Izene's Haven Assisted Living

Type of visit: Required - 1 Year

On 06/06/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA was greeted by Licensee (L1) Marguerite and was granted entry into the facility. LPA introduced self and stated the purpose of the visit. LPA conducted tour with L1. All six residents were present during inspection. The tour started in the common areas, into kitchen to resident's rooms. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Fire extinguisher was observed with purchased date 04/10/22. At approximately 12:06AM, LPA and L1 observed one resident medication cup fill for AM and one resident medication cup for noon both fill with medications on kitchen counter unlock. LPA reviewed residents’ MARS. First aid kit was observed and contained all required items. An adequate supply of perishable and non-perishable food was observed. Refrigerator maintained at a 58 degrees F. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. LPA observed 2 shared residents’ bed to be at least 6 feet apart and 2 single occupant bedrooms. Bathrooms were properly equipped. Hot water temperature 115.4 to in bathroom 1 and ranged between 116.1 degrees F to 116.4 degrees F in bathroom in the shared bedroom. Cleaning supplies and chemicals are kept in locked in laundry room. Outside of facility toured. Outside seating was observed available for residents. Side gate was self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational. A sample of residents’ file reviewed to have update Emergency contacts, Admission agreement, Pre-Appraisal form, and physician report. A sample of staff's files were also reviewed to have current First Aid/CPR, Personnel Record, Health Screening, and associated with facility. A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. An exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 06/13/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability insurance, control of property, and current Administrator. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Jun 6, 2023

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide authorized representative access to confidential documents Staff did not issue a refund

On 04/14/23, Licensing Program Analyst (LPA) M. Yang arrive unannounced visit to deliver the findings on the above allegation. LPA was greeted by Licensee Marguerite Bruton and was granted entry. During the course of the investigation, LPA obtain record and conducted interviews. A copy of Admission Agreement was requested by letter by responsible party. Licensee stated no copy was provided to resident’s responsible party. Licensee stated a check was mailed late December 2022 to early January 2023. The responsibility party have not received the check that was mailed for the refund for the prorated amount after resident death. Based on records reviewed and interview conducted, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6 are being cited on the attached LIC 9099D. An exit interview was conducted, and a Plan of Correction was reviewed and developed with Licensee. A copy of this report and appeal rights was provided to Licensee. Substantiatedthe state’s words, verbatim · CDSS document, Apr 14, 2023 · control 24-AS-20230315102447

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Apr 20, 2023

HSC 1569.652 (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual... contractually responsible for the fees... within 15 days after the personal property is removed. This requirement was not met as evidenced by: Based on interviews conducted and record review, Resident 1 passed away on 10/02/22 and was not issued a refund for the remaining unused days to the resident’s responsible party. Licensee mailed the check late December 2022 early January 2023. The responsibility party have not received the check that was mailed. Responsible have not received a copy of the Admission Agreement as requested.This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 14, 2023

Plan of correction: Licensee agreed provided a copy of the resident’s Admission Agreement and issue a check to R1's responsible party and provide a copy of the check and a copy of the post office mailing receipt to the Fresno CCL office by the POC due date. POC will clear when resident’s responsible party confirm record and money order has been received.

Type of visit: Case Management - Other

On 01/31/23, Licensing Program Analyst (LPA) Yang arrived unannounced to conduct a case management inspection. LPA introduced self, stated the purpose of the visit and was greet by the Administrator Marguerite Bruton. LPA was granted entry by Administrator. The purpose of today's visit is to obtain copies of record. LPA conducted interview with Administrator. The information provide will be reviewed; a follow up case management will be conducted if necessary. No deficiencies issued during today's inspection. Exit interview conducted. A copy of this report was provided to Administrator, Marguerite Bruton, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Jan 31, 2023

Type of visit: Case Management - Other

On 08/10/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management inspection. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. LPA met with Administrator, Marguerite Bruton. The purpose of today's visit is to return resident records that were removed from the above facility on 08/08/2022. No deficiencies issued during today's visit. An exit interview was conducted. A copy of this report was discussed and provided to Administrator, Marguerite Bruton, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Aug 10, 2022

