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Based on record review and interview, the facility failed to maintain an Emergency Preparedness Program (EPP). This was evidenced by missing documentation for arrangement with other facilities. This affected four of four residents and could result in the failure to react during an emergency.

Findings:

During record review and interview with the Director of Facilities (DOF) on 4/30/24, the EPP was requested and reviewed.

At 1:54 p.m., the facility was unable to provide transfer agreements of arrangements with other facilities or other providers to receive residents in the event of limitations or cessation of operations to maintain the continuity of services to facility residents. Upon interview, the DOF stated that they would provide the memorandum of understandings. As of 5/1/24 requested records were not received by the California Department of Public Health.

Based on record review and interview, the facility failed to maintain an Emergency Preparedness Program (EPP). This was evidenced by missing information in the emergency power supply system policy and procedure. This affected the four of four residents and could result in the failure to properly react during an emergency.

Findings:

During record review and interview with the Director of Facilities (DOF) on 4/30/24, the EPP was reviewed.

At 2:31 p.m., the facility was missing a written and specified policy and procedure for maintaining emergency power during an outage such as, how back up fuel would be acquired and how long back up fuel could sustain emergency power. The facility was unable to provide a plan for how it will keep emergency power systems operational during an emergency. Upon interview, the DOF confirmed the finding and stated that they were not aware of the regulation.