Facility Evaluation Report

On today's date, LPA Quiroz conducted an unannounced Case Management-Deficiencies visit in conjunction to complaint investigation follow up for complaint control #22-AS-20210701151949. LPA Quiroz met with Licensee/Administrator (L/AD) Tin Le and discussed the purpose of today's visit.

On today's date, to assist with complaint investigation for complaint control #22-AS-20210701151949, LPA Quiroz requested resident records for Resident 1 (R1). (L/AD) Tin Le indicated "I don't have the original documents, the resident was here only less than 2 weeks and the Family never returned the packet back to me, I only have the LIC 602 in an email." LPA Quiroz not able to review the following requested documents for (R1) during today's date: Admission Agreement, Pre- Appraisal, Needs and Services Plan, Identification Form due to R1 records not being available on site or in centralized location. (L/AD) Tin Le concluded "We don't have them."

LPA Quiroz provided consultation on the following California Code of Regulation to (L/AD) Tin Le:

Resident Records - 87506 (e) : Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.

Facility Cited during today's visit (See LIC 809-D). Plan of correction was cleared during today's visit.

LPA Quiroz conducted an exit interview with (L/AD) Tin Le and provided a copy of this report, Appeal Rights, LIC 809-D, Cleared POC Letter and LIC 811- Confidential Names at exit.