Non-compliance follow-up·November 19, 2024

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Legal Non-Compliance Case Management inspection and met with Resident Services Director Tiffany Roas (RSD). Admin not present but was available by phone. RSD gave Senior Business Office Manager (BOM), Mitchell Moore permission to sign report. As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, the facility submitted a Monthly Quality Assurance (QA) Audit that includes but is not limited to staffing, physical plant, dementia care, medication records and infection control. LPA reviewed QA and found that there were deficiencies pertaining to medications: two [2] resident rooms were not free of medications and creams/lotions were left out in resident rooms ( deficiency cited, see 809D ). LPA conducted a tour of the facility 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. Per QA, check of staff training was in compliance. LPA reviewed training records of employees identified on the QA report and found documentation present, except for one employee. One employee (S1) identified as having CPR certificate present in their file actually did not have a CPR certification or training certificate present in their file. LPA contacted Director of Regulatory Compliance (DRC), person whom submitted the QA report, to ask about this discrepancy. LPA asked if there were any circumstances under which they would mark that the CPR card was present when it actually was not present, DRC answered that it must have been a mistake but will move forward with increased diligence. Continued on 809C... Continued from 809... LPA reviewed the most recent staff schedule to verify that facility has sufficient staff for resident's needs including but not limited to residents needing two-person assists. Per conversation with Administrator, they staff two caregivers for each unit on each shift, with a rotating Med Tech that will serve as the Med Tech for both Memory Care buildings. Managers will provide additional assistance for breaks and lunches, when needed. Staffing is still an issue, but per LPA review of LIC500 and conversation with Administrator, facility has hired 8 new staff members and a new Resident Care Coordinator. New staff members are currently undergoing their training and will be added to the shift as soon as shadow training is successfully completed. Per Admin, facility is not allowing new hires to be put into the 4/2 rotation (work 4 days, then off 2 days) until they have shadowed a complete 4/2 rotation. Additionally, Admin explained that should the staff be identified not quite ready, facility will have them complete another 4/2 rotation shadowing. Review of audit showed other minor instances of non-compliance however the instances were not significant or frequent enough to warrant a health and safety concern. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with BOM. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with BOM and a copy of this report was given .