Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20240328103849. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Pamela Junge arrived during the visit.

During the course of the complaint investigation, LPA interviewed Facility Administrator and reviewed documents pertinent to the complaint investigation. Resident 1 (R1) admitted into the hospital on 03/16/2024 for a urinary tract infection, skin wound and assessment of ostomy. Per Kaiser Case Manager, R1 was ready to discharge from hospital on 03/19/2024. Case Manager indicated Administrator stated needing to follow up with Licensing for return protocols. Administrator indicated emailing the department for guidance and receiving no response. The department is not aware of any further requests for guidance from the facility. Case Manager states calls were not returned regarding resident discharging and Administrator did not assess resident until 04/06/2024 resulting in continuing hospital charges and a risk of the resident losing Assisted Living Waiver. Conversations with Licensing precipitated the resident being assessed. However, the hospital re-assessment took place 18 days after potential discharge. Department regulations require a re-assessment of resident when a change of condition is present.

Based on the observations made from today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.