Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies in conjunction with a complaint visit (Complaint Control # 28-AS-20250820145116). The purpose of this visit is to issue deficiencies that were observed by LPA that are not part of the complaint allegation. The reason for the Case Management - Deficiencies was explained to Administrator Bryanna Luke.

During the complaint visit on 09/15/2025, LPA discovered that Resident #1 (R1)'s several unwitnessed fall incidents including those that happened on 08/10/2025, 08/11/2025 and 08/28/2025, resulting in injuries and required emergency visit/hospitalization were not faxed to Community Care Licensing (CCL). Interviews with the Administrator and Staff #2 (S2) confirmed that the incident reports were not faxed to Community Care Licensing (CCL) due to a broken fax machine. Additionally, the Administrator and S2 acknowledged R1's frequent falls and the need for a higher level of care or 1:1 supervision, however, a re-appraisal to assess R1’s condition was not completed.

Deficiencies noted on LIC 809D. Exit interview, a copy of this report along with the appeals rights were provided to Bryanna Luke, Administrator.