Facility Evaluation Report

On 7-12-23 at 12:05pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding a relocation of memory care door. LPAs met with business office manager Eddie Itliong and explained the purpose of the visit. Administrator Anuradha Saini was made aware of LPAs visit. On 6-20-23 LPA received LIC 200 and updated facility sketch from licensee indicating plans for memory care door relocation. At that time, Licensee was to not complete construction prior to clarification for the need to update fire clearance. Upon entry, LPAs observed memory care door was moved forward from previous spot allowing for extra rooms accessible to assisted living residents. LPAs interviewed Staff1 (S1) and Administrator. Based on interview and observation, it was determined that door construction was completed prior to a fire department consultation as well as an updated fire clearance. Moreover, it was determined that a building permit was not obtained prior to construction. Additionally, based on observation, the memory care door alarm was not functioning due to a malfunctioning bar door when tested by LPAs. During LPA's visit today, maintenance immediately repaired door to appropriate functional status as observed and tested by LPAs. Furthermore, it was determined based on interview and record review, that licensee did not ensure a plan of provision of safety during time of this construction to ensure adherence of memory care resident rights and overall safety.

Based on today's case management, deficiencies are cited under Title 22, Division 6. Immediate civil penalties in the amounts of $500 were issued in addition to citations due to fire safety hazards and fire clearance. An exit interview was held with Eddie Itliong and a copy of this report was left with Eddie. Appeal Rights provided.