Facility Evaluation Report

At approximately 11:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit and met with Executive Director, Kimberly Humphrey. The purpose of today's visit was to conduct the facility's quarterly Non-Compliance inspection and to follow up on an incident report that was self submitted to Community Care Licensing (CCL).

LPA reviewed files for staff members hired between July 2025-October 2025 related to the below concerns:

Administrator and Designated Representatives

LPA observed that identified staff members hired within this time frame had appropriate training documented.

LPA followed up on an incident report that was submitted to CCL on 10/01/2025. Report states that on 09/25/2025, Resident 1's (R1's) medication was administered to Resident 2 (R2). Per report, both residents have the same medication with the same dosage. Residents were placed on 72 hour monitoring to observe for any adverse effects (deficiency cited, LIC809D, regulation 87465(a)(4)).

Facility provided proof of training conducted on 09/25/2025 on "The Six Rights" related to the incident report. Deficiency cleared during visit and Corrections Letter provided.