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 review of the residents’ care records, LPA observed, and Licensee/manager interview confirmed:

For Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4), Licensee did not have written proof of a negative tuberculosis (TB) test result for them, which was required before each of these residents moved-in. (During LPA’s site visit, these residents did not show signs/symptoms, observable to the layperson, of active tuberculosis infection). For R4, Licensee also did not have any LIC602 Physician’s Report (or equivalent Medical Assessment) or a LIC603 Pre-Placement Appraisal (or equivalent preadmission appraisal document) for them; these were both required to be completed before they moved in. There were also no subsequent written care appraisals on file for R4.

For Resident #5 (R5), their latest LIC602 Physician’s Report (from 12/06/2019) showed they were diagnosed with Dementia by their doctor. However, Licensee did not have an updated LIC602 Physician’s Report (or equivalent Medical Assessment) or a care reappraisal completed for R5 within the last year, which was required for residents diagnosed with Dementia. For Resident #1 (R1), R2, R4, and R5, Licensee also did not have file an LIC625 Appraisal/Needs and Services Plan (or equivalent “written record of care the resident will receive”). There was also no evidence that Licensee held a care-conference meeting with their respective responsible persons (RPs) within the last twelve (12) months, as was required. Interviews of multiple RPs confirmed this.