Non-compliance follow-up·April 11, 2025

Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Case Management visit to conduct a Non-Compliance Plan Quarterly Visit and met with Meghian Geul, Administrator. LPA announced the purpose of the visit. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 04/26/2024. LPA requested the following documents for in-service training for staff between 12/01/24 to 04/01/25. Which included but not limited to: Elopement, Working with hospice, emergency drill, Medication assistance, Cognitive issues, emergency drill, PPE and hand washing, preventing recognizing and reporting abuse, elopement protocol, back to basic medication assistance, medication error policy, miss or refused medication policy, the six rights, controlled medication, medication storage, change of condition/scabies/skin reporting, medical emergencies calling 911, elopement response time(shift report), shower skin sheet, medication error prevention, security door checklist, shift report documentation, hospice nursing service, ADL competency, controlled medication, pharmacy profiling, activity engagement, behavioral expressions, foley catheter empty bag, security door checklist for door shift change, meal roster, shower sheets, temperature logs, safe in room, dementia behaviors abuse prevention, what is hospice, and staff crossover. LPA toured the memory care unit and tested egress doors and the doors made an auditory sound when opened, all exit doors to courtyard in memory care have a auditory alarm when opened that needs a code to reset. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Meghian Geul and a copy of the report was provided.