Facility Evaluation Report

A case management visit was conducted by Licensing Program Analyst (LPA) Angela Panushkina today based on a facility’s Non-Ambulatory status (for the 2 nd floor) approved in error by the Fire Department in 1995 and 2011. LPA met with the Operations Specialist - Dimple Kamdar, District Director of Clinical Services - Leslie Tripp, Business Office Manager - Veronica Gomez, Wellness Director (LVN) - Anchirriza Concepcion and explained the reason for the visit.

The facility is currently cleared for 258 Non-Ambulatory residents on a 1 st and 2 nd floors with capacity of 268. Cleared for 10 Bedridden in rooms #107, 111, 119, 121,123,127, 161, 163, 165, 167. It was determined that there as a "Clerical error" made, twenty (20) years ago. Due to the Fire Clearance Safety Regional Office (RO) is requesting for an additional monitoring on 2 nd floor . LPA informed the facility team, as this is a Health and Safety issue, to provide a following Written Plan within 48-hours:

1. A list of people that need to be relocated (non-ambulatory and or bedridden on a 2 nd floor). LPA was informed that no bedridden residents currently reside on the 2 nd floor. As for Non-ambulatory residents, the facility will submit Names and Room #'s of each resident by 5:00pm on 10/10/24.

2. Anticipated move for those residents will be as follows: LPA was informed that the families/residents must be informed and upon approval the family/resident will coordinate and organize the transfer with the help of community. An addendum must be in place and attached to a current Admission Agreement, due to room changes and pricing.