Facility Evaluation Report

This report has been AMENDED from the Original Report.

On 10/30/2025 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a case management visit. LPA was allowed entrance into the facility by staff.

During todays visit LPA observed the same double dead-bolt on the outside gate and knock box. LPA asked how many dementia residents were at the facility and Administrator stated about 15. LPA showed Administrator current fire clearance on file which does not indicate a double dead-bolt or knock box. Fire Clearance on file was cleared on 4/1/2021. LPA observed R1's Admission Agreement which has Addendum E with a revised date of 6/17/2024 due to having outside perimeter locked. The revised Addendum comes after the fire clearance was cleared. Administrator provided verification of Fire Inspection completed on 4/15/2025, which indicates a knock box needs to be installed. Administrator stated the fire department stated the knock box needs to be installed so the fire department can access the facility in case of an emergency. This is conflicting due to the fire department not previous having access from 4/1/2021-4/15/2025. This means fire clearance is not being maintained with. LPA also observed a staff's car to be double parked while working and caring for residents, which can cause a dangerous obstruction. Deficiency will be cited under Title 22. Civil penalty will be issued.

When changes are made to the current fire clearance on file, there is proper paperwork to be filed with licensing so the updated fire clearance can be on file. Licensee did not file the proper paperwork to update fire clearance. Due to facility failing to properly notify licensing and file proper paperwork. Deficiency will be cited under Title 22.

Exit interview was conducted and a copy of this report LIC809, LIC809D, appeal rights, and civil penalty were provided to Administrator.