Facility Evaluation Report

At 10:00am, Licensing Program Analysts (LPAs) Huma Rahimi, Angela Panushkina, and Perchui Milena Khurshudyan conducted a Case Management Visit. LPAs met with the Staff # 1, Mari Akmakchyan and explained the reason for the visit.

During the visit, S1 informed LPAs that S2 started working at this facility on 01/08/2024. LPAs conducted review of Licensing Information System and did not observe S2's association to this facility. LPAs informed the S1 that all staff members must be fingerprint cleared and associated prior to employment.

Moreover, Administrators' Certificate on file has been expired and the facility does not currently have a back up Administrator.

LPAs observed that only three (3) out of five (5) residents facility files are missing documents/signatures (incomplete).

The facility is not approved to retain any bedridden resident; however, LPAs observed R2 and R3 were in bed and review of their Physician's Report indicated that they are both bed bound. Moreover, LPAs were informed that both residents are receiving Hospice Care (facility is currently approved for one (1) hospice waiver only). No Hospice files for R2 and R3 were available upon request. Lastly, LPAs observed R2 and R3 had full bed rail and no Physicians order on file.

LPAs observed that R1 is on a wheelchair. Facility License (Effective 03/18/2019) is APPROVED FOR CAPACITY OF 6 AMBULATORY; APPROVED FOR HOSPICE WAIVER FOR 1 HOSPICE RESIDENT .

The facility also failed to submit an Incident and Death Report for R6 to the Community Care Licensing Division (CCLD) in a timely manner. Based on Title 22 Regulation: a written Unusual Incident / Injury Report / Death Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed Administrator that all staff members are mandated reporters and they are all responsible for reporting.

Exit interview conducted, appeal rights explained and copy of this report signed and delivered.