Follow-up on corrections·January 25, 2024

Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management visit to address deficiencies observed during facility tour and interviews conducted today. LPA met with Executive Director (ED) Monica Reyes. Entrance interview conducted. During an unrelated visit conducted at the facility today, LPA interviewed staff at 10:10AM, 10:20AM and between 12:26PM to 01:50PM, interviewed ED at 11:02AM, toured the facility with ED at 11:47AM, and LPA reviewed and obtained copies of documents. Interviews revealed that during the overnight shift from 10:00PM to 05:30AM, there were 2 (two) staff present at the facility for 55 residents residing in the facility. The two staff present are responsible for administering medications, checking multiple residents at 15 minute intervals, answering any phone calls and residents' calls for assistance, as well as all assistance with activities of daily living. The facility consists of an Assisted Living (AL) unit and a separate locked Memory Care (MC) unit and there were 2 staff present for the entire building, including both AL and MC. Interviews revealed that on this particular date that a staff had called out and that typically there are 3 staff present during this shift. Interviews revealed there have been previous times there were the same number of staff present, but no dates were clearly identified during today's visit. The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.