Facility Evaluation Report

Licensing Program Analysts (LPAs) Mariana Agban and Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20231009085600. LPAs met with the Administrator and explained the reason for the visit.

During the visit it was observed that staff #2 (S2) and staff #3 (S3) were working in the facility without being associated with this facility. Record review revealed S2 and S3 do have fingerprint and background clearance, but is not associated to this facility. Employee records revealed S2 started employment at this facility in June of 2022. In addition, Staff #3 (S3) started employment at this facility about two years. Interviews with residents and staff corroborate S2 and S3 have worked in the facility and provided assistance to residents. Team requested and reviewed personnel files. There were no transfer request forms in the personnel file. The Licensee/Administrator did not request a transfer with the department. This was previously cited on 07-23-2023. A civil penalty will be issued. Due to time constrains LPA was unable to complete citations. The Administrator was informed that additional visit will follow to render the citations.

Copy of this report provided, appeal form given. Exit interview conducted.