Correction check·September 9, 2022

Licensing Program Analyst Willis arrived unannounced to conduct a Plan of Correction visit and to amend a report and met with Administrator, Angie Smith. On August 31, 2022 facility was cited for violating regulation 87411(a) Personnel Requirements - General and 87464(f)(4) - Basic Services. Licensee has submitted a correction to 87411(a). The correction for deficiency 87464(f)(4) states that " Licensee agrees to submit an updated policy outlining how all staff including but not limited to kitchen staff, caregivers, Medication Technicians and Activity Directors will be notified of resident's needs and how facility will ensure the needs are met." Licensee has written a letter indicating that they will not be changing their policies or protocol. Because a correction to the deficiency is required, LPA discussed the concern with the Administrator. Based on LPA's observation today and conversation with Administrator LPA will clear deficiency 87464(f)(4) and Administrator agrees to submit an updated LIC500. On the LIC809D form dated August 31, 2022 LPA put an incorrect code under the Section Number so has returned to correct that error. Facility has a new Administrator and LPA has notified them of the requirement that documents to change the Administrator of record must be sent to CCL within 30 days. No deficiencies cited during this inspection.