Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced plan of correction (POC) case management visit to the facility above. The reason for this visit was to conduct a follow-up in reference to deficiencies that were cited during a case management visit that occurred on 09/20/2024. The LPA met with facility staff member Kina Nkumbula, at 02:46 PM and explained the purpose of the visit. Facility staff contacted the facility administrator Elba Khachatryan who arrived at the facility at approximately 03:00 PM. Entrance interview conducted and the reason for the visit was explained.

During today’s visit LPA Byrne interviewed the facility administrator. The facility administrator stated that they have not had time to submit the statement of understanding required to satisfy the POC for the deficiency that was cited. LPA informed the administrator that the POC is now considered late.

The facility administrator was advised during the original complaint investigation that failure to correct deficiencies would lead to additional penalties. The facility administrator did not provide the LPA with the required documentation within the appropriate timeframe. As this is a failure to correct the POC within the given timeframe and no extension was requested a civil penalty is being assessed in the form of $500. The total of the civil penalty is calculated at $100 per day starting after the due date of the POC. The POC for this deficiency was due on 09/27/2024 and today’s date is 10/02/2024. LPA informed administrator that failure to correct the deficiency may lead to additional penalties.

Exit interview conducted, civil penalty assessed, appeal rights provided, and a copy of the report delivered.