Type of visit: Case Management - Other

On 08/08/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Marguerite Bruton. The purpose of today's visit is to obtain records for copying. LPA will return the resident records within 3 business days. No deficiencies issued during today's inspection. An exit interview was conducted with Administrator. A copy of this report was discussed and provided to Administrator, Marguerite Bruton, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Aug 8, 2022

Type of visit: Case Management - Other

On 08/01/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Marguerite Bruton. The purpose of today's visit is to return residents records that were removed from the facility on 07/27/2022. No deficiencies issued during today's inspection. An exit interview was conducted with Administrator. A copy of this report was discussed and provided to Administrator, Marguerite Bruton, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Aug 1, 2022

Type of visit: Case Management - Other

On 07/27/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an case management inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Marguerite Bruton. The purpose of today's visit is to obtain the complete resident file for R1. LPA will return the records to the facility/Licensee within 3 business days. No deficiencies issued during today's inspection. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Marguerite Bruton, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Jul 27, 2022

Allegation investigated: Resident records are incomplete Staff records are incomplete

On 05/06/2022 Licensing Program Analyst (LPA) L. Salazar and A. Walton arrived at the facility unannounced to deliver findings on the above allegations. LPA requested staff files when the complaint was opened. L1 was unable to provide did complete staff and resident files for LPA to review. Based on the: LPA’s observation the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. An exit interview was conducted with Licensee Marguerite Bruton. A copy of this report and appeal rights were discussed and provided to Licensee. A plan of correction was developed by licensee and reviewed with LPA. Substantiatedthe state’s words, verbatim · CDSS document, May 6, 2022 · control 24-AS-20220110135143

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87606(a) · Plan of correction due date: May 20, 2022

87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement was not met as evidenced by LPA observation of resident records. Required LIC forms are in the file, however, they are not completed in their entirety.the state’s words, verbatim · CDSS document, May 6, 2022

Plan of correction: Licensee will review all resident files and ensure all LIC forms are completed in their entirety, including . "Not appplicable" (N/A) may be used on the form for areas that are not applicable.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87654 · Plan of correction due date: May 20, 2022

(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.THis requirement was not met as evidenced by LPAs' observation at the time the complaint was opened, staff records were not complete and available.the state’s words, verbatim · CDSS document, May 6, 2022

Plan of correction: Licensee will ensure all personnel records are complete and up to date at all times. 2 out of the 3 staff no longer work at the facility. LPA observed staff files to have the required LIC forms. Health screeening for Staff S1 has been addressed in the annual insepction with a POC date of 06/06/22. **POC cleared**

Allegation investigated: Staff Records are incomplete Resident Records are incomplete

On 05/06222, Licensing Program Analysts (LPAs) L.Salazar and Alexandria Walton arrived at the facility to deliver findings on the above allegations. LPAs were greeted by Licensee, Marguerite Bruton, stated the purpose of visit and we allowed entry. COVID precautionary measures were taken at the time of entry. During the investigation, LPA reviewed resident and staff files, which were found to be incomplete. without the required LIC forms. Based on the LPAs observations the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. Deficiencies are being cited based on CCR Title 22. See LIC 9099D. A plan of correction was developed. Plan of correction was provided by licensee and reviewed with LPA. An exit interview was conducted with Licensee Marguerite Burton. A copy of this report and appeal rights were discussed and provided to licensee. Substantiatedthe state’s words, verbatim · CDSS document, May 6, 2022 · control 24-AS-20220110135143

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: May 6, 2022

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by LPA's request for resident records and Licensee was unable to provide the required documents in the LIC 311F.the state’s words, verbatim · CDSS document, May 6, 2022

Plan of correction: Licensee completed resident files per the LIC 311F provided to L1 by LPA. L1 submitted proof to correction at the time of visit. **POC cleared**

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a) · Plan of correction due date: May 6, 2022

