Facility Evaluation Report

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct a case management visit. LPA was greeted and granted entry by staff. LPA met with Assistant Administrator (AA) Paige Rohrer and discussed the purpose of the visit.

During the investigation of complaint 22-AS-20230905130429 Resident #1 (R1) file was given to LPA for review and it was incomplete. LPA did not observe medication records, physicians reports and needs and services plans for R1. Staff #1 (S1) informed LPA that they do not have all the documents of past residents due to the management at the time not storing files properly and not saving the documents for the regulatory amount of time. R1 was admitted to the facility on March 20, 2022, with the latest documentation of R1 still being at the facility on July 24, 2023. LPA was unable to confirm the exact date of R1 leaving the facility.

Based on today’s observations a deficiency is being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this along with LIC 809D and appeal rights were left at the facility.