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25 | Licensing Program Analysts (LPAs) Dang Nguyen and Juliana Barfield conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Julia Lopez.
Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 01/05/2024), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1].
During today’s visit, LPAs performed a brief facility tour, collected copies of pertinent records, and interviewed relevant staff.
According to the LIC624 and corroborated by staff interviews: Sometime between 12/23/2023 and 12/26/2023, an item of jewelry was stolen from R1’s nightstand, which was inside their bedroom.
Records review, confirmed by manager interview, showed: Licensee did not possess and maintain a complete written personal property inventory for R1, which was required from time of R1’s move-in to the facility. Licensee also did not maintain a written record of lost and stolen resident property from over the last 12-months having a value of $25 dollars or more.
One (1) deficiency was cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D). Plans of Correction was jointly developed with the licensee.
An exit interview was conducted with Lopez, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
02/08/2024
Section Cited
CCR
87218(a)(1)
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7 | 87218 Theft and Loss: “(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative.” | 1
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7 | Per records and interviews, R1 has since passed away. Licensee agreed to audit files to ensure that all remaining residents have a complete and signed LIC621 Personal Property Inventory. Licensee also agreed to retrain all its admissions staff on the requirements of Regulation 87218 Theft and Loss, and to submit the training sign-in sheet to LPA, by the POC due date. |
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14 | This requirement was not met, as evidenced by: Based on records review and interview, for 1 of 87 residents (R1), Licensee did not maintain a personal property inventory, completed by the licensee and the resident and/or their representative, which posed a potential personal rights risk to persons in care. | 8
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Type B
02/08/2024
Section Cited
HSC1569.153(c)
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7 | 1569.153 Theft and Loss Program, ect.: "A theft and loss program shall be implemented by the residential care facilities for the elderly…The program shall include all of the following: (c) Documentation of lost and stolen resident property with a value of twenty-five dollars ($25) or more within 72 hours of the discovery…for the past 12 months…” | 1
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7 | Licensee agreed to complete and maintain an LIC9060 Theft and Loss Record, to document any theft/loss against any resident over the last 12 months where the value lost was $25 or more. Licensee agreed to E-mail the completed LIC9060 to LPA, by the POC due date. |
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14 | This requirement was not met, as evidenced by: Based on records review and interview, Licensee did not maintain documentation of lost and stolen resident property with a value of twenty-five dollars ($25) or more within the past 12 months. This posed a potential personal rights risk to 87 of 87 residents (R1 through Resident #87). | 8
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