Facility Evaluation Report

On 01/07/25, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on a complaint investigation. LPA was greeted by Staff S1, stated the purpose of the visit, and was allowed entry into the facility. LPA met with Administrator to discuss deficiencies observed during the course of LPA's investigation.

LPA Salazar reviewed Resident R1's facility file/records. R1's Needs and Service Plan (IPP) was not observed on file, R1's Medical Assessment (LIC 602) dated 11/14/24 was incomplete and did not have the required information. R1's Functional Capabilities assessment (LIC 9172) dated 11/14/24 had conflicting care and supervision needs. LPA observed diagnosis' for 4 out of 4 residents. Medical assessments (LIC602a) dated 12/26/24 state 4 out of 4 residents are ambulatory. Based on LPA's observation and records review, 4 out of 4 residents meet Title 22 definition of non-ambulatory. Facility license and fire clearance shows approval for 2 ambulatory and 2 non-ambulatory.

Based on the information received and per California Code of Regulations, Title 22, Division 6 Chapter 1, the following deficiencies are being cited on the attached LIC 809D. An immediate civil penalty in the amount of $500 is hereby assessed for fire clearance violation. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care.

Due to time and circumstances, LPA was not able to review report and deficiencies with Administrator on 01/08/25. LPA returned to the facility on 01/08/25 to review. On 01/08/25, an exit interview conducted with Administrator. A plan of correction was developed by Administrator and reviewed with LPA. POC date will be 24 hours from delivery of deficiency, which is 01/09/25. A copy of this report and appeal rights were discussed and provided to Administrator, whose signature on this form confirms receipt of this document.