Facility Evaluation Report

On 05/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit in order to make observations regarding facility operations and staffing. LPA met with business office manager Jovy Castro and explained the purpose of today's visit. At this time there is no administrator assigned that sits in the facility providing oversight.

This is a two level facility. During today's visit LPA obtained the current staff schedule for this week and next week May 5 through May 11, and May 12 through May 18, and a facility resident roster. The facility is cleared to have 10 hospice residents and there are currently 8 on record under hospice. LPA toured the facility independently and conducted interviews at random. LPA observed dining room staff assisting resident and family members with a meal. LPA observed activities taking place on the ground floor. Per LPAs observations and review of staffing schedule there is only one med-tech on this day assisting residents with medications and care for both floors of the facility when usually there should be one med-tech on each floor. LPA observed 2 caregivers on the schedule on each floor in place. That is 2 caregivers on each floor totalling 4 caregivers for 57 residents in care. PM shift it identifies the addition of one staff member totalling 5 caregivers, if no one calls out, to 57 residents but still 1 med-tech handling medications for both floors which is the same med-tech from the AM shift. LPA conducted interviews at random and discovered a shortage of med-techs at this time resulting in the newly hired memory care director to hand out medications without having earned a med-tech certificate. This staff person is not fully trained at the time of today's visit and has handed out medications prior to the visit for several days. Per additional review and interviews it is discovered that additional med-tech and staffing into the weekend there is only 1 med-tech for AM and PM shifts, 3 caregivers for AM shift and 3 caregivers for PM shift for 57 residents in care for the entire facility.

Per LPA observations made on this day and documents reviewed there are staffing and training violations taking place. These violations pose a health and safety risk to residents in care. Citations are being issued on this day on the following LIC809-D.

Report is reviewed with business office manager Jovy Castro. A copy of this report is provided on this day.