Follow-up on corrections·October 15, 2021

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting a follow-up visit regarding complaint (#18-AS-20200608131822). LPA Colvin met with Administrator Dekki Mawikeri and advised them of the purpose of the visit. During LPA Colvin's visit, LPA Colvin addressed the following issue which was discovered during the investigation: The complaint (#18-AS-20200608131822) that LPA Colvin investigated primarily revolved around an incident that occurred on 6/8/20 when paramedics were called due to a medical emergency regarding one of the residents at the facility. During LPA Colvin's review of Community Care Licensing's (CCL) record of reported incidents from this facility, LPA Colvin observed that CCL did not receive an Incident Report for 6/8/20. In fact, CCL has not received any Incident Reports or Death Reports from the facility since their opening in 2014. All unusual incidents (and deaths) which may pose a risk to a resident's health or safety (such as: calls to 911 or medical emergencies) are to be reported to CCL within 7 calendar days. Deficiency cited. Additionally, facility staff admitted in interviews that the previous staff member (S1) took photos of the residents (R1) who was receiving emergency medical care from the paramedics. It was confirmed that the facility does not have prior written permission from the resident or responsible party to have photographs taken. Deficiency cited. R1 passed away and was unable to be interviewed regarding consent for photographs. During today's visit, LPA Colvin observed that one of the staff members present (S2) was not associated to the facility. Additionally, the Administrator was unable to provide proof of background clearance for S2, as it was not in their file. According to previous interviews conducted by LPA Colvin, S2 has been working at the facility for 4 months. Deficiency cited. LPA Colvin will be assessing a civil penalty of $100 per day that S2 has worked at the facility without background clearance. Since it was reported to LPA Colvin that S2 has worked for 4 months and the facility does not have any records stating otherwise, LPA Colvin will issue penalties for the maximum of 5 days. $100 per day x 5 days = $500 in civil penalties being assessed today. Lastly, all staff files must contain pertinent records that reflect their eligibility to be employed at the facility. LPA Colvin was unable to confirm S2's background clearance due to the facility not having a copy of it in their file. Deficiency cited. LPA Colvin conducted an exit interview with Administrator Dekki Mawikeri, and a copy of this report, LIC809D, LIC421BG, and appeal rights were provided.