Non-compliance follow-up·June 20, 2023

On 6-20-23 at 9:00am, a meeting was held with licensee to discuss a Technical Support Program Engagement Summary (TSP) generated on 05/25/2023. This meeting was held virtually via Teams Meeting. Present at this meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Maja Jensen, LPA Jennifer Fain, and Ombudsman Kathryn Thomas. At the beginning of the meeting, Licensee confirmed receipt of TSP material from virtual visits on 2/7/23, 2/23/23 and 3/2/23 as well as the on site visit from 2/23/23. LPM and LPA discussed the following topics previously addressed at the TSP Engagement: · Client assessments update requirements · Licensee generated system to track specific files requiring updates · Use of CARE tools to aid in maintaining compliance · Communication with LPA to preemptively address discovered issues and resolutions · Assessment procedures to ensure staff are able to meet needs of clients · Reporting requirements such regulatory requirements and what constitutes an incident report · Medication Management including destruction of Medication and PRN’s Continued on LIC 809C.... Continued from LIC 809... The Licensee has agreed to the following: A medication audit to be completed by the 6/30/23 with audit results submitted to LPA Maja Jensen at maja.jensen@dss.ca.gov . Submission of the Needs and Service Plan tracking system currently in place to be submitted to LPA Maja Jensen at maja.jensen@dss.ca.gov by 6/30/23 A medication training refresher for all staff to be completed within 90 days A Reporting Requirements training refresher for all staff to be completed within 90 days No citations issued today. An exit interview was conducted with Jean Alvarez and a copy of this report was emailed to Jean with a request to return with signature to maja.jensen@dss.ca.gov .