Facility Evaluation Report
Capacity6
Census2
Date signed12/28/2022 02:19:08 PM
At approximately 12:30 p.m. on 12/28/2022 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit for complaint number 31-AS-20221220142848. During a record review at approximately 1:15 p.m., LPA discovered missing resident records.
The facility did not maintain the LIC 602A, LIC 603, LIC 625, or LIC 601 for Resident #1 (R1).
The facility did not maintain the LIC 603 or LIC 625 for Resident #2 (R2).
The deficiency is addressed on this case management report.
Exit interview conducted. Appeal rights discussed. Copy of report provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction