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25 | Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 10/11/2023 at 2:26 PM. LPA Martinez met with Belinda Guzman and explained the purpose of the visit.
The purpose of the visit today is to conduct a quarterly visit. LPA Martinez followed up with the following:
- Care and Supervision. AM Shift three care staff PM two care staff Noc Shift 1 care staff. One Med-Tech per shift.
- Resident Appraisals/Needs- and Service Plans. 5 out of 5 files were maintained
- In-Service Training For All Staff. Staff documentation maintained and training provided to staff.
- Reporting Requirements. LPA Martinez reviewed Community Care Licensing Department (CCLD) Unusual Incident Report (UIR) LIC 624 file for the month of September 2023. The Department received 2 UIR reports. Per Belinda LIC 624 have been emailed to LPA Campbell.
- Tour Physical Plant.
- AWOL's: Belinda Guzman reported the facility has not had an AWOL.
Quarterly Visit Review:
LPA Martinez reviewed the 2023 Annual in-Service and Education Program report. It was learned the facility offered the following in-service training to staff: Postural supports, dementia training, hospice services, physical limitations and personal care services, fire/disaster/emergency, missing resident policy and test, and corporate compliance. In addition, LPA Martinez reviewed five employee files. The files contained in-service training documentation. LPA Martinez reviewed five physician reports LIC 602. The physician reports were maintained.
No deficiencies were cited at this visit. An exit interview was conducted, and a copy of this report was provided to the facility.
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