Provencio Hope Assisted Living, LLC

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. On September 5, 2023, the Compliance Officer requested the following documents during the on-site inspection: - D1's rabies documentation; - Disaster Drills for employees: and - Evacuation drills for employees and residents. 2. In an interview, E1, acknowledged this information was not provided to the Compliance Officer within the two hours after a Department request.

Based on record review, documentation review, and interview, the manager failed to ensure, before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid training for one of three caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs during an emergency. Findings include: 1. A review of E1's personnel record revealed E1 was the manager of this facility and had a hire date as the manager of October 20, 2021. 2. A review of E1's personnel record revealed documentation of a "BASIC LIFE SUPPORT BLS Provider (CPR and AED) Program" with the American Heart Association logo affixed. However, current documentation of first aid training certification was unavailable for review at the time of the inspection. 3. A review of staff schedules revealed E1 was scheduled to work as a caregiver on August 4, 11, 18, 19, 25, 26, 2023, and September 1, 2, 3, 9, 2023 from 10:00 pm to 7:00 am. 4. A review of a policy's and procedures revealed a policy titled "CPR and First Aid". This policy states "A. The Manager or Manager's Designee shall ensure that each caregiver working in the facility has received training in CPR and First Aid and provides documentation". 5. In an interview, E2 acknowledged E1's personnel record did not include documentation of first aid training.

Based on observation and interview, the provider failed to ensure a dog allowed in the facility was vaccinated against rabies. Findings include: 1. The Compliance Officer observed one small white dog, D1 in the facility. 2. The Compliance Officer requested D1's rabies vaccination documentation. E2 reported that D1 belonged to E1 and didn't live at this home. E2 contacted E1 for D1's documentation. E2 reported being unable to provide this documentation. 3. In an interview, E2 acknowledged D1 did not have documentation of a rabies vaccination.