Facility Evaluation Report

On 3/6/24 at 1pm, Licensing Program Analysts (LPA) Arvin Villanueva arrived at the facility to conduct an unannounced Plan of Correction (POC) visit. LPA initially met with the staff on duty and explained the purpose of the visit. The facility administrator, Chukwudi Ikiseh, was notified of the visit via telephone. LPA spoke to the administrator via telephone and explained the purpose of the visit. The purpose of this visit was to verify the plan of correction that was required to be completed on 11/28/23 and 12/4/23 for deficiencies that were previously cited on a prior visit conducted on 11/27/2023. Present during this visit are 4 residents in care with 1 staff on duty.

Upon arrival to the facility, LPA observed a medicine cup filled with medication pills. On the cup, a resident's name is on it. Per interview with staff on duty, the resident is currently sleeping and not ready to take the medication pills. Staff on duty put away the medication. During staff file review, LPA observed 2 of 3 staff have expired first aid certificate. Additionally, files for the above administrator, Chukwudi Ikiseh is not available for review during this visit.

Based upon this inspection, LPA Villanueva observed the following:

The deficiency cited under Title 22 Regulation 87465(e ) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.

The deficiency cited under Title 22 Regulation 87412(a)(11) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.

The deficiency cited under Title 22 Regulation 87412(f) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.

The deficiency cited under Title 22 Regulation 87412(a) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. LPA observed during today's POC visit that the administrator's file is not present at this facility and not available for review at this time.