Correction check·March 17, 2022

LPA Albert Johnson arrived unannounced for a case management visit. To follow-up on clarification with the Licensee if there has been any progress in the change of ownership since the last request on 11/24/2021 and to confirm who has current control of property, when the residents were notified of any changes and if there was a change to the management company. During the inspection on 11/23/2021 LPA Johnson requested to the department the required information outlined in this regulation 87211(a)(h). (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (h) Any change in the chief corporate officer of an organization, corporation or association shall be reported to the licensing agency in writing within fifteen (15) working days following such change. Such notification shall include the name, address, and the fingerprint card of the new chief executive officer, as required by Section 87355, Criminal Record Clearance. The information was to be submitted to the department by 12/03/2021. LPA Johnson has not received this information as of this date 3/17/2022. The repeat citation will be included on the attached 809D page. Continued. The facility was to submit documents to the Department on February 27, 2022 and to this date the facility/licensee et.al. have not provided the requested information. As of today March 17, 2022 the following items are still outstanding: Section A Documents: A4. Administrative Organization (LIC 309) · Resubmit LIC309 – box 8, include percentages of ownership. A7. Monthly Operating Budget (LIC 401) · Resubmit LIC401 – line 7, revise Food Costs, should be at minimum $200 per resident. Resubmit LIC401 – line 27, include monthly rent. A9. Financial Information Release and Verification ·Submit – Northstar Senior Living, Inc bank statement, from within the past 60-days, to demonstrate one month’s operating costs (line 37 of LIC401). A10. Personnel Report (LIC 500) Resubmit LIC500 – specify days of shifts. A13. Criminal Record Statement (LIC 508) Submit LIC508 – for Leslie. Section B Supportive Documents: B1. Partnership Agreement/Articles of Incorporation/Articles of Organization ·Submit – Articles of Incorporation (from Secretary of State) for Northstar Senior Living, Inc. Other: RCFE Disclosure Worksheet (LIC606) – submit. · COVID 19 Mitigation Plan (LIC 808) – submit (Licensee may have one on file; can submit). Driver’s License – submit, for Leslie, to complete facility association. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed and cited during this visit. Exit interview held and a copy of report given and appeal rights at the conclusion of the visit.