Facility Evaluation Report

At around 2:25 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a POC visit and met with Shirley Marshall. LPA explained to Administrator purpose of the visit.

LPA and Administrator reviewed updated medication list and medicine. LPA observed Vit D3 order is 25 mcg but the supply is 10 mcg. And a new prescription, Vit D2 was added to the list. Administrator states the new prescription is waiting for order from the doctor.

One of the staff went to the pharmacy to pick up correct dose of Vit D3.

Additional civil penalty of $600 from 4/6 - 4/11, 2023 (6) days is being assessed.

Administrator will notify LPA once Vit D2 is received.

The deficiency related to ongoing civil penalties is cleared.

A copy of this report was provided to Administrator.