Health inspection·June 6, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00894329. Representing the Department, HFEN # 43452 A Class "B" Citation was written. REGULATORY VIOLATIONS: Cal. Health & Safety Code § 1416.6 (a) It shall be a misdemeanor for any person to act or serve in the capacity of a nursing home administrator, unless he or she is the holder of an active nursing home administrator's license issued in accordance with this chapter. Persons carrying out functions and duties delegated by a licensed nursing home administrator shall not be acting in violation of this chapter. (b)(3) No person shall act as an administrator for more than 10 days unless arrangements have been made for part-time supervision of his or her activities by a nursing home administrator who holds a license or provisional license under this chapter. Supervision shall include at least 8 hours per week of direct onsite supervision by the licensed administrator. The program shall be notified in writing of the nature of this arrangement. No person shall act as an administrator for more than two months without the written approval of the program. The program shall not approve a person to act as an administrator for more than six months. (b)(4) If the acting administrator is an administrator in training, then the supervision required by paragraph (3) may be counted towards the total hours of supervised training required by subdivision (f) of Section 1416.57. On 4/12/2024, the California Department of Public Health (CDPH) made an unannounced visit was conducted at the facility to investigate complaint regarding resident neglect. The facility failed to ensure the Administrator in Training (AIT) had the required education and under a preceptor (Licensed Administrator) at all times. As a result, the facility had complaints from Residents regarding neglect and death of a resident that was not reported to CDPH. This deficient practice had the potential to affect the safety and over all well-being of the residents and could result in poor management of the facility. During an interview with Director of Nursing (DON) on 4/18/2024 at 2:04 p.m., DON stated, they don't have an Administrator (ADM) present in the facility as she has been on leave of absence (LOA). During an interview with Licensed Vocational Nurse 7 (LVN7) on 4/18/2024 at 4:18 p.m., when asked who the Administrator is, LVN7 named AIT as the Administrator. LVN7 further stated, AIT would advise them when they have questions, and she would present herself to the residents as the Administrator in the facility. LVN7 was asked if he knows someone with a particular name (ADM), and LVN7 stated, he does not know who that was. During an interview with the AIT on 4/18/2024 at 2:06 p.m., stated the ADM was on LOA for more than two weeks now. AIT stated, she is not on school to obtain an Administrator license. AIT further stated, she has been doing the Administrator roles and responsibilities in the absence of the ADM. A review of AIT's Employee's Information Sheet, dated 9/7/2023, indicated AIT was hired with a Job Title of "AIT... with two years completed in Junior College". A review of the facility's policy and procedure (P&P) titled, "Administrative Management (Governing Board)", with reviewed date of 1/25/2024 indicated that the facility's governing board is the supreme authority and has full legal authority and responsibility for the management and operation of our facility. The Administrator is appointed by and accountable to the governing board. The facility failed to ensure the AIT had the required education and under a preceptor (Licensed Administrator) at all times. As a result, the facility had complaints from Residents regarding neglect and death of a resident that was not reported to CDPH. This deficient practice had the potential to affect the safety and over all well-being of the residents and could result in poor management of the facility. The above violations had a direct relationship to the health, safety, or security of all the residents in the facility.