Facility Evaluation Report

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Legal Non-Compliance inspection at the facility today. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. Areas discussed:

A. Licensee shall operate the facility in substantial compliance with regulations and statures governing the operation of a residential care facility for the elderly. During today’s visit, the LPA reviewed a random sample of ten staff records. Out of the ten files reviewed, the following was noted:

a. Four out of ten staff (Staff #2, Staff #3, Staff #6, Staff #7) had a job application that was either incompletely filled out, blank, or missing

b. Four out of ten staff (Staff #1, Staff #6, Staff #7, Staff #8) had a health screening that was either incompletely filled out or blank

c. Three out of ten staff (Staff #2, Staff #3, Staff #7) did not have first aid certification on file

d. Three out of ten staff (Staff #1, Staff #3, Staff #8) require tuberculosis results

B. Career Smart will conduct quarterly audits and have weekly calls with the Administrator. Last quarterly was 3/4/2022 and today, 6/1/2022. Staff confirmed that weekly calls are still taking place. LPA obtained a copy of the quarterly report from 3/4/2022.

C. Licensee will include specific inquiries regarding sexual behaviors and aggressive behaviors during the initial evaluation of new residents Reappraisals will address sexual behaviors and aggressive behaviors when such conduct is evident . Addendum has been added, per licensee. LPA obtained a copy of the addendum. There was one move-in for April and May of 2022 in which facility utilized the new addendum. Copies are kept in a file at the facility.