Facility Evaluation Report

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced case management – legal/non-compliance visit. LPA met with Administrator (ADM) Nicholas Inneh. LPA stated the purpose of the visit.

The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on 10/23/2024.

LPA discussed the non-compliance plan with the ADM to include ensuring that all staff are trained to provide resident care meeting physical, emotional, and social needs; plan for regular observation from the resident and documentation of resident functioning changes; ensuring the facility is kept clean, safe, sanitary and in good repair, addressing any signs of bed bug infestation; ensuring all incident and death reports are documented and reported to CCL per Title 22; ensuring all staff obtain a criminal record clearance and association to the facility; ensure all residents medical assessments include a TB result prior to admission; ensure all resident’s reappraisals are updated annually; ensure all meals meet dietary and physician ordered nutritional requirements, and ensuring the Administrator provides proper oversight and administration of the facility operations in alignment with Title 22 regulations.

During visit, LPA toured the facility with ADM include the resident bedrooms, hallways, bathrooms, dining room, kitchen, and exterior.