Facility Evaluation Report

On 03/07/2025, Licensing Program Analysts (LPAs) L. Salazar and M. Garza arrived at the facility unannounced to conduct the Annual required inspection. LPAs were greeted by DSP who called Administrator, Brandy Frazier, who is unavailable. Area Director Donte Williams arrived shortly after to conduct the visit with LPAs.

LPA Salazar conducted the records review for staff and clients and will document on this report. LPA Garza conducted the physical plant tour inside and out and will document on a separate report.

Based on LPAs observation, 3 out of 4 residents in care had outdated IPP's however the facility's Needs and Service plans were dated 2024. 3 out of 4 resident's physicians reports were observed to be over a year. Routine medical visits were observed in file. Administrator will send proof of recent physician's visits by 03/21/25. Staff records were unavailable at the time of visit due to Administrator being out sick and having the key to staff records. Requested information will be sent to LPA by 03/14/25.

No deficiencies cited on records review, any deficiencies from the annual inspection will be cited on a separate report by LPA Garza. An exit interview was conducted.