Facility Evaluation Report

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced CASE MANAGEMENT- DEFICIENCIES visit to this facility and met with, Laila Landu Kulungu - facility representative. The case management visit is being conducted due to deficiencies observed during the investigation of complaint control # 29-AS-20240823160942. The Administrator was unable to sigh the report at the time it was delivered but has designated facility representative to sign on their behalf.

During the complaint investigation, the following deficiency was observed:

On 8/27/2024, during the initial visit, LPA conducted a review of both current and former residents’ records. The review revealed missing required signatures from residents and/or their responsible parties on key documents. Resident’s #1 (R1’s) file contained a preplacement appraisal information dated on 04/06/2023, and appraisal/needs and service plan form dated on 03/30/2023 and on 11/14/2023, all of which were missing the necessary signatures. Resident’s #2 (R2’s) appraisal/needs and service plan dated on 11/14/2023 lacked the required signatures. Additionally, Resident #3 (R3) needs and service plan dated on 1/18/2022 was also missing the required signatures. During an interview, the facility administrator stated they were unaware of the missing signatures. It was noted that the facility representative is responsible for ensuring that all documentation is complete and kept up to date. The facility representative indicated that documents requiring signatures were typically left for family members to sign during their visits before being filed. However, they were uncertain as to why these particular documents had been filed without the necessary signatures.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies was cited (refer to LIC 809-Ds):

Exit interview conducted and copy of the report was issued and appeal rights provided.