On 8-2-22, a citation was issued to facility due to staff training requirements for 2 out of 5 staff files reviewed on this date, Section 1569.625(b)(2). Facility was unable to provide documentation of completed 20 hours annual training. Administrator stated staff are now being trained timely to include dementia training for all staff.

On 8-18-22, a citation was issued to facility, Section 87211(D), due to an AWOL occurring on 8-15-22 who was absent from facility for approximately 5 hours. Administrator stated missing resident policy has been reviewed with staff. In addition, Administrator will ensure sign in and sign out policy will be reinforced for all residents and visitors, and ensure staff continues to be aware of policy. Administrator further stated that staff are checking resident rooms every 2 hours to ensure residents’ general whereabouts. A list of residents who can leave unassisted shall be maintained and available to all appropriate staff. Administrator to develop a plan to maintain a roster of residents who are unable to leave facility unassisted including regular scheduled assessments of residents.

{Cont. on 809C}

On 8-22-22, a citation was issued to facility for Basic Service Requirements H&S Code 1569.312(d) due to an AWOL (Absence without leave) which occurred on 5-17-22 which led to intoxication and injury to a resident. Administrator will continue to enforce 2 hour check on residents. LPA suggested documentation of whereabouts for any high-risk elopement residents.

On 8-22-22, a citation was issued to facility for Administrator Qualifications, Section 87405(b) due to facility not ensuring the timely reporting of a missing person on 5-17-22 to police. An additional citation was issued, Section 87405(h)(5) on this date due to lack of AWOL training necessary to ensure necessary services to residents in the event of an AWOL. Administrator has included AWOL training as part of staff general training as well as missing person policy including when to call law enforcement.

On 8-22-22, a citation was issued for Reporting Requirements, Section 87211(a)(1)(D) due to an AWOL not properly reported to a resident’s responsible party. Administrator has modified incident report to include a section for reporting to appropriate responsible party timely.

On 9-29-22, a citation was issued for Reappraisals, Section 87463(c) due to licensee not ensuring a meeting arranged with responsible party of a resident after a significant change in condition. Administrator has developed and will maintain a file system to alert appropriate staff to schedule meetings annually and/or in the event of a significant change in condition.

On 9-29-22, a citation was issued due to increase fees with a lack of 60-days’ notice provided to responsible party of a resident per regulatory requirements, H&S Code 1569.655(a). An additional citation was issued to facility on this date due to a level of care rate increase which did not include a proper level of care rate increase notification, Section 1569.657(a). Administrator has read regulations and stated she will follow regulation going forward including itemized list of charges to reflect level of care service change.

Department is requiring the following documents to be submitted by 10/10/22:

1. Updated LIC 500 reflecting hours and days of Administrator on duty

2. Updated LIC 308 designating manager(s) on duty in case of Administrator’s absence

Department will conduct unannounced quarterly visits to monitor the following including but not limited to:

1. Reporting requirements to appropriate persons timely

2. AWOL procedures and staff training

3. Dementia training for new staff and annual for existing staff

4. General staff training for all new staff and annual for existing staff

5. Review of updated resident list of who can leave unassisted

6. Sign in and sign out sheet to ensure its completeness and accuracy

Department will pull random files for review of training and other regulatory requirements.

At this time, Department is requiring the presence of Administrator to be on duty 40 hours per week minimum which is to be reflected in the updated LIC 500.

An exit interview was conducted with, and report was read to Belinda Guzman via phone. A copy of this report was emailed to Belinda with a request to return to LPA via email at Michael.Bilger@dss.ca.gov.