Facility Evaluation Report

At 12:35 p.m. on 09/29/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out.

During a complaint investigation on 09/28/2022, LPA Reed conducted a file review at approximately 5:00 p.m. LPA observed 1 staff present was not associated to the facility in the Guardian system. The assistant Administrator confirmed over the phone that all staff had background clearances but needed to be associated.

LPA conducted another file review on 09/29/2022 at 12:30 p.m. The staff present were still not associated to the facility in the Guardian system. Deficiency is cited on the attached LIC 809-D page.

Exit interview conducted. Copy of report, appeal rights, and citation issued.