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. 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 January 2023 and LIC500 Personnel Report. The facility has 1 staff for morning shift 6:00am-10:00am, 2 staff for afternoon shift 2:00pm-10:00pm and 1 staff for night shift 10:00pm-6:00am. Also, LPA/Administrator observed daily care log for the month of December 2022 and January 2023 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 attention 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 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 has a Registered Nurse that provides monthly training to all staff and helps with the resident's care plans updates. Facility provided tentative staff training calendar for this year.

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