Facility Evaluation Report

Licensing Program Analysts (LPAs) Christine Dolores and Tracy Pham arrived unannounced to open the initial complaint investigation. During visit, LPAs observed deficiencies in which a case management - deficiencies visit was conducted. LPAs met with Administrator, Nicholas Inneh.

Upon arrival to the facility, LPAs was greeted at the front door by staff (S1). Based on review of the facility's staff roster, the individual was not associated to the facility. LPA reviewed Guardian and observed S1 is fingerprint cleared. LPAs reviewed the staff schedule and roster and did not observe 3 other staff members associated to the facility. The 3 staff members were not present during visit nor was scheduled to work today. Administrator was advised to submit the LIC9182 or LIC9188 to associate the staff members to the facility, ASAP. Administrator was advised that the staff members should not be working in the facility until associated. Administrator stated understanding.

During interview, LPAs was informed by the Administrator that a resident (R1) was sent out to the hospital for medical treatment and later passed away in the hospital about 2 weeks ago. The individual was still a resident at the facility. The review of the facility's incident reports did not show a death report or incident report was submitted. Administrator verbally confirmed a death report and incident report was not submitted to the Department. LPA Dolores advised the Administrator of Title 22 regulations on reporting requirements.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S1) working at the facility without association. See LIC421BG.

Exit interview was conducted with Administrator, Nicholas Inneh and a copy of the report was provided along with the appeal rights.