Facility Evaluation Report

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management-Deficiencies visit due to deficiencies observed during the course of the audit investigation for C#29-AS-20210310091929. LPA Urena and Jessica Chen, General Auditor III (joined via Microsoft Teams) met with facility representative Molly Aayala, and explained the reason for the visit.

During the course of the audit investigation for complaint C#29-AS-20220826155207, the Department’s Audit Section concluded the following three deficiencies:

Deficiency #1: Safeguards for Resident Cash, Personal Property, and Valuables

The audit review revealed the following -The facility’s cash handling policy and procedures describe that residents sign for their deposits and withdrawal on the ledgers (LIC 405). However, residents’ signature/initials were not found on the ledgers, only the accounting personnel typed initials were recorded on the ledgers. Residents are given a “petty cash slip” to sign when the residents receive cash. The “petty cash slip” is the only place a signature from the resident is obtained, which includes the business manager/staff initials/signature on the slip as facility representative. This system does not allow for the resident to acknowledge their balance including deposits and withdrawal amounts. Residents should be able to see their ledger amounts to ensure they are free of error and deposits are entered in a timely manner. Residents were asked to sign the individual “petty cash slips” which would not allow for the resident to be aware of the total amount they have and how much is credited each month. A LIC 405 ledger was maintained for each resident the facility handles cash for, however, the LIC 405 forms submitted for audit review appear to be entered by the accounting personnel at the corporate office, with accounting personnel initials typed in, and not at the facility.No residents’ signatures were observed on the LIC 405 ledgers, which is inconsistent with their policies and procedures.