Facility Evaluation Report

Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to continue the case management initiated last December 7, 2021 in this facility. Administrator (AD) Abdol Arastoo arrived in the facility shortly after receiving information about the presence of LPA in the facility. LPA stated the purpose of the visit.

On December 9, 2021, Regional Manager (RM) Marina Stanic conducted a video teleconference meeting with Licensee Marjan Arastoo and AD A. Arastoo. Licensing Program Manager (LPM) Luz Adams, and LPAs Albert Marin and Lydia Martinez were also present. RM Stanic reiterated required corrections (including the additional staffing) that need to be met by due date of December 15, 2021 as discussed during the non-Compliance Conference (NCC) meeting held last November 16,2021. Licensee was encouraged to work closely and collaboratively with Community Care Licensing (CCL) staff. LPAs Marin and Martinez provided Licensee and Administrator with list of the staffing registry.

LPA Marin conducted a tour of the facility which included client rooms, common bathrooms, dining hall, kitchen and facility grounds. LPA observed 1 staff member on the floor and 20 clients on the floor . LPA reviewed the sign in and out log and observed five clients were out of the facility. LPA reviewed the Coronavirus 2019 (COVID 19) mitigation plan. LPA observed staff member wearing mask while at work. COVID 19 booster shots had been given on December 1, 2021 to most clients in care. LPA observed that the soda and vending machines were empty and not in service during the visit. Lunch meal service was completed when LPA arrived in the facility; but based on the interview, meals served were consistent with the posted menu. The serving consisted of protein, greens, and choice of fruit (orange or apple).

LPA Marin conducted consultation with Staff 1 about having a specific log for endorsements for the Administrator. Staff 1 provided a notebook and labelled it as staff book endorsement book. LPA discussed with AD best practices with in facility documentation and to utilize maintenance logs for the facility physical plant, observation logs for the clients, and staff endorsement logs.