Follow-up·June 7, 2024

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted a case management visit for an exemption request for staff (S1) that cannot be completed due to incomplete information and incorrect form used. LPA met with Administrator (ADM) Elizabeth Bautista and stated the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) that serves individuals who are age 60 and over, approved for 6 non-ambulatory of which 1 may be bedridden and hospice waiver for 4. LPA observed 5 out of 6 residents and 2 staff (S2 and S3), at the facility. 1 Out of 5 resident was in the living room watching TV, 1 Out of 5 is under hospice care, 3 out of 5 are in bed and resting. 1 out of 5 is out of the facility for medical appointment. LPA checked Guardian S2 and S3 are both associated with the facility. LPA interviewed S2 and S3. and 4 out of 5 residents (R1 to R4). LPA reviewed staff record and found that S1 worked at the facility since 5/7/2023 and no exemption transfer request was submitted to CDSS CPMB (Care Provider Management Branch). Based on interview with S1, S2, and residents (R2 and R5) S1 works at the facility and provides care to residents. ADM stated that S1 has been working as a part time for the facility since 5/7/2023, and had an exemption from the old license that was closed on 8/23/2022. The exemption transfer approval for S1 was not transferred to the new license. ADM stated that he/she assumed that the exemption transfer approval of S1 from the old license is still effective after the closure of the old license. Continuation on LIC 809-C, page 1 of 2 LPA discussed with ADM Title 22 CCR 87355 (e)(3) Criminal Record Clearance wherein, (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r) unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility LPA discussed with ADM the importance of Title 22 CCR 87405 - Administrator Qualification (d)The administrator shall have the qualification as specified in Section 87405(d)(1) through (7). (2) Knowledge of and the ability to conform to the applicable laws, rules and regulations. During visit, ADM started to work on the exemption transfer request for S1, filled the LIC 9188 and faxed the request to CPMB. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC 809-D. A civil penalty is being assessed for the amount of $500 for S1 working in the facility for more than 5 days without receiving criminal record exemption transfer approval. The civil penalty will be for $500 ($100 per day x 5 days = $500). See LIC421BG. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator Elizabeth Bautista and a copy of the report and Appeal Rights were provided. end of report page 2 of 2