Facility Evaluation Report

At 2:00 p.m. on 09/25/24 Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced case management visit. LPA and LPM met with the administrator and disclosed the reason for the visit.

This case management visit was conducted in conjunction with complaint investigation #31-AS-20240318122411 to address deficiencies unrelated to the complaint.

During the initial complaint investigation, LPA Nicholas Reed was informed by the Administrator that Staff #1 (S1) was fired based on the outcome of the complaint investigation conducted by the Licensing Office and Regional Center. Upon further discussion LPA was informed that the Administrator spoke with other facility staff, and they provided the information that could be grounds for termination.

The Administrator did not document his communication with other staff to support his decision to terminate S1. He was advised to provide written declaration to the Licensing office explaining the reasons leading S1’s termination. At the time of investigation LPA also noted that the facility staff had knowledge of internal incidents that could pose hazard to the residents’ health, safety, and personal rights. However, no staff member reported the issues to the Administrator. In addition, during the complaint investigation staff revealed that while S1 was absent, Staff #2 (S2) and Staff #3 (S3) provided shower assistance to all clients. When staff told them to turn around, each of them naturally bent over to touch their toes. That didn’t seem like a natural thing. S2 and S3 asked about it to the other staff working in different shifts and over the weekends and they all confirmed they noticed same thing. Although staff noticed something unusual, none of them reported the issue to the Administrator, and therefore the facility did not submit any incident reports or other required reports to the Licensing Division. At the time of this visit, the Administrator was informed that staff are not following reporting requirements and all failed to follow AB40 - Abuse Reporting Requirements. Deficiencies are cited on the corresponding 809-D page.

No immediate health or safety hazards were observed during today's visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.