Facility Evaluation Report

On 10-24-22 at 1:00pm, regional office conducted an informal meeting with facility to discuss recent citations issued and additional concerns. This meeting was held virtually via Teams Meeting. Present at the meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Michael Bilger, Licensee William Puckett, Assistant Administrator Carrie Mumphrey, Ombudsman Kathryn Thomas, and Regional Center representatives Stephanie Medina and Katina Richison. Topics in this meeting included the following: (1) Needs and Service plan, (2) Personal Rights, (3) Client Records, (4) Reporting Requirements, (5) Building and Grounds, (6) Administrator Qualifications, (7) Food Services, (8) COVID precautions, and (9) Care and Supervision.

LPA Bilger and LPM King discussed with licensee and assistant administrator the following citations and the associated plans of correction going forward:

On 3-9-22 a citation was issued under 80070(a)(b)(10) Client records due to incomplete medication log sheets. Training was conducted by licensee and a sign off sheet per shift as been developed and in use.

On 4-28-22 a citation was issued under 80068.3(a) Modifications to needs and service plan due to needs and service plan not updated after a recent fall episode involving a resident. Check sheet to review needs and service plan with incident reports has been developed by Licensee and currently in use to address needs to change needs and service plan, individual program plan (IPP) and/or Individualized Service Plan (ISP)

On 6-14-22 multiple citations were issued under the following:

80076(18) Food services due to inappropriately labeled food and unsecured food storage,

80064(a(3) Administrator Qualifications and Duties due to not ensuring the following of COVID precautions,