Health inspection·November 7, 2024

The following reflects the findings of the California Department of Public Health (Department) during the investigation of a complaint. Complaint number: CA00923059. A Class B citation was issued. Regulatory Violations California Health & Safety Code- Section 1416.55 - Administrator-in-Training Program (b) A person who seeks to satisfy requirements for admission to licensure examinations through participation in an AIT Program shall first receive approval to begin the AIT Program. An applicant shall successfully complete the AIT Program in a program-approved facility under the coordination, supervision, and teaching of a preceptor who has obtained certification from the program and continues to meet the qualifications set forth in the rules and regulations of the program. Health and Safety Code Section 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. 22 CCR §72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 10/10/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident rights, admission, transfer, and discharge rights. The facility failed to ensure that the Administrator in Training (AIT) was under the coordination, supervision, and teaching of a preceptor who has obtained certification from the Nursing Home Administrator Program and was not left alone to manage the operations of the facility. As a result of this deficient practice, there was the potential to affect the safety and over all well-being of the residents and the poor management of the facility. During an interview and record review of the consumer board (board displayed in visible areas of the facility which contain information such as facility ownership, administrator's license, survey ratings etc.) with the AIT on 10/10/2024 at 1:10 pm, the AIT stated that the Licensed Administrator (AD) whose certificate was displayed on the consumer board was in fact a regional AD and oversee 19 facilities in total. The AIT stated that the Administrator came to the facility once a week to once every two weeks. The AIT stated that the Director of Nursing had taken some time off and would not be in the facility for an unknown period. During an interview with Physical Therapist (PT) 1 on 10/10/2024 at 1:30 pm, PT 1 named the AIT as the Administrator and did not know a particular name (AD) when mention. During an interview Certified Nursing Assistant 1 (CNA) on 10/10/2024 at 1:34 pm, CNA 1 did not recognize the AD's name when mentioned and stated that the AIT was the administrator. During an interview with Licensed Vocational Nurse 1 (LVN) on 10/10/2024 at 1:38 pm, LVN 1 stated that the AIT was the administrator. During an interview with the AD on 10/11/2024 at 3:10 pm, the AD admitted that his titled was Regional Administrator and oversee 19 facilities. The AD confirmed and stated that he visited the facility at least once in two weeks and that the needed to have a Licensed AD for a successful completion of the training. During a review of the facility's policy and procedure (P&P) titled "Administrator," reviewed on 4/17/2024, the P&P indicated a licensed administrator appointed by the governing body of the facility was responsible for the day-to-day functions of the facility. the same P&P indicated "In the absence of the administrator, the assistant administrator or director of nursing services is authorized to act in the administrator's behalf. Should both the administrator and the assistant administrator or director of nursing services be absent, the chain of command as established by this facility shall be followed." The facility failed to ensure that the AIT was under the coordination, supervision, and teaching of a preceptor who has obtained certification from the Nursing Home Administrator Program and was not left alone to manage the operations of the facility. As a result of this deficient practice, there was the potential to affect the safety and over all well-being of the residents and the poor management of the facility. The above violation had a direct relationship to the health, safety, or security of all the residents in the facility.