Facility Evaluation Report

An unannounced Plan of Correction (POC) visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. The purpose of this visit is to follow up on the pending Plan of Corrections (POCs) that were issued during a required annual visit conducted on 01/25/2022 by LPA Avetisyan, Additional citations were issued on 7/27/2022 during a Complaint investigation and Case Management visit.

On 1/26/2022 Licensee/Administrator were cited for the following, and complete plan of corrections were not submitted. On 1/26/2022 Administrator faxed LPA written statements however the written statement did not have the information as discussed and documented on the Annual Report.

87608 (a)(5)(B) and 87608 (a)(3) Postural Supports :

87705 (c)(5)(A) Care of Persons with Dementia.

87633 (b) Hospice Care of Terminally Ill Residents

ON 7/27/2022 Licensee/Administrator were cited for the following. As of Todays visit Plan of Corrections have not been submitted.

87468.1 (a)(2) Personal Rights of Residents in all facilities.

87470 (c)(1) Infection Control Requirements

87211 (a)(2) Reporting Requirements. - This deficiency was a repeat citation therefore civil penalty in the

amount of $250.00 was issued. Administrator was informed that additional civil penalty in the amount of $100 per day would continue to accrue until a detailed/complete Plan of Correction was submitted to the Department.