Facility Evaluation Report

Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - POC visit at the facility. LPA met with staff Colleen Papp - Interim Executive Director. Interim ED called and spoke with Ann Wood - Senior Vice President of Operations via telephone who initially authorized Regional Vice President of Resident Care, Sharlene Gephart to sign and review documents. However, Memory Program Director, Collette Philipp, was ultimately authorized to review and sign the reports.

During the inspection on 8/29/2022, the facility was issued a citation for not having Interim ED, Colleen Papp associated to the facility. The Plan of correction date given to submit the paperwork necessary to associate Interim ED was 8/30/2022. However, the plan of correction was not met as Interim ED has not been associated to the facility as of today. Additionally, LPA met with Regional Vice President of Resident Care; however, information gathered during the inspection revealed staff who was originally designated to sign off the report is also not associated to the facility. Interviews with staff revealed that Staff has been working at the facility since Tuesday, 8/30/2022.

Civil penalties are being assessed today in the amount of $200, $100 X 2 days for Interim ED not being associated to the facility and $200, $100 X 2 days is also being assessed due to Regional VP of Resident Care not being associated to the facility either. Civil penalties will continue to accrue until proof of correction has been received by CCL. Total amount of civil penalties assessed today is $400.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

Exit interview conducted. Appeal Rights discussed. A copy of the report was provided via email.