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25 | Licensing Program Analyst (LPA) Jaynae Boyles arrived at the facility unannounced on 4/8/2024 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 3/23/2021. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review upon request. LPA met with the Administrator, Lisa Fennel and by phone, Carly Taylor (CCO)and Simone Turner (Regional Operations Support).
During today's visit, LPA reviewed the following stipulations of the order:
1. Staff shall be sufficient in number
-During inspection, LPA observed LIC 500s and staff schedule and found staff to be sufficient in number. The facility is in compliance with the stipulation staffing ratios of Memory care 1:6 and Assisted Living 1:10.
2. Administrator shall prepare monthly rosters of all staff to the LPA
- Administrator will continue to email the roster monthly.
3. Facility shall report unusual incidents
- Facility will ensure that all unusual incidents are reported to the Department. The facility received a citation on todays date for noncompliance. Administrator will review and send the Unusual Incident reporting policy and procedure to the LPA.
4. Facility shall ensure that the administration of medications to residents are in full compliance with regulation section 87465 at all times.
- LPA observed incident reports of medication errors within the last three months. LPA substantiated a complaint regarding medication administration errors within the last three months.
5. Staff shall have criminal background clearance
- LPA checked criminal background clearance for all staff
6. Facility stall notify all present and future residents of the stipulation.
- LPA observed a crafted letter used in the admissions agreement to notify new residents of the stipulation.
LPA observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report provided.
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