The purpose of this visit is to follow up on deficiency identified during the annual inspection conducted on 12/03/24. During the inspection, it was learned that the facility sketch did not match the physical layout of the plant observed. According to facility records, the facility is licensed for 6 non-ambulatory residents and approved for 2 hospice waivers. The LIC 850 and facility sketch submitted to the department on 11/08/19 indicate that the facility was approved for 6 non-ambulatory residents in bedrooms 1 through 6. The sketch did not designate a specific room for facility staff. However, during the 12/03/24 inspection and interview, it was revealed that the facility is using bedroom 4 as a staff/office room, which has not been licensed or fire cleared for such use. It was also observed that one resident occupies each of bedrooms 1, 3, 5, and 6, while 2 residents occupy bedroom 2. During today’s visit, the LPA advised the administrator to submit an updated facility sketch, designating bedroom 4 as a staff/office room. Additionally, LPA informed the administrator that an LIC 850 Fire Safety Inspection Request may be needed and reviewed by a fire inspector. The administrator confirmed that an updated facility sketch will be submitted to LPA Lee by 01/16/25. LPA Lee informed administrator that any changes to the facility physical plant must be reported to (CCLD) and ensures that the physical plant and facility sketch aligns with each other and is current at all times.

As a result of this case management visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted, and a copy of LIC 9102 Technical Violation was provided to the facility.