Facility Evaluation Report

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management - Deficiencies visit in conjunction with a complaint visit. LPA met with and explained the reason for the visit with facility Designee Mario Ramos. Administrator was unable to come to the facility at the time of the visit.

While conducting a record review in conjunction with a complaint investigation, LPA discovered that Staff (S1) was not cleared to work in the facility. S1 was working during a facility visit on 1/16/2024.

On 1/16/24 LPA Brown contacted and informed the Administrator that S1 was to be immediately removed from the facility. AD visited the Regional Office that same day and was informed that S1 could not be Associated to the facility based on not-eligible status.

A deficiency for Criminal Background Clearance is being cited on the attached 809-D.

Civil penalty is assessed on the attached LIC421BG.

An exit interview was conducted and Plan of Correction was developed. A copy of these reports and Appeal Rights were discussed and left with Mario Ramos, whose signature on this form confirms receipt of these documents.