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25 | Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 11/06/2023 at 1:42 PM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee was greeted by care staff, Ehon Mellis and asked staff to call the Facility Designated Administrator, Julie Adriana to let her know that CCL was present at this time for a POC visit. The current Census is 4 with 1 staff present in the facility.
LPA explained the purpose of the visit. The purpose of this visit is to follow-up on a plan of correction that was due 10/18/2023 and 10/24/2023. Administrator, Julie Adriana sent pictures of POC on 10/18/2023; however, LPA Lee needed to conduct a POC visit to ensure that resident bedroom #3 window screen is placed on the window and that resident bedroom #2, the hole in the wall with exposed wire has been covered up. LPA Lee toured and inspected the facility to ensure the deficiency previously cited on 10/17/2023 have been corrected.
LPA reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.
Based upon this inspection, LPA Lee observed the following:
1. Deficiency cited under Title 22 Regulation 80087(a)(1) has been cleared. The license complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
2. Deficiency cited under Title 22 Regulation 87303(a) has been cleared. The license complied with the terms of the POC by POC due date.
The administrator complied with the terms of the POC by POC due date. Facility was provided with POC cleared letter. Exit interview conducted and a copy of this report provided.
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