Facility Evaluation Report

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct a plan of correction (POC) visit for deficiencies cited on 6/20/2024. The LPA met with Licensee, Erica Graham-Bullock, who was informed of the purpose of the visit. During today's visit LPA conducted a walk through, and conducted interviews and records review.

Deficiency was cited under Title 22 Regulation section 80072 Personal Rights. The POC made with the licensee was to meet with the residents and revise the house rules to account for personal rights by the POC due date of 6/21/2024. LPA received the POC from the licensee via email and the POC was reviewed. Revisions on the POC were emailed back on 7/3/2024 as the house rules submitted for the POC do not meet the department requirements for personal rights. LPA met with the licensee on today’s visit who submitted the corrections to LPA during the visit. The rules were signed by (5) of (6) residents, licensee stated they would send this signed form by the end of the business day to LPA.

The following deficiencies was not corrected by their POC due dates, but were corrected during today's POC visit. Civil penalties are being assessed for the dates the POC's was late:

Deficiency was cited under Title 22 Regulation section 80075 Health Related Services. The POC made with the licensee was to conduct a training with staff on proper medication documentation and send proof of this by the POC due date 6/27/2024. On today's visit LPA received written proof of training conducted with staff on medication documentation. Therefore, the POC was met and the deficiency was cleared and a clearance letter was issued to the licensee.