Facility Evaluation Report

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced case management visit regarding an incident reports that were not reported to the Community Care Licensing Department. LPA met with Ewa Nyczak (Administrator) and explained the reason for the visit.

On 01/11/2024, during a complaint investigation (complaint control number: 28-AS-20240105092231) LPA Mora found out that the facility failed to report Resident 1 (R1) fall, hospitalization and death back in September 2023. During the visit, the Administrator could not remember the date of the fall and hospitalization. The death date is 09/18/2023.

The deficiency cited is documented on the LIC809-D. Exit interview held and a copy of the report and appeal was provided.