Non-compliance follow-up·October 27, 2022

Licensing Program Analyst (LPA) David Marrufo conducted a quarterly non-compliance visit and met with Administrator Elyse Gerson and Assistant Executive Director Preet Kaur. LPA Marrufo reviewed the facility training logs that are part of the following facility non-compliance plan: 1. Licensee shall develop a plan in writing describing the training of facility staff on identifying and reporting residents’ change in conditions for timely appropriate medical attention. 2. Licensee shall develop a plan in writing describing the training of facility staff on observation and assessment of residents for any changes in physical, mental, emotional and social functioning to develop a plan of care to meet the resident’s needs. 3. Licensee shall develop a plan in writing describing training of facility staff on identifying prohibited and restricted health conditions and on submitting exception requests to the Department for residents with prohibited or restricted health conditions. Staff should be trained on when to retain a resident, when to request an exception request for the resident, and when to seek a higher level of care for the resident. 4. Licensing shall develop a plan in writing describing the facility protocol when readmitting residents to the facility from the hospital or skilled nursing facility. The plan should include re-appraisals of the resident and developing a new plan of care to meet the resident's needs. 5. Licensee shall develop a plan in writing describing how the personal rights of residents are not violated when resident exhibits wandering behavior, particularly for residents diagnosed with dementia. 6. Licensee shall develop a plan in writing describing the facility protocol to collaborate with other agencies such as hospice agencies and home health agencies to ensure that doctors' orders in the care of the resident are met. 7. Licensee shall develop a plan in writing describing the duties and responsibilities of the Administrator to ensure that resident's health conditions and needs area addressed. The plan shall include staff meetings to communicate resident health conditions and needs. See LIC809-C for more information. Page 1 of 2. LPA Marrufo observed training for the non-compliance plans were conducted on 08/16/2022, 08/30/2022, 10/11/2022, and 10/13/2022. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Assistant Executive Director Preet Kaur and a copy of the report was provided.