Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit for a Case Management deficiency. LPA was greeted and granted entry by the Concierge at 9:45am. LPA met with Executive Director (ED) Tonya Reynolds and explained the purpose of the visit.

During a complaint investigation, by the Department, it was discovered that Activities of Daily Living (ADL) care documentation is shredded monthly by Memory Care Director (MCD) and Health Services Director (HSD) due to the documents being classified as “internal” and that this was proprietary information. LPA requested copies of the ADL care documentation for review. Per review of documentation provided, documents contained information related to resident’s ADL care which could impact the resident's ability to function or for needed services required.

Per facility policy on Retention of Resident Related Records, “Resident records will be retained according to CA state requirements. In the absence of a state requirement, the records will be retained according to the following guidelines: 5. Resident Monthly Staff Assignment Sheets: Completed sheets are considered worksheets and destroyed when completed at the end of the month.” While the ED stated the information on the ADL care logs were transcribed into the alert charting notes, transcribing of the records does not comply with requirement of original records or photographic reproductions.

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Executive Director (ED) Tonya Reynolds and a copy of this report was given to the facility along with a copy of the LIC 809-D and Appeal Rights.