Facility Evaluation Report

Licensing Program Managers (LPMs) Robyn Clark and Lizzette Tellez conducted an unannounced case management deficiencies visit. LPMs were met by Staff 1 (S1), Evangeline Pingul, and were granted entry into the facility. The purpose of the visit was discussed with facility staff.

During today's visit, LPMs, along with facility staff, conducted a brief tour of the facility, observed residents in care, and reviewed facility/resident records.

Three residents (R1-R3) did not have information or forms as required including LIC 602 (Physicians Report) or LIC 601 (Emergency Identification and Information). Two residents (R4 and R5) did not have information or forms required for their medical assessment (LIC 602 Physicians report, or similar).

During the visit, LPM Clark inspected facility time sheet records which indicated that five additional staff members (S2-S6) had time sheets indicating that they had recently worked in the facility. A review of Guardian indicated that only three of those staff members (S1-S3) had active Background Clearance associations to the facility. LPM Clark interviewed Staff 7 (S7) regarding the staff members and S7 reported that they had only worked in the facility for a few weeks and had never met S4, S5, or S6.

LPMs conducted a further review of the Guardian Background Clearance System in an attempt to identify the staff members named in the time sheet log. A name search for S4 revealed no results or indications of an active clearance. S5 was discovered with an active clearance however they were associated to a different facility licensed by the Department. [continued on LIC 809(c)].