Follow-up on corrections·October 18, 2023

On October 18, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to the case-management visit that was conducted on 9/22/2023. LPA met with Administrator, Scott Evans and explained the purpose of the visit. During the investigation conducted by the Department, it was revealed that Staff 1 (S1) had a clerical/administrative position while being employed at the facility. Based on documentation reviewed, S1 did not have any formal caregiving training to be able to provide care to residents at the facility. In addition, Staff 2 (S2) and Staff 3 (S3) acknowledged that S1 did not have any formal training in caregiving duties. During the investigation, it was also discovered that S1 required a criminal record exemption in October of 2020, however failed to complete the exemption process by January of 2021. S1 was disassociated from the facility on 1/12/2022 but continued to work in the facility until S1’s resignation on June 1, 2023. According to the staff interviewed, on May 27, 2023, the NOC shift had a last-minute call off and S1 offered to work overtime. S2 and S3 approved S1’s request for overtime as a last-minute caregiver to ensure the facility had enough staff for the night , however due to S1’s lack of training and caregiving experience, S1 was instructed to contact other caregivers on shift if a resident needed assistance. According to the Administrator, there are usually 3-4 NOC shift staff members, but on the evening of May 27, 2023 to the morning of May 28, 2023, there were only three staff members; S1, Staff 4 (S4) and Staff 5 (S5). During this shift, S4 only saw S1 when he/she arrived to work and denied having any further interaction with S1 the rest of his/her shift. S1 and S5 went to three resident rooms to provide incontinence care together, however at 3:18am, S1 was observed entering Resident 1’s (R1’s) room alone. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with Administrator; a copy of the report is provided with appeal rights. Copy of civil penalty is provided