Follow-up on corrections·August 23, 2023

Licensing Program Analysts (LPA) Esther Cortez conducted an unannounced Case Management -Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20230818091916 ). The purpose of the visit is to issue citations for deficiency observed during the complaint investigation which is not related to the complaint. The LPA met with Administrator Sean Beharry and the reason for the visit was explained. On today’s visit, the LPA was denied access to two staff rooms located in the basement. Administrator informed the LPA that the rooms were locked by staff who were not present at the facility. The Administrator did not have a copy of the key to staff rooms and the LPA was not able to inspect both rooms. During the facility tour the Administrator stated that the second floor was only for staff. Both entry stairwells to the upstairs area are locked with key from the inside and outside, inhibiting residents from going upstairs or back to the first floor. At approximately 10:00 a.m. the LPA observed resident #1 (R1) in the living room area on the second floor. Upon observation, the administrator stated that R1 lives in one of the upstairs bedrooms with staff (S1) who is also their family member. The LPA also observed the following items on the second floor unlocked and accessible to R1: Acetaminophen pain reliever pills, prescribed medications, and over the counter Vitamin D on a shelf in the upstairs living area. An unlocked drawer with knives in the kitchen. One unlocked cabinet with Raid, Disinfectant Spray, Mr. Clean Antibacterial cleaning solution, and Mop&Glo 3-in-1 cleaning solution in the kitchen. An unlocked office with scissors. One unlocked cabinet with a bottle of bleach, arm & harmer laundry detergent, and Lysol Spray in the unlocked staff bathroom. One unlocked glass cabinet with Raid, paint gloss, and a large knife. Report will continue on LIC809-C During file review, the LPA identified that Resident #2 (R2) requires an updated physician’s report (LIC602), and appraisal/needs and services plan (LIC625) due to the diagnosis of dementia. The LPA observed R2’s LIC602 dated 9/20/20 and LIC625 dated 9/24/2020 and not filled out. Pursuant to Title 22 of the California Code of Regulations Division 6, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted . A copy of the report and appeal rights provided to Administrator Sean Beharry