Non-compliance follow-up·May 25, 2021

Licensing Program Analyst (LPA) Alviso, conducted a case management- Legal/Non-compliance inspection, on 5/25/21, at approximately 12:50pm; LPA met with Administrator Stephanie Limberg. This is a continued case management inspection, first inspection held on 4/29/21 and 4/30/21, see LIC809s/809Cs. The facility grounds inside and out, and facility records must be in compliance regarding health and safety, per title 22 regulations, health and safety code, and in compliance with t he terms and conditions of the probation order. CDSS #7218211101-F, PER STIPULATION, WAIVER & ORDER 11/19/18, LICENSE REVOCATION, STAYED FOR 2 YEARS, PROBATION PERIOD EFFECTIVE 8/7/19 TO 8/7/21. REPOPULATION WAS APPROVED 8/7/19. LPA reviewed thirteen(13)emergency preparedness training files on staff; LPA also reviewed staff designated as disaster leaders to have obtained emergency preparedness training & disaster leader emergency training as well. This is the facility's training in how staff will act/proceed in the event of an emergency. It was difficult for the LPA to see training requirement had been met by the file review only. The Administrator had to gather and provide additional documentation in order for the LPA to identify if staff had required emergency preparedness training, and if a designated disaster leader also had training as required by the facility's emergency preparedness plan/facility emergency plan/manual. LPA found that staff had required training. LPA provided technical assistance to the Administrator during the inspection regarding some ways tracking training records, and having proof of training ready and available for review, and clearer to see the proof of training, on emergency preparedness training, and the emergency disaster leaders training. LPA asked that the proof of training documents include and/or have attached the topics covered, keep information together, in order to show it meets the requirement. The designated leaders in charge are the leaders in the event of an emergency such as an evacuation, etc, this training is very important and part of the emergency plan, requires proof of training. Administrator stated that she will ensure the proof of training documentation will have all topics attached, as this was something that didn't show on certificates being printed on staff's obtained training(s). Administrator stated that staff will also be doing the required training(s) by anniversary date of hire. No citations issued. Exit interview conducted with Administrator Stephanie Limberg.