Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance inspection to this facility and met with Administrator Megan Lawrence-Ferreira. Licensee Sarah Lawrence arrived later. LPA was following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 9/9/22:

80078 (a) Responsibility for Providing Care and Supervision: facility staff failed to notice unstageable pressure injury and any bruises which resulted in client sustaining unexplained injuries while in care. During this visit, LPA/Administrator reviewed staff schedule for the month of September 2022 and LIC500. The facility has 1 staff for morning shift 6am-10am, 2 staff for afternoon shift 2pm-10pm and 1 staff for night shift 10pm-6am. Also, LPA/Administrator observed daily care log starting on 9/27/22 for each resident.

80075 (a) Health Related Services: facility staff failed to seek timely medical attention. LPA reviewed resident’s records and self-incident reports and it appears that staff had been responding timely to medical emergencies.

80065 (a) Personnel Requirements: Facility will provide necessary staff to meet client’s physical, social, emotional, safety and health care needs. LPA reviewed staff training records and most of staff (S1, S2, S3 and S4) has received DSP Year 1 and 2 annual training including special incident reporting, valid CPR/1st aid and assessing for changes in residents functioning, injuries and crisis intervention. Facility is in the process to associate a Registered Nurse to provide training to staff.

No deficiencies cited during today's inspections. Exit interview was conducted with Administrator a copy of this report was provided.