Facility Evaluation Report

Licensing Program Analysts (LPAs) Hiratsuka and Mikkelson conducted this unannounced plan of correction visit in response to deficiencies cited for Complaint 59-AS-20241022104408 and a Case Management visit on 10/24/2024. LPA Mirlohi arrived later to conduct her own Plan of Correction visit.

On 10/24/2024, the following deficiencies were issued and they are not corrected as of today:

-Health and Safety Code 1569.312(e) Basic Services- this was cited because a resident made it out of the facility unnoticed by staff and was found about four blocks away. The Licensee was to submit a written plan of correction on how she shall ensure how staff monitor residents based on needs. Licensee did not submit this plan. Civil penalties of $500.00, is issued today and shall accrue at $100.00 until Licensee submits contacts LPA Hiratsuka.

-Title 22 Regulation 87465(e) Incidental Medical and Dental Care. this was cited because per Title 22 the facility shall telephone 9-1-1 if there is an imminent threat to the health and safety to residents. A resident left the facility unnoticed and Licensee took approximately 30 minutes before calling 9-1-1. Licensee was to submit a written plan that addresses what staff are going to do when a resident is missing. Civil penalties of $500.00, is issued today and shall accrue at $100.00 until Licensee submits contacts LPA Hiratsuka.

-87307(d)(6) Personal Accommodations and Services. This was cited because the front door was blocked by two chairs and the sliding glass door had a wood rod put on the track to keep the door from sliding open. The chairs and wood rod were removed, but the licensee did not submit a written plan of correction on how she is going to ensure the exits are not blocked. Civil penalties of $500.00, is issued today and shall accrue at $100.00 until Licensee submits contacts LPA Hiratsuka.