Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Christopher Diaz. LPA also spoke via phone with Licensee Dr. Mohammed Rahman, during the visit.

During records review, LPA observed: Licensee did not maintain in Resident #1 (R1)’s care records the name and contact information for R1’s current primary care physician (PCP), dentist, and nurse practitioner (NP), as required. The physician that was listed on R1's Face Sheet was obsolete. Interviews showed that the NP had come to the facility in person on prior occasions to provide care to R1 and had identified themselves to and interacted with facility staff. Licensee also did not maintain in Resident #2’s (R2) care records the name and contact information for R2’s current dentist, as required. [See LIC811 Confidential Names List for a description of R1 and R2]. Licensee also did not have file an LIC625 Appraisal/Needs and Services Plan (or equivalent “written record of care the resident will receive”) for R1 or R2. There was also no evidence that Licensee held a care-conference meeting with R1 and R2's responsible persons within the last twelve (12) months, as was required. Although R2’s responsible person could not be reached for interview, interview of R1’s responsible person confirmed they had not participated in a care conference with Licensee within the last year.

Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Dr. Rahman, to whom a copy of this report, the LIC 809-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.