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:(4) Written verification that the employee is at least 18 years of age, including, but not necessarily limited to, a copy of his/her birth certificate or driver's license. This requirement was not met as evidenced by LPA's request for resident records and Licensee was unable to provide the required documents in the LIC 311F.the state’s words, verbatim · CDSS document, May 6, 2022

Plan of correction: Licensee completed staff files per the LIC 311F provided to L1 by LPA. L1 submitted proof to correction at the time of visit. **POC cleared**

Type of visit: Required - 1 Year

On 05/06/2022, Licensing Program Analysts (LPAs) Walton and Salazar arrived unannounced to conduct an Annual Inspection - Infection Control. LPAs introduced themselves, stated the purpose of the visit and requested to meet with the Administrator. LPAs met with Administrator, Marguerite Bruton. Facility has one central entry and exit point. Facility has implemented a sign in policy for visitors. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathroom did have a trash cans with lid. Hand washing posters were observed by the bathroom sinks. Bedrooms are single occupant. LPAs checked residents’ locked medications. Overflow medications were observed to be locked with cleaning supplies. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Facility does have an adequate supplies of required PPE. Staff records were reviewed, LPAs did not observe a health screen for facility staff. Per Administrator, S1 does not have a health screen. Facility staff was observed with mask on. Residents wear masks when away from the facility. Resident’s files did not have updated emergency contact information. LPAs are requesting the following documents be submitted to the Fresno CCL office by 05/20/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond, and the Mitigation Plan (LIC808) CONTINUED TO 809C Based on observation and interviews, a deficiency is being issued in accordance with the California Code of Regulations, Title 22, Division 6 on the attached 809D. Exit interview conducted and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Marguerite Bruton, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 6, 2022

Type of visit: POC

On 04/7/22, Licensing Program Analysts Les Xiong arrived at the facility unannounced to conduct a Plan of Correction inspection. LPA met with Licensee and informed her the purpose of the visit. On 2/16/22, deficiencies were issued for Title 22, Sections 87755(c) and 87407(a) and the due date for the Plans of Correction (POC) was set at 3/4/22. Subsequently, an extension of the due date was approved to 3/31/22 however you have not submitted all of the documents requested by the Department’s auditor and have not submitted proof of administrator recertification. A review of active and pending administrator certifications indicates that your administrator certificate is not active and there is no re-certification pending at this time. Because you have not submitted required and/or sufficient documentation to clear the deficiencies, civil penalties are being assessed in the attached and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 7, 2022

Type of visit: POC

On 03/11/22, Licensing Program Analysts (LPAs') L. Salazar and A. Walton arrived at the facility unannounced to conduct a Plan of Correction inspection. LPAs' were greeted by Licensee, stated the purpose of their visit and were allowed entry into the facility. LPAs met with Licensee, and asked for the Plan of correction for deficiency cited on 02/16/2022. Licensee provided documentation for LPA to review. LPA called Administrator Certification line who stated the information had not been received as of yet. Licensee provided a copy of a Fed Ex receipt showing documentation was sent to Sacramento's Administrator Certification address. LPA will follow up before POC date. LPA is extending the POC date to 03/31/22 to allow LPA time to review documentation. LPA will return by POC date of 03/31/22.the state’s words, verbatim · CDSS document, Mar 11, 2022

