Non-compliance follow-up·February 24, 2023

Licensing Program Analyst Bertozzi arrived unannounced to conduct a Legal Non-Compliance Case Management inspection and met with Administrator, Cinthya Gamino. As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, the facility has submitted monthly reports to LPA that include an LIC500 that shows staffing, resident roster that includes how many residents are 2 person assists, and a Monthly Quality Assurance Audit that includes but is not limited to staffing, physical plant, dementia care, medication records and infection control. Facility provides monthly training to existing staff in order to comply with the Stipulation and Waiver, and Order and contracts with a vendor to ensure the staff training requirement is met. Administrator provided LPA with proof of training for Managers, Caregivers and Medication Technicians. LPA reviewed the most recent staff schedule to confirm that facility has sufficient staff for resident's needs. Per conversation with Administrator, they continue to staff two caregivers for each unit on each shift to ensure sufficient staffing. Managers and Medication Technicians provide additional assistance for breaks and lunches, if needed. Facility continues to submit Special Incident Reports within the regulatory time frame. Review of audits showed some minor instances of non-compliance however the instances were not significant or frequent enough to warrant a health and safety concern. Issues noted in the audit were immediately remedied by the facility. Other areas inspected are addressed as part of the Post Licensing inspection conducted today. No deficiencies cited during this inspection.