Facility Evaluation Report

On July 23, 2026 Licensing Program Analysts (LPAs) B. Miranda & M. Vega arrived at the facility unannounced. LPAs conducted a case management visit to cite deficiencies found while conducting an investigation for complaint # 24-AS-20260717154025. LPAs met with Administrator, Brittany Kavanaugh.

LPAs reviewed R1’s centrally stored medication log to not be properly completed. Nicotine 21 MG/24 HR Patch, RX 07803603, Expiration date 10/3/2026, Date Filled (blank), Date Start 7/1/2026; Spiriva Respimat 2.5 mcg, RX 07803598, Expiration date 10/3/2026, Date Filled (blank), Date Start 7/1/2026; Diclofenac Sodium 1% gel, RX 07803597, Expiration date 10/3/2026, Date Filled (blank), Date Start 7/1/2026. Centrally stored medication log is not being properly maintained.

During the visit on July 18, 2026 LPAs observed R1 & R2 to be in room 152. Room 152 is listed as having a bedroom and living room. R1 was placed in the living room, and would have to cross into R2’s bedroom in order to used the bathroom. LPA spoke with S1 and asked if the fire clearance for the facility had been updated with the Fire Dept, S1 stated yes but was not able to provide verification during the visit of July 18, 2026. LPA asked S1 if Licensing had been informed, S1 stated they believed so. LPA checked the facility’s records and there was no notification from the facility regarding the new fire clearance for changes made.

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