Facility Evaluation Report

Licensing Program Analyst, LPA , Noel Wolf Petersen arrived unannounced to conduct a case management related to a report that was received by DHCS. LPA met with Program Administrator/Program Director, PAPD Donna Colbert to explain the purpose of the visit.

LPA reviewed the report with the PAPD, In a review of client records, nine defficencies were noted by the DHCS analyst, Title 9 Article 3.5, section(s) 532.1(c), 532.2(a)(1), 532.2(b), 532(b)(4), 532.2(c), 532.2(c)(3)(B), 532.2(c)(4), and 532.2(f) of California Code of Regulations. The citations are generally related to the admission and discharge processes, and the facility relayed were largely due to staffing concerns and a lack of redundancy in the checking of paperwork.

The facility provided to the LPA that redundancy and staffing concerns have been addressed and ongoing commitments in the following areas will be adhered to: the educational matierals provided to the resident by the doctor will be documented, admission agreements will be signed at the time of admission by the client and a representative of the facility, assessments of vocational skills/limitations will be conducted during the admission process, an assessment for an anticipated length of stay to identify and accoplish goals will be completed at admission, treatment plans will be completed within 72 hours of admission the clients, treatement/rehabilitation plan will be reviewed at an ongoing 30 day period, discharge summaries are to include evidince of goals accomplished/plan for discharge/referal for follow up.

Per Title 22, the facility is responsible to follow all applicable laws and regulations, a citation is issued on a following D Page.

A copy of the report was given to the PAPD, appeal rights were provided, and an exit interview was conducted.