Facility Evaluation Report

Licensing Program Analyst (LPA) Mariana Agban conducted a case management- Deficiencies visit to the above facility. During file review, LPA observed that Staff#1 (S1) is missing required Licensing forms from the personnel file. In addition, Resident#1 (R1), Resident #2 (R2) and Resident #3 (R3) do not have a written hospice care plan as specified CCR 87633(a)(4) prior to the initiation of hospice services. Moreover, the Licensee did not notify the Department in writing within five (5) working days of the initiation of hospice for R1, R2 and R3 as specified in CCR 86632(d)(2) and stipulated on the approved Hospice Waiver. Lastly, Licensee have not provided a written request signed by each terminally ill resident or prospective resident upon admission, or by the resident's or prospective resident’s health care surrogate decision maker to allow for his or her acceptance or retention in the facility while receiving hospice services.

Exit interview conducted, citations issued, appeal rights given and copy of this report delivered.