Facility Evaluation Report

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to Conduct a Case Management - Deficiencies visit. LPA met with facility Administrator Nancy Cudal, and explained the purpose of today's visit.

Staff 1 worked the overnight shift starting from 12 a.m. to 8 a.m. beginning on 04/13/2026 alone with no assistance supervising 46 facility residents. Staff 1 was responsible for nightly 2 hour rounds checking on residents, preparing and cooking the residents breakfast meal, and also passing resident morning medications. The facility residents care needs were not met during this time.

The following deficiencies are being cited Per Title 22 Regulation.

Exit interview conducted with facility Administrator Nancy Cudal, and a copy of this report along with appeals rights provided.