Non-compliance follow-up·September 15, 2023

A Non Compliance Conference (NCC) was conducted on this day, 09/15/2023, by the Sacramento South Regional Office via Teams meeting. The purpose of this Non Compliance Conference meeting was to follow up with the facility after the Informal Conference was last held on 05/23/2023. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Charlie Yang, and Facility Designated Administrator Steven Paul Hardin with Licensee Georgia Wilcomb. The Non Compliance Conference process was explained during this meeting to include the Administrative Process as well. The focus of the concerns at this time were as followed: Designated Facility Administrator-Qualifications/Duties Facility staffing Physical Plant Issues-Flooring/Carpeting for facility bedrooms and common areas Maintaining continued compliance Oversight of facility staff for proper care and supervision Reporting Requirements/Communication Licensee Role, Duties, and Responsibilities Licensee agreed to do the following in order to bring the facility into compliance: Complete and Submit the LIC 500 for the most current staff, shifts, and coverage by COB 09/22/2023 Complete and Submit the LIC 308 by COB 09/22/2023 Complete and Submit proof of most recent training in the areas of Medication Handling, Dispensing, and Proper Documentation. Proof of submission to include name of outside vendorized trainer, topics covered with duration of training, and list of all attendees by COB 09/22/2023 Complete and submit proof of certified Administrator for this facility by COB 09/22/2023 Not withstanding the above statement, the Department will take the following actions: The facility will continue to have additional monitoring and facility inspections to verify improvement in compliance. Facility designated Administrator has agreed to enroll and enlist services from TSP Complete and submit plan of admission for all residents by COB 09/22/2023 Failure to maintain substantial compliance outlined on LIC 9111 dated 09/15/2023 will result in the Licensee/Facility being referred to the Legal Department for review and possible Administrative Action. Exit Interview Licensee/Administrator signature on file.