Facility Evaluation Report

At 1:00 p.m. on 06/19/25, Licensing Program Manager (LPM) Naira Margaryan and Licensing Program Analysts (LPAs) Nicholas Reed and Huma Rahimi conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit.

Today’s case management visit was conducted to ensure the health and safety of facility residents and the facility’s compliance to Title 22 Regulations.

LPM and LPAs interviewed staff and residents between 1:10 p.m. and 2:00 p.m. today, conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 1:25 p.m., and toured the facility inside and out at 1:30 p.m.

Interview with Staff #1 (S1) at approximately 1:15 p.m. revealed today was their first day working in the facility. File review at 1:20 p.m. today revealed S1 was not associated to the facility. Telephonic interview with the administrator at approximately 1:35 p.m. confirmed today was S1’s first day working and they were not associated to the facility. A deficiency is issued for S1 not being associated to the facility on the corresponding LIC 809-D page.

Record review of staff files revealed the most recent trainings were conducted on 05/15/22. Additionally, the facility did not maintain a staff file for S1. Interview with the administrator revealed staff trainings have been conducted annually, but the certificates are not available for audit today. A deficiency is assessed for not maintaining necessary files at the facility and making them available for audit.

Record review of Resident #1’s (R1) file revealed their most recent medical assessment was incomplete and did not contain a primary diagnosis. A deficiency is issued for an incomplete medical assessment.

Exit interview conducted. Appeal rights discussed. Copy of report provided.