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13 | Licensing Program Analyst (LPA) Tuesday Cabiness and Licensing Program Manager (LPM) Troy Agard met with Administrator LaQuencia Davis and informed her the reason of the visit, which was to deliver the final findings of the allegations mentioned above:
Allegation # 1: It was alleged that staff did not provide consumer services as specified in the consumer’s IPP. During today’s visit, from 930am to 1130am, LPA conducted interviews with Regional Center staff, Administrator, and reviewed facility and client records. On 06/19/2024, LPA reviewed the corrective action plan (CAP) that was issued by North Los Angeles Regional Center (LARC). According to the CAP, the facility had a semi-annual review by Regional Center on 05/06/2024, and during the visit, the facility could not confirm client #1 and # 2 received the total number of specific contractual services for the following: nursing, psychiatric and recreational. During today’s visit, LPA interviewed Administrator who confirmed, the (CAP) was correctly issued, and admits the deficiencies. The Administrator will provided the requested documents for the plan of correction. Therefore, based on documentation and interviews, the allegation is Substantiated. |
| Substantiated | Estimated Days of Completion: |
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32 | Allegation # 2: It was alleged facility does not have adequate staffing to provide care and supervision. During today’s visit, from 930am to 1130am, LPA conducted interviews with Regional Center staff, Administrator, and reviewed facility and client records. On 06/19/2024, LPA reviewed the corrective action plan (CAP) that was issued by North Los Angeles Regional Center (LARC). According to the CAP, the facility had a semi-annual review by Regional Center on 05/06/2024, and during the visit, provided documentation that demonstrated a shortage of of hours allotted for clients. During today’s interview, the Administrator confirmed to LPA, the (CAP) was correctly issued, and admits the deficiencies. The Administrator will provided the requested documents for the plan of correction. Therefore, based on documentation and interviews, the allegation is Substantiated.
Both allegations are potential health and safety risk to clients in care.
Exit interview and copy of report provided to Administrator. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
07/15/2024
Section Cited
CCR
80078(a) | 1
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7 | 80078- Responsibility for Providing Care & Supervision (a) The licensee shall provide care and supervision as necessary to meet the clients' needs. This requirement was not met as evidenced by, based on documentation and interviews, facility staff | 1
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7 | Administrator has AGREED to provide required documents that was requested by Regional Center, in the CAP, pertaining to a staffing plan. POC must be completed and submitted to LPA on or by July15, 2024. Additionall time maybe granted, but request must be submitted to LPA |
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14 | could not ensure adequate staffing necessary for the care and supervision to meet client's needs. Documentation received showed facility could not provide provided documentation that demonstrated a shortage of of hours allotted for clients. This is an immediate health and safety risk to clients in care. | 8
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14 | in writing. |
Type B
07/05/2024
Section Cited
CCR
85078(a)(1) | 1
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7 | Responsibility for Providing Care and Supervision (a) In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not
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7 | Administrator has AGREED to submit a proposal and plan to ensure all clients receive the required consulting hours for each client in the facility. The plan and proposal must be submitted on or by July 15, 2024. Additional time maybe granted, but request must be submitted to LPM in writing. |
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14 | met, evidenced by, based on documentation and interviews, facility staff could not confirm clients received the total number of hours allotted for specific contractual services: nursing, psychiatric and recreational. This a potential health and safety risk to residents in care. | 8
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