Facility Evaluation Report

Licensing Program Analyst (LPA) Shawna Doucette and Jimmy Duarte arrived at the facility unannounced to conduct a complaint investigation. During the course of the investigation LPA's observed additional deficiencies. LPA met with Administrator Nancy Cudal. Due to technical issues LPA had to reissue the 809D. The purpose of the report is to add the missing 809D page and civil penalty.

LPA reviewed records and observed discrepancies in S1's file. After checking LIS, it was found S1 was not listed to be fingerprint cleared. S1's clearance shows pending. LPA obtained copies of facility records and staff schedule. During the records review of S1's file, LPA observed S1 to not have a current TB test. S1 took her file and marked the positive box and wrote a date of 8/17/25, altering the health screening.

Additionally, facility Administrator resigned 11/12/25. Facility does not have a current Administrator. Administrator Nancy Cudal is assisting until facility finds an Administrator.

A copy of this report was provided along with plans of correction and appeal rights. A Civil Penalty was issued.