Facility Evaluation Report

Licensed Program Analysts (LPAs) Cassandr a Mikkelson and Kerry Hiratsuka arrived unannounced to conduct a Case Management following deficiencies cited.

During annual visit on 10/02/2024 conducted by LPA Bethany Mirlohi, the following deficiencies were cited. 87506 Resident Records (a)- facility did not meet regulations for resident files, ensuring that all resident files are complete and up to date.

87457(c) - Resident's needs and service plans were absent in resident files.

87458(a) - Residents physicians' report were absent in resident files.

1569.69(a)(2)- Administrator did not ensure that all employees, new and existing, meet the appropriate training requirements per Title 22 regulations.

During complaint visit on 10/24/2024 conducted by LPA Mikkelson and Hiratsuka, the following deficiencies were cited.

87203- Fire safety- facility had chairs blocking the front door and a wooden dowel blocking the glass sliding door.

1569.312(e)- Licensee not ensure the safety of the resident by a resident leaving the facility through the side gate unnoticed by staff. This is an immedate health and safety risk to residents

87465(g)- Licensee did not ensure the safety of the resident because a resident left the facility unassisted and the Licensee did not call for emergency services for at least 30 minutes.