Follow-up on corrections·June 24, 2022

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 06/24/2022 at 08:45 AM unannounced in order to initiate a Case Management visit. LPA Brown met with Administrator/Licensee Letitia Isai and LPA Brown explained the purpose of today's visit. During the visit last 03/08/2022 at 11:30 AM, LPA Brown requested Licensee/Administrator Isai to lock R1's room door knob and also requested to open R1's room from the outside and LPA Brown observed that LIcensee/Administrator Isai is having difficulty opening R1's room door. LPA Brown observed R1's door knob in disrepair. LPA Brown informed Licensee/Administrator Isai that LPA Brown will be issuing a deficiency as this poses immediate Health, Safety or Personal Rights risks to residents in care. Licensee/Administrator Isai informed LPA Brown that new door knobs will be installed on all resident bedrooms after the visit. In addition, LPA Brown reviewed facility's incident reports and LPA Brown observed that no incident report was submitted regarding R1's fall or R1's observed scratch or bluish mark on R1's forehead. Also, LPA Brown noticed that the facility's last incident report submitted was 12/21/2020. LPA Brown informed Licensee/Administrator Isai that all incidents at the facility involving residents and staff must be reported to Community Care Licensing Division (CCLD) and LPA Brown will be issuing a deficiency for this item as this poses a potential Health, Safety or Personal Rights risk to residents in care. Moreover, interview with Staff 2 (S2) last 06/16/2022 at 03:53 PM indicated that no awake staff on duty at the facility to provide night supervision to the residents in care at all times. S2 reported "I worked from 8:00 PM to 8:00 AM. I checked the residents every two (2) or three (3) hours. Then, If everything's ok, I sleep at the sofa." *** Continuation on LIC809C *** LPA Brown reviewed the facility's LIC500 Personnel Report and it indicated S1 works 8:00 AM to 08:00 PM and S2 works 8:00 PM to 08:00 AM. LPA Brown explained to Licensee/Administrator Isai that if they have resident with dementia like R1 in reference to R1's pre-admission appraisal, and physician report (LIC624), it requires awake night supervision at all times. Thus, LPA Brown will be issuing a deficiency for this item as this poses an immediate Health, Safety or Personal Rights risk to clients in care. An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to Licensee/Administrator Letitia Isai.