Type of visit: Case Management - Other

On 2/16/22, Licensing Program Analyst (LPA) L.Salazar and Licensing Program Manager (LPM) Melinda Hoffmann, arrived at facility unannounced to follow up on Plans of Correction in relation to Facility Evaluation Report dated 1/10/22, at which time, deficiencies were cited for Inspection Authority and Administrator Certification Requirements. LPA and LPM were greeted by Licensee, Marguerite Bruton. LPM stated the purpose of the visit and was allowed entry into the facility. LPA and LPM had temperature taken upon entry to facility as COVID precautionary measure. Plans of correction were not received on 1/24/22 and a POC visit was not conducted within 10 days of that date therefore the deficiencies are being re-cited in accordance with CCL Title 22, and new correction dates were provided, in the attached 809-D. Plans of correction were discussed with Licensee. During today's visit, it was observed that R1 has full bed rails however R1 is not on hospice and does not have a Physician's order for the full rail therefore deficiency cited in accordance with CCL Title 22. Plan of correction discussed with Licensee. Also observed today, was that R2 has a catheter and colostomy bag and there was no restricted health care plan and/or home health care plan in place to address the care with regard to these therefore deficiency cited in accordance with CCL Title 22. Plan of correction discussed with Licensee. An exit interview was conducted. During the visit, technical issues were experienced and LPA and LPM left the facility for a short time to resolve the matter before returning to obtain hard copy signatures on the report. Appeal rights were provided to Licensee.the state’s words, verbatim · CDSS document, Feb 16, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(c) · Plan of correction due date: Mar 4, 2022

Inspection Authority of the Licensing Agency (c) The Licensee shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours..**This requirement was not met as evidenced by Licensee not responding to a request for audit from Licensing. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2022

Plan of correction: Licensee will submit the records requested, to Licensing, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87407(a) · Plan of correction due date: Mar 4, 2022

Administrator Recertification Requirements (a) Administrators shall complete at least forty (40 classroom hours of continuing education during each two (2)-year ceritication period...**This requirement was not met as evidenced by Licensee not having a current Administrator certificate. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2022

Plan of correction: Licensee will submit proof of current certification by the date or will appoint a qualified administrator who holds a current certification and shall submit a request to change the administrator, along with qualifying documents to make that change.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Feb 17, 2022

Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. **There is no Physician's order on file for R1's full bedrails. Immediate risk to resident in care.the state’s words, verbatim · CDSS document, Feb 16, 2022

Plan of correction: By tomorrow's due date, Licensee will submit a Physician's order for the bed rails or submit proof that the rails were removed from R1's bed. Proof may be a picture.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87611(b) · Plan of correction due date: Feb 1, 0333

General Requirements for Allowable Health Conditions (b) The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following: (1)Documentation from the physician of the following: (A) Stability of the medical condition(s); (B) Medical condition(s) which require incidental medical services; (C) Method of intervention; (D) Resident's ability to perform the procedure; and (E) An appropriately skilled professional shall be identified who will perform the procedure if the resident needs assistance. (2) The names, address and telephone number of vendors, if any, and all appropriately skilled professionals providing services. (3) Emergency contacts. **R2 was observed to have a colostomy bag and catheter and no plan of care for these were on file. Immediate risk to resident in care.the state’s words, verbatim · CDSS document, Feb 16, 2022

Plan of correction: By tomorrow's due date, Licensee will submit a Plan of Care for R1, that includes the required elements as listed herein.

Allegation investigated: Facility does not provide a safe environment for resident.

On 01/10/2022, Licensing Program Analysts (LPAs) L.Salazar and Shawna Doucette arrived at the facility unannounced to amend findings on the above allegation. LPA was greeted by Licensee, Marguerite Bruton. LPAs stated the purpose of the visit and was allowed entry into the facility by Licensee. LPAs had temperature taken upon entry to facility COVID precautionary questions were asked at the time of entry. Based on interviews and observation of additional information, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. An exit interview was conducted with Licensee Marguerite Burton. A copy of this report and appeal rights were discussed and provided to licensee. A plan of correction was developed by licensee and reviewed with LPAs. Substantiatedthe state’s words, verbatim · CDSS document, Jan 10, 2022 · control 24-AS-20211015163924

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Jan 11, 2022

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by interviews and observation of videos taken of Resident on the ground after sliding out of bed. Resident R1 was on the ground for up to 10 hours. Licensee does not have written consent to video Resident.the state’s words, verbatim · CDSS document, Jan 10, 2022

Plan of correction: Licensee will obtain personal rights written consent from Resident to record video of Resident's behaviors.

Allegation investigated: Licensee does not have a fire clearance for bedridden resident. Licensee does not have required facility postings Licensee does not have staff associated to facility.

