Follow-up·May 21, 2025

At 11:20pm on 05/21/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to continue the investigation to a subsequent complaint. LPA met with, Administrator, Lisa Gerr announced who he is and the reason for the visit. LPA conducted a cursory tour of the facility. LPA conducted interviews with staff and attempted interviews with residents, and reviewed documentation. It was discovered that Direct Care Staff 1 (S1) had not been registered with Guardian and was not present on Licensing Information Systems (LIS) when checked during the complaint investigation visit. Administrator stated that S1 was cleared and associated, however it S1 did not appear on both background clearance cites. LPA assisted Administrator to attain S1's PERS number as was able to associate S1 during the course of the visit. Administrator stated that this was S1's first day. This resulted in a citation of S1 not being cleared for 1 day (87355(a)). During the complaint visit LPA requested Registry of Residents. Administrator stated the f acility did not have a Register of Residents (LIC9020) upon demand during normal business hours resulting a citation issued (87508(b)). Administrator was able to create a new LIC9020 during the course of the visit. LPA issued two citations and a civil penalty as a result of this subsequent case management visit to the complaint report issued on the same day and visit. Exit interview, report read, citations and civil penalty issued, appeal rights and report provided.