Follow-up on corrections·June 27, 2023

On 06/27/2023 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown met with Executive Director (ED) Julie Dion at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office for a Case Management Deficiency. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation. During the facility visit last 06/02/2023, LPA Brown toured the facility, observed residents in care in the dining area during the visit. LPA Brown requested a copy of Resident Roster and LIC500 Personnel Report from Executive Director Julie Dion. During the process of the investigation, LPA Brown observed last 06/24/2023 that Staff #7 (S7) was working at the facility since 03/14/2021 without criminal background clearance exemption as S7 criminal exemption was denied. On 06/26/2023, LPA Brown contacted ED Dion via telephone and informed ED Dion that S7 must act immediately to remove S7 at the facility as S7 does not have criminal background clearance due to S7's Criminal Exemption being denied. LPA Brown explained to ED Dion that deficiency will be issued as this pose immediate health, safety and personal rights risk to residents in care. A civil penalty of $500.00 was assessed for Staff #7 working at the facility without criminal background clearance exemption and will continue to be assessed of $100.00 per day until corrected during the Office visit. Also, during the investigation, LPA Brown discovered that the facility failed to report Resident #9 death at the facility to Community Care Licensing Division (CCLD). LPA Brown informed ED Dion that Technical Violation will be issued to the facility for this issue. An exit interview was conducted where this report, LIC809, along with LIC809D, LIC421BG, LIC9102 and Appeal Rights were discussed and provided to Executive Director Julie Dion.