Facility Evaluation Report

On 5/14/24, at 2:30pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct an annual continuation visit. The purpose of this visit is to continue the required annual inspection initiated on 3/29/24. LPA met with the administrator Leilani Nitta. Present during this visit were 4 clients in care with 2 staff on duty.

From last visit on 3/29/24, it was discovered during client record review that licensee did not ensure all facility staff completed training prior to assisting Client#1 (C1) with their glucose testing. Per review of C1’s restricted health care plan dated 9/29/2022, only one staff was trained by a licensed professional. Per interview with the administrator, Leilani Nitta, on 3/29/24, current staff were not trained prior to assisting client with their glucose testing. Interview with Staff#1 (S1) on 3/29/24, staff are the ones that perform the glucose testing for C1.

The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Note that failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted with Leilani Nitta and a copy of this report and appeal rights were provided.