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25 | On 1/4/2024, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to deliver complaint findings and conduct a case management inspection. LPA met with Executive Director Tiffaney Santoro and announced the purpose of the inspection.
The purpose of this inspection was to address deficiencies which were observed during the investigation of a complaint made against the facility, complaint control number 24-AS-20231115122107, received 11/15/2023.
It was discovered that facility staff conducted a reappraisal on 11/19/2023, due to a change in a resident's condition, which did not include the responsible party of the resident. See California Code of Regulations Title 22, Division 6, Chapter 8, Article 8, Section 87463 Reappraisals.
It was also discovered that, after a rate increase due to a change in the level of care of a resident, facility staff did not provide appropriate written notice of this increase in fees to the resident's representative within two business days of providing services at the new level of care. See Health and Safety Code, Chapter 3.2, Article 6, 1569.657.
See attached LIC809D for deficiencies cited in accordance with California Code of Regulations and Health and Safety Code. Failure to correct these deficiencies could result in Civil Penalty. Exit interview conducted. A copy of this report and Appeal Rights were provided to the licensee. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/12/2024
Section Cited
CCR
87463(c)
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7 | 87463 Reappraisals: (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition...This requirement was not met as evidenced by: | 1
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7 | Executive Director agreed to conduct refresher training for herself and appropriate staff on Title 22 requirements for reappraisals. |
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14 | Based on record review and interview, the licensee failed to meet this requirement by conducting at least one reappraisal which did not include the responsible party for the resident being appraised. This presents a potential risk to the health and safety of residents in care. | 8
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Type B
01/12/2024
Section Cited
HSC1569.657
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7 | §1569.657 (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative...written notice of the rate increase within two business days after initially providing services at the new level of care. This requirement was not met as evidenced by: | 1
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7 | Executive Director agreed to provide a sample written notice for a rate increase to CCLD by POC due date, as well as conduct staff training on requirement set forth in Health and Safety Code 1569.657. |
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14 | Based on interview and records review, the licensee failed to meet this requirement for at least one resident and their responsible party, by not providing written notice within two business days of raising fees due to a change in the level of care. | 8
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