Follow-up on corrections·July 28, 2023

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management – Deficiencies visit in conjunction with complaint control # 29-AS-20230406155619. Upon entry into the facility, the LPA observed that the front door was equipped with delayed egress. Per the fire clearance granted by the Department on 8/10/2021, delayed egress for this location was not approved. An interview with Executive Director Gary Lee confirmed that there are four (4) doors (including the front door) equipped with delayed egress. It was communicated that the delayed egress mechanism is not activated; however, all of the doors were alarmed. Executive Director G. Lee indicated they had not submitted any paperwork to the department yet, as they were informed that they would need to obtain approval from the fire department prior to sending paperwork to the department. Per Executive Director G. Lee, the fire department came out and did a walk-through in May 2023, and indicated that the facility was not approved for delayed egress at that time. The Executive Director indicated that the facility was still in the process of making corrections for the delayed egress to be approved. The LPA tested the four exterior doors at 12:23 p.m., 12:26 p.m., 12:27 p.m., and 12:29 p.m., and observed that the egress mechanism was not engaged, and the LPA was able to egress out of the door without delay. The LPA was unable to identify any documentation to determine that the licensee informed the Department of the installation of the delayed egress doors. Executive Director Lee indicated that the mechanisms had been installed on the doors for some time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency cited (refer to LIC 809-D): Exit interview conducted, today's reports and appeal rights were reviewed and issued.