Non-compliance follow-up·June 6, 2023

Licensing Program Analyst (LPA) 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 continues to submit monthly reports to LPA that include an LIC500 that shows staffing, resident roster that includes how many residents are two 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. Administrator also provided the most recent medication audit that was completed by a vendor. LPA conducted a tour of the facility around 9:00am with Administrator that included both memory care units, the assisted living care unit and the grounds. Facility provides monthly training to 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 including but not limited to residents needing two person assists. 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. Continued on LIC809C Continued from LIC809 Facility continues to submit Special Incident Reports within the regulatory time frame. Facility recently reported an elopement of a resident who resides in Memory Care. Per discussion with Administrator, they believe that the resident followed a staff or visitor out of the memory care unit. Facility followed their elopement protocol and resident was found about a block from the facility. Resident had a skin tear but facility was unsure if the resident had fallen so they were sent to the hospital. No additional injuries were noted and resident returned to the facility the same day. 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. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. .