Facility Evaluation Report

On 11/9/22 at 10:15am LPA Jensen arrived at facility to open a complaint investigation. LPA Jensen with Administrator Jean Alvarez and explained the purpose today's visit. During the course of the investigation, LPA Jensen discovered deficiencies and conducted a case management.

LPA Jensen reviewed a resident file for resident 1 (R1). The file for R1 had incomplete documentation including the LIC 9158, LIC 613C and LIC 603. In addition the resident file was consent forms, emergency contact and ID forms, immunization forms and safeguards for property and valuables.

LPA Jensen also determined that R1 and Resident 2 (R2) are bedridden. Both bedridden residents are on hospice care. LPA Jensen reviewed the facility sketch and there are no rooms designated for bedridden. LPA Jensen reviewed the STD 850 and determined there is no clearance for bedridden, only 6 non-ambulatory residents. LPA Jensen reviewed the LIC 200 and determined there is no request for bedridden capacity. LPA Jensen also observed a Inspection Record for Permit for voluntary fire sprinkler system dated 9/14/22.

Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6. A civil penalty is also being assessed.

LPA Jensen observed the bedridden resident rooms to have exit doors and the facility had what appeared to be a fire sprinkler system.

An exit interview was conducted a copy of this report along with appeal rights was provided to the Licensee.