Facility Evaluation Report

On 02/21/2024 at 11:55 am, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct Case Management visit. LPA met with Administrators, Keith & Stephanie Mauer and explained the purpose of the visit. LPA conducted an Annual Inspection on 12/14/2023 and cited facility. The original Plan of Correction (POC) was scheduled for 01/11/2024. The administrator requested an additional 30 Day extension on 01/08/2024 in which LPA L. Alexander granted the request and confirmed that the new due date is 02/09/2024. Due to LPA L. Alexander was not able to return to the facility for a POC visit, LPA returned to recite and cite for new deficiencies.

LPA L. Alexander conducted an Annual Inspection on 12/14/2023 and cited facility for the following:

CCR 87411(f) Personnel Requirements – General – Health Screening and TB - deficiencies not cleared

HSC 1569.695(c) - Fire Drill - deficiency cleared

CCR 87412(b)(3)(B) Personnel Records - deficiencies cleared

CCR 87705(c)(6) Care of Persons with Dementia – Appraisals - deficiency cleared

CCR 87705(f)(1) Care of Persons with Dementia – Toxic Chemicals –cleared during visit on 12/14/2023

HSC 1569.618(c)(3) First Aid and CPR – deficiency cleared