Facility Evaluation Report

Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management- Deficiencies visit at the facility today due to deficiencies observed during an initial complaint visit for complaint control # 29-AS-20220512132643.

At 9:13 a.m., the LPA observed one (1) bed with a mattress, and was completed with full linens in the facility’s Dining room. The Administrator confirmed that facility staff have been using the bed to rest at night. The LPA advised the administrator the facility shall provide comfortable living accommodations and privacy for the residents, and staff who may reside in the facility. The administrator acknowledged, and stated that the bed be removed from the facility dining room.

At 9:15 a.m., the Administrator advised LPA Walker that one (1) facility resident was hospitalized on 05/09/22. Record review revealed that the facility failed to submit a written report to Licensing regarding Resident #1 (R1) being hospitalized. The LPA advised the administrator that a written report shall be submitted to the licensing agency within seven (7) days of the occurrence of any incident which threatens the welfare, safety or health of any resident. The Administrator acknowledged, and stated they will ensure an incident report is submitted for R1 to CCLD by 5/19/22.

During today’s visit, the LPA conducted a physical plant tour along with Administrator Asmik Nadrian. At 9:39 a.m., the LPA observed Resident #2 (R2) is currently residing in room #1 which is fire cleared for non-ambulatory only. The facility currently has the room numbers on the resident bedroom doors differing from the Facility Sketch, and room #1 at this time is displaying a #4 not in accordance with the Fire clearance nor submitted Facility Sketch. The LPA advised the administrator that the facility has an approved Fire clearance for five (5) non-ambulatory residents total in rooms 1 (shared), 2 (shared), and 3 (shared); and, one (1) bedridden resident only in room #4 (private).