Facility Evaluation Report

On July 20, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to complaint investigation (complaint number: 14-AS-20230714123226). LPA met with Operation Specialist, Kathleen Calobeer and explained the purpose of the visit.

During the complaint investigation visit, LPA found that the facility failed to submit the incident report for the incident that occurred on July 12, 2023 where Resident 1 (R1) signed out and left the facility unassisted. According to the Resident Care Coordinator, Rowena Cancino, it was acknowledged an incident report was not submitted to CCL.

87211 Reporting Requirements- A civil penalty of $250 is assessed on 7/20/2023 for a repeat violation within 12 months. This violation was cited on 6/29/2023.

During the visit, LPA observed Staff 1 (S1) to not be fingerprint cleared. Based on personnel record review with facility, LPA observed S1 to not be fingerprint cleared and association status to be pending. Operations specialists immediately notified S1 and S1 left the facility during LPAs visit and will not return until fingerprints are cleared.

This violation results in a civil penalty of $100 per day x 1 day = $100

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in additional civil penalties.

Report is reviewed with Operations Specialist and a copy is provided with civil penalties and appeal rights.