Facility Evaluation Report

On 3/27/23 Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management in relation to program certification review completed on March 15, 2023 by the Department of Health Care Services (DHCS). LPAs Jensen and Fain met with site manager Karen Edmond and explained the purpose of today's visit. LPA Jensen also spoke to Lisa Owens, Program Director and explained the purpose of today's visit.

During the course of the on-site program certification review conducted on March 15, 2023, the DHCS determined the facility was out of compliance with the California Code of Regulations (CCR), Title 9, Section 532.1(b). Based on a review of 3 open client records, 2 of 3 records did not contain documented evidence that a screening for medical complications was conducted 30 days prior to or after admission.

LPA Jensen conducted an interview with Program Director Lisa Owens by telephone. The Program Director advised that on the same day the review by DHCS was conducted, a new process was implemented that has intake staff checking to verify a screening for medical complications has been conducted. As an additional measure, the assigned Administrator will also be verifying that the required screening has been conducted prior to admission. The 2 step verification process was immediately implemented and remains in effect at this time.

A deficiency is being cited from CCR, Title 22. Failure to correct deficiencies may result in the assessment of civil penalties.

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