Facility Evaluation Report

On 03/02/2022, at 1:35 p.m., Licensing Program Analyst (LPA) Sandra Urena, conducted an unannounced Case Management-Deficiency visit to address the deficiencies noted during complaint control # 29-AS-20210813133851, conducted on 08/18/2021. LPA Urena spoke with administrator Siranush Alvadzhyan, and explained the reason for the visit.

At 2:30 pm on 08/18/2021, the LPA conducted residents’ file review, and the LPA found that the facility failed to ensure that a resident’s file for Resident #1 (R1) was completed prior to the time of admission. LPA interviewed Staff # 1(S1), and S1 stated that Resident R1 arrived in the middle of the night, and didn’t have time to create a resident’s file. The R1 resided at the facility from 07/18/2021 to 07/21/2021. The licensee did not create a file for R1 with all the required documents prior to admission, and during R1’ s stay at the facility. The following documents were missing:

. · Appraisal Need and Services Plan, when applicable (LIC 625).

· Physician’s Report for RCFE (LIC 602A) Residential Care for the Elderly,

· Medical Assessment Section 87569 and General Requirements for Allowable Health Conditions,

· Identification and Emergency Information (LIC 601).

· Current admission agreement with authorized signatures, Admission Agreement Guide for RCFE

· Evidence of receipt of personal rights information by resident and/or authorized representative