Non-compliance follow-up·April 15, 2024

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Legal/Non-compliance inspection and met with Executive Director (ED) Lola Bullock. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) office after a Non-Compliance Conference held on 07/25/2023. The case management of inspections will be conducted every 3 months for 2 years. LPA reviewed the plans and policies regarding the resolution for the prior deficiencies with ED. LPA reviewed the plans and policies addressing the resolutions for the prior deficiencies. LPA reviewed the staff training records. LPA discussed with ED regarding the facility protocol of completing residents' appraisals/reappraisals and training provided to staff regarding appraisal/reappraisals for residents, identifying fall risk residents and maintaining a list of fall risk residents and the safety plans for them. LPA discussed with ED regarding residents' needs and service plans, residents' hospital discharge orders, doctor orders and the changes of resident care plans are enforced and met. LPA discussed with ED regarding the residents' medications administration and maintenance of resident medication records. LPA discussed with ED regarding the duties and responsibilities of Administrator and staff to ensure residents' needs are met. LPA discussed with ED regrading providing regular staff training with medications, appraisal/reappraisal, care and supervision, and fall risk and prevention of fall. LPA toured the facility with ED from first floor to forth floor including the memory care unit, assisted living unit, wellness center, dining room, kitchen, activity room, kitchen and laundry room. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED.