Follow-up·March 12, 2025

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Other and met with Administrator Myla Ilagan. The purpose of this visit is to follow up on deficiencies that were issued during an Annual Inspection on 1/16/2025. LPA explained the purpose of the visit to ADM. LPA observed 18 clients and 6 staff at the facility. On 1/16/2025, LPA conducted an Annual Inspection visit. During review of resident records, LPA observed that R3 and R8's medical assessment's ambulatory status is non-ambulatory. R3 and R8 occupy ambulatory rooms. A deficiency was issued and a Plan of Correction (POC) was developed with the ADM. The ADM stated the facility would talk with the families of R3 and R8 about moving into the appropriate rooms based on their ambulatory status. LPA also issued a deficiency for 19 resident bathrooms that did not have slip-resistant mats. ADM stated the facility would purchase slip-resistant mats for 19 resident bathrooms as part of the POC. During today's visit, LPA inspected R3 and R8's room and observed R3 and R8 are still in ambulatory rooms. ADM stated she was still working with the families of R3 and R8 about moving rooms. LPA advised ADM to submit a fire clearance request to the Department by the end of visit today 3/12/2025. ADM submitted fire request to Department during visit. LPA inspected 19 resident bathrooms and observed a non-skid mat in each resident bathroom. LPA cleared the deficiencies cited on 1/16/2025 during today's visit. A Letter of Deficiency Citations Cleared was printed and provided to ADM during today's visit. No deficiencies were cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with ADM Myla Ilagan and a copy of this report was provided.