• Executes regulatory management programs.• Provides input on data for critical reporting components for trending and mitigation actions to the appropriate committees, departments, individuals, and regulatory agencies.• Executes on the remediation and closure of internal and external (e.g., assessments, surveys, inspections) for regulatory management.• Provides input on data for critical reporting components for trending and mitigation actions to the appropriate committees, departments, individuals, and regulatory agencies.• Effectively partners with leaders to provide subject matter expertise in the joint execution to assessments for their areas of responsibility for exposures to loss and unsafe processes and conditions.• Collaborates with the quality and regulatory staff in matters related to regulatory compliance, policy planning and implementation.• Collaborates with the development and revisions of policy and procedures as requested.• Ensures compliance with various codes, laws, rules and regulations concerning patient care/safety, including those mandates by County, State and Federal agencies.• Coordinates and Tracks licensing • Coordinates regulatory readiness rounds and mock surveys• Maintains AMP survey readiness tool for The Joint Commission

Responsible for planning and implementing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff, and Governing Body. Facilitates performance improvement activities, and CQI activities throughout the hospital. Acts as resource person to administrative team, department managers, and medical staff. Performs clinical risk management functions. Assists department managers with preparation for medical staff committees. Oversight responsibility for all regulatory body surveys, such as, JCAHO, State Licensing Review, HCFA (CMS) Validation surveys. Maintains oversight responsibility for all performance improvement activities conducted throughout the hospital.

• Develop compliance policies and protocols on behalf of agency that provides ABA services• Develop and implement a compliance program to ensure the organization operates in accordance with state and federal laws• Determine compliance metrics and establish a system for tracking them • Remain up to date on federal and state laws related to the organization and update policies accordingly• Perform compliance audits to determine whether establish protocols are being followed and where they can be improved

• Responsible for compliance at Front Porch, a California nonprofit healthcare agency with seven skilled nursing facilities and eleven clinics in four counties.• Lead on COVID-19 policies and safety implementation• Responsible for pandemic related PPE supply for Los Angeles sites• Directs programs, policies, and practices to ensure that skilled nursing facilities and clinics are in compliance with all policies and regulations. • Designed and implemented Medicare/CMS and Title 22 compliant emergency operations program• Tracks healthcare laws and regulations that might affect the organization’s policies and implements necessary changes. • Lead on OIG and Medicare compliant Compliance Manual and annual work plans• Responsible for Compliance & Ethics Hotline• Design and implement compliance training programs for all staff at seven care centers and eleven clinics across California.• Creates functional strategies and specific objectives for the compliance department and develops policies/procedures to support the infrastructure.

• Responsible for compliance, quality improvement and contracting for PACE program, a capitated managed care program for older, frail adults funded by CMS.• Worked closely with the Medical Director, Executive Director, and Interdisciplinary team (IDT) to identify standards, develop indicators, collect and analyze data and provide corrective action to improve performance.• Maintained confidentiality of all records, documentation, and information that pertain to the QAPI and Compliance programs and serves as the HIPAA Privacy Officer.• Facilitated and directed the work of the Quality and Compliance Committee.• Provided oversight and direction for development, change control management, and implementation of PACE (senior managed care) policies and procedures. • Organized and served as project lead for audits by regulatory agencies. Developed tools to aid in preparation for audits; monitors progress of audit preparation; provided on-site direction for reviewers; develops and implements corrective action plans (CAP); and ensured timely submission and communication with regulators agencies regarding the audits

• Oversaw development efforts to create marketing materials, including newsletter, fundraising calendar and appeal letters • Responsible for Human Resources including hiring, staff development, procurement of benefits, payroll, staff retention and Workers’ Compensation• Represented agency to all of its constituents and the wider public• Coordinated and directed work of the Management Team• Monitored revenue and spending for all programs• Oversaw billing to First Five, LA Universal Preschool and other contracts• Ensured that programs met all legal requirements in regards to personnel issues, childcare safety, fire safety, earthquake safety and building safety• Oversaw licensing process for licensed activities and coordinates with funding sources for funded programs- Managed all human resources at site, including attracting and hiring high performing staff, professional development opportunities, collaborative team culture, and managing performance

• Assures that the mission of the agency is reflected in all program planning, implementation and evaluation• Monitors compliance with grants, contracts, and regulations, including the preparation of performance reports and the maintenance of appropriate records• Responsible for Human Resources including hiring, staff development, procurement of benefits, payroll, staff retention and Workers’ Compensation• Responsible for public relations and marketing for NAMI-OC and the OC WarmLine• Increased annual revenue by over 200% in three years• Responsible for all grant and proposal submissions including RFPs and SIQs for MHSA (Prop 63) funding• Represents NAMI-OC at MHSA Steering Committee and community networking meetings• Designed and implemented the OC WarmLine• Expanded educational programs to include curriculum and services in Spanish, Vietnamese, Korean, Arabic and Farsi• Promotes program expansion into unserved and underserved populations