Follow-up on corrections·January 19, 2024

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility to return facility records and discuss issues found during LPA's review of records. LPA met with licensee Elizabeth Colunga who was informed of the reason for the visit. On 01/12/2024, LPA conducted an unannounced required annual visit for this facility however no staff or resident records were available for review. As part of the correction plan and, as agreed upon by Licensee and LPA, Licensee brought facility records to the Regional Office on 01/16/2024 for LPA Bueno to review. LPA has returned all staff and resident records to the facility during this visit. All deficiencies cited on 01/12/2024 has been satisfied. Letters for cleared proof of correction were issued during today's visit. Personnel records review: LPA reviewed employee records for fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, including Dementia care. LPA confirmed that administrator certification is current but awaiting verification from the Department. Resident records review: LPA reviewed resident files and found current medical assessments and TB test results, necessary consent forms, identification and emergency information, appraisal needs and service plans, admission agreement, and personal rights notification. LPA found that Resident 1 (R1) is diagnosed with Dementia. This facility does not have an approved Dementia care plan. This poses a potential health and safety risk to residents in care. Refer to LIC 809D for deficiency cited. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to licensee Elizabeth Colunga