Facility Evaluation Report

On 9/19/24 at 9:15am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Plan of Correction (POC) inspection to ensure all previous deficiencies have been corrected and all written plans of correction have been completed.

LPA met with the licensee and discussed plans of correction. LPA was informed no current written plans of correction have been completed but the facility has taken the following action.

facility has informed placement agency they will no longer be accepting residents for placement who do not meet the facility's criteria for placement including being over the age of 60 and not having any diagnosed mental disorder other than dementia. - Facility will communicate this as part of their written plan of correction.

Staff bedroom will be restored to a resident bedroom and identified for use as a bedridden resident. Staff member currently occupying bedroom will move out on today's date, 9/19/24. Written plan to be submitted as part of the Plan of Correction.

Vendor Yolo Hospice will conduct personal rights training for staff members. written plan of correction will include the future date identified for training.

door has been removed, Licensee will submit as written plan of correction with statements of staff supervision will be provided to manage any resident behaviors that may be a danger to themselves or others.

As the licensee has not yet completed all plans of correction and is over 10 days since facility was cited, facility will be recited and plans of correction will be completed by the POC due date or will subject to immediate civil penalties for a failure to correct. Report Continued on LIC 9099-C.