Office review·August 22, 2023

A Non-Compliance Conference (NCC) was conducted on this day, 08/22/2023, by the Sacramento South Regional Office via Teams meeting. The purpose of this Non-Compliance Conference meeting was to discuss existing deficiencies, problem areas in the operation of the facility, and ways to bring the facility into compliance as to avoid legal action. Present at the meeting were Regional Office Manager (RM), Stephenie Doub, Licensing Program Managers (LPMs) Liza King and Stephen Richardson, and Licensing Program Analysts (LPAs), Kimberly Viarella and Jason Lund. Representing Koelsch Senior Communities were Eva Arant, Chief Operating Officer, Michelle Baker, Vice President of Operations, Steve Sarine, Regional Director of Operations – CA, Kayleen August, Regional Director of Nursing – CA, and Kent Mulkey, Executive Director, El Rio Memory Care. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process. The focus of the concerns at this time: Reporting Requirements Assessment and Reassessment - Restricted Health Conditions - Resident on Resident (R:R) Altercations Outbreak Infestations The Licensee agreed to do the following in order to bring the facility into compliance by the following dates: · The presence of an Administrator 40 hours a week. · Conduct training related to the following every 6 months for a year then annually thereafter. Proof of training to include name of trainer, topics covered with duration of training, and list of all attendees. Documentation shall be available for review by Community Care Licensing (CCL) during increased monitoring visits. - Reporting Requirements (All staff) - Restricted Health Conditions (Care Staff) - Wound Stages (Care Staff) - Facility Protocols re: Outbreaks and Infestations (All staff) * Scabies · Maintain facility pest inspection reports accessible to CCL staff During the conference, Licensing requested the following documents by the close of business on 08/24/2023. All in-service trainings from January 1, 2023 to present Including a copy of the reporting requirement trainings that were already conducted A copy of the policy outlining how and when to call 911 (especially if the Med Tech does not think it is necessary) Community Care Licensing agreed to take the following steps to assist the facility in achieving and maintaining compliance: CCL will provide additional quarterly monitoring and facility inspections to verify improvement incompliance. Provide TSP services agreed upon during this meeting. . Failure to maintain substantial compliance outlined on LIC 9111 dated 08/22/2023 may result in the Licensee/Facility being referred to the Legal Department for review and possible Administrative Action. Exit interview conducted, and copy of report provided.