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32 | A permanent administrator (Staff 1) was in the process of renewing their certificate, but would be assist in managing the facility before being officially named AdministratorThe previous administrator resigned on or about 7/12/2023. Staff 1 was disassociated from the facility on 12/18/2023. On April 29, 2024, Regional Director of Operations informed CCL they were leaving their position and another interim staff would oversee the Administrative role. CCL requested documentation for the certified Administrator associated with this facility. Multiple responsible parties interviewed confirmed there had been no permanent Administrator for the facility from December 2023 to February 2024, at time of interview. From 7/12/2023 to 10/11/2023, and 12/18/2023 to present, the facility did not have a Certified Administrator on record with CCL. Based on the information obtained, the allegation is deemed Substantiated at this time.
On the allegation: Staff are not providing adequate care and supervision. It was alleged that staff were not providing adequate supervision to the residents in care.
LPA reviewed incident reports received from the facility. On 1/10/2024 at 1pm, Resident 2 (R2) was observed to exit the front gate when a visitor entered the gate. Staff went to redirect the resident back into the facility. On 2/2/2024 at 3pm, staff received a call from the police that R2 was in their care, as they found R2 at a bus stop. Staff conducted a search to ensure no other residents were missing. The incident reports states to prevent future occurrences, staff had an in-service training on resident safety. It also states in the future staff will escort visitors to the front gate to ensure residents do not follow visitors out. Staff did not know R2 had left the facility until the police called.
Based on the evidence obtained, the allegation is deemed Substantiated at this time.
Exit interview conducted, copy of report given. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
05/07/2024
Section Cited
CCR
87405(a) | 1
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7 | 87405(a) Administrator Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. This requirement was not met as evidenced by: Based on interview and record review, | 1
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7 | Licensee will provide documents for CCL to update the Certified Administrator on record assigned to manage and oversee this facility by 5/7/2024. |
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14 | the Licensee did not comply with the regulation above when facility has not had certified administrator for months, which posed an immediate health and safety risk to residents in care. | 8
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14 | |
Type A
05/07/2024
Section Cited
CCR
87468.2(a)(4) | 1
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7 | Personal Rights…Residents…have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, | 1
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7 | Community Manager will provide proof of adequate staffing coverage by 5/7/2024. Community Manager provided proof of inservice training, POC cleared. |
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14 | qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the regulation above when there | 8
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14 | was insufficient supervision that allowed R2 to elope, which posed an immediate health and safety risk to residents in care. |