Non-compliance follow-up·February 20, 2025

Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager, Billy Mitchell. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with staff to include garden house (aka memory care), plaza, common areas, and courtyard areas. During the tour, LPA observed 11 staff members who are fingerprint cleared and associated to the facility. In Garden House, LPA randomly entered into rooms 125A, 124, 122A, 120, and 113 with the Garden House Director. All sharp objects, chemicals, disinfectants, and garden supplies observed secured in garden house. LPA observed 1 out of the 5 rooms had hygiene products accessible, however, based on the resident's physician's report the resident is not at risk if allowed direct access to these items. LPA observed the resident's room door was closed. In Plaza, LPA randomly entered into rooms 210 and 202 with the Health Services Director. LPA observed 1 out of 2 resident rooms (R1) contained chemicals/disinfectants to include laundry detergent and dish soap accessible in the cabinet underneath the kitchen sink. Based on review of this resident's (R1) file, the resident is diagnosed with dementia and should not have access to chemicals/disinfectant items per the signed physician's communication sheet. HSD removed the items immediately and informed the resident. Page 1 of 2. Based on the non-compliance plan, training was scheduled to be completed by a certain date for reporting requirements; change of condition and observations of decline in condition or ability; personal rights of a resident; reappraisals; and care of persons with dementia as it pertains to toxic substance and sharp objects. LPA observed all training topics stated on the non-compliance plan was completed on July 18, 2024 . Staff were also provided in-service training on personal rights in December 2024. The training document contains the topic, date, name and signatures of the participants. LPA advised the GM to ensure all staff are provided annual training on these specific topics per the non-compliance plan. 5 random resident files were reviewed. The files reviewed contained a signed personal rights form, physician’s report, and a signed up-to-date appraisal/needs and services plan. 5 random staff files were reviewed. 5 staff are associated to the facility and fingerprint cleared. LPA Kabariti advised to ensure all new staff review and receive instruction regarding resident rights upon hire and the training must be documented in the staff’s file. LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. GM was reminded of the discussion on June 13, 2024 of the facility being under frequent monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with General Manager, Billy Mitchell and Health Services Director, Jocelyne Bailon and a copy of the report and appeal rights was provided. Page 2 of 2.