Non-compliance follow-up·September 12, 2023

Licensing Program Analysts (LPAs) Bertozzi and Rummonds 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. LPAs conducted a tour of the facility around 9:20am with Administrator that included both memory care units, the assisted living care unit and grounds. Facility appeared to be safe, sanitary and in good repair. 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. Training documents were not accessible during this visit but Administrator agreed to submit documents to LPA. 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. 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. No deficiencies cited during this inspection.