrections·May 10, 2023

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to the fire clearance for non-ambulatory residents. LPA met with Rowena Tirasol, caregiver, and Rosanna Mead, Administrator, and explained purpose of the inspection. LPA recently received an exception request for a non-ambulatory resident (R1) to be allowed to reside in a room approved for an ambulatory resident. During today's inspection, LPA reviewed the prior physician's report (LIC602) dated 8/24/21 which notes R1 is wheelchair bound and non-ambulatory. LPA also reviewed the updated LIC602, dated 3/7/23 where it also denotes R1 as wheelchair bound and non-ambulatory. LPA observed R1 to be awake and ambulating on her own in a wheelchair. Administrator and LPA contacted Sac Metro Fire Department to inquire when they could visit the facility and evaluate if the room R1 currently resides in can be approved for a non-ambulatory resident. Administrator stated to LPA that in years past, the room where R1 is staying was approved for a non-ambulatory resident and then later approved for staff use in March 2009. LPA reviewed documentation supporting this. The Department will follow up and send an STD850 to Sac Metro requesting R1's room be inspected for possible approval for non-ambulatory, as it is near an exit door. R1 moved to the facility on/around August 2021, moved out in March 2023 and returned in May 2023, and has resided in the same room the entire time. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency is issued on the 809D page. Exit interview. Copy of report and appeal rights provided to Administrator.