Follow-up on corrections·February 19, 2025

Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct an initial 10-day Complaint Investigation Visit and subsequently discovered other unrelated deficiencies resulting in this Case Management - Deficiencies Inspection. The purpose of this case management visit was address these areas of noncompliance observed during today's visit. During today's visit, LPA made observations, obtained documents, and conducted interviews with Licensee and I1. LPA was informed that facility currently has one resident in care. However, LPA observed an additional non-personnel Individual 1 (I1) sitting in the facility's common area who appeared to be receiving care. LPA asked Administrator/Licensee if I1 is a resident and Licensee stated they are not. Licensee stated that I1 only came for the day while their primary caregiver went to an appointment. Later, LPA asked I1 how often they come to the facility. I1 stated they come about once per week. LPA asked if I1 ever stays the night and they stated "no." LPA asked I1 if they take medication at the facility, and I1 stated "yes." Licensee was unable to provide LPA with any records for I1. (See LIC809D.) During Compliant Investigation, LPA was made aware of two staff who work at the facility in addition to the Licensee. During this visit, LPA reviewed the facility personnel report, Guardian roster, and personnel files. Staff 1 (S1) did not have proof of the required annual training hours or annual medication training hours, (see LIC809D). Staff 2 (S2) was not associated to the facility, (see LIC8009D). Additionally, Licensee was unable to provide LPA with multiple required personnel documents including training for S2, (see LIC809D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 and/or the Health and Safety Code. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given. Exit interview was conducted with Licensee, whose signature on form confirms receipt of documents.