Failure to Timely Notify State Agency of Change in Administrator
Penalty
Summary
The facility failed to notify the State Agency (SA) within ten days of a change in administrator (CHOA) that occurred on 11/13/2023. Multiple staff interviews confirmed that the new administrator (ADM 1) assumed the role on that date, following the resignation of the previous administrator (ADM 2). Staff, including the DON, Medical Records Director, and Social Services Director, were aware of the change internally, but there was uncertainty and lack of knowledge regarding the external reporting requirements to the SA. The new administrator and the Vice President of Operations (VPO) both stated that the responsibility for reporting the change to the SA was understood, but neither could provide proof that the required notification was sent or received by the SA. A review of facility documents showed that the offer letter for ADM 1 was dated 11/13/2023, and the resignation letter from ADM 2 was effective 9/15/2023. The Applicant Individual Information (HS215A) form was completed and signed by ADM 1 on 12/30/2023, but there was no evidence of receipt by the SA. Both ADM 1 and the VPO stated that documents were mailed to the SA, but neither could provide proof of mailing or confirmation of receipt. Additionally, there was no facility policy or procedure for reporting changes of administrator to the regulatory authority. A review of the State Agency's Electronic Licensing Management System (ELMS) indicated that as of 12/11/2025, ADM 2 was still listed as the active administrator, with no end date, and the most recent CHOA application was pending as of 12/3/2025. There was no record of a CHOA application between 4/22/2022 and 12/3/2025. The California Code of Regulations requires written notification to the Department within ten days of a change in administrator, including the name and license number of the new administrator. The facility was unable to provide evidence that this requirement was met.