On 01/10/222, Licensing Program Analysts (LPAs) L.Salazar and Shawna Doucette arrived at the facility to conduct the required 10-day site inspection. LPA was greeted by Licensee, Marguerite Bruton. LPAs had temperature taken upon entry to facility but COVID precautionary questions were asked at the time of entry. LPAs toured the facility, reviewed resident and staff files. The Physician's report (LIC602) for Resident R1 states "bedridden" status, facility is not fire cleared for bedridden. Required Personal Rights posting are not posted in the facility. Staff S1 was not associated to facility. This department has investigated the above allegations. Based on the LPAs Observation the preponderance of evidence standard has been met; therefore, the above allegation(s) is/are found to be substantiated. Deficiencies are being cited based on LPA's observation, interviews conducted, and record review in accordance with the CCR Title 22. See LIC 9099D. Civil Penalties were issued for a Fire clearance and Fingerprint clearance. An exit interview was conducted with Licensee Marguerite Burton. A copy of this report and appeal rights were discussed and provided to licensee. A plan of correction was developed by licensee and reviewed with LPAs. Substantiatedthe state’s words, verbatim · CDSS document, Jan 10, 2022 · control 24-AS-20220110135143

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Jan 11, 2022

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by Resident R1's LIC 602 and review of facility file in Regional Office. *Civil Penalty Assessed*the state’s words, verbatim · CDSS document, Jan 10, 2022

Plan of correction: Licensee will complete and submit the LIC 200 to include Resident R1's bedridden status per LIC602. Licensee will submit a copy of the facility sketch (LIC999) to LPA by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jan 11, 2022

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or which poses an immediate health, safety and personal rights risk to residents in care. This requirement was not met as evidenced by Facility Roster in the Guardian system. *Civil Penalty Assessed*the state’s words, verbatim · CDSS document, Jan 10, 2022

Plan of correction: Licensee will call the Regional Office to verify Fingerprint transfer for staff are completed and all staff are associated to the facility by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(c) · Plan of correction due date: Jan 21, 2022

87468 Personal Rights (c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public.This requirement was not met as evidenced by: Licensee did not have personal rights posted in the facility which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 10, 2022

Plan of correction: Plan of Correction POC Licensee agrees to post personal rights LIC 613C2 by POC due date.

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 01/10/222, Licensing Program Analysts (LPAs) L.Salazar and S. Doucette arrived at the facility unannounced to amend findings a complaint allegation. LPAs were greeted by Licensee, Marguerite Bruton. LPAs stated the purpose of the visit and was allowed entry into the facility by Licensee. LPAs had temperature taken upon entry to facility but COVID precautionary questions were asked at the time of entry. During the course of complaint investigation, LPA Salazar and LPA Doucette observed the following deficiencies: Administrator Certificate is expired. Audit Request documentation was requested from Licensee to be sent to CCLD. Documentation states Licensee did not comply with request. Deficiencies are being cited based on LPA's observation of records review and interviews conducted, and in accordance with the CCR Title 22. See LIC 809D. An exit interview was conducted with Licensee Marguerite Burton. A copy of this report and appeal rights were discussed and provided to licensee. A plan of correction was developed by licensee and reviewed with LPAs.the state’s words, verbatim · CDSS document, Jan 10, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(c) · Plan of correction due date: Jan 24, 2022

87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement was not met evidenced by: Licensee did not respond to request for audit from Licensing which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 10, 2022

Plan of correction: Plan of Correction POC - LPA will provide licensee with copy of CCLD's request for audit documentation by 01/12/2022. Licensee agrees to submit documenation requested by Auditor by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87407(a) · Plan of correction due date: Jan 24, 2022

87407 Administrator Recertification Requirements (a) Administrators shall complete at least forty (40) classroom hours of continuing education during each two (2)-year certification period, including. This requirement was not met as evidenced by: Licensee does not have a current Administrator certificate which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 10, 2022

Plan of correction: Plan of Correction POC Licensee agrees to complete Administrator certification by POC due date.