Facility Evaluation Report

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to conduct a Case Management visit. LPA Hurt met with facility Facility staff Terry Lacey and Licensee Lidia Silveira.

LPA observed Resident 1 was admitted to this facility on 12/24/2024, and resident 1's medical assessment was completed on 09/22/2020, signed by physician on 08/04/2021.

LPA Hurt has visited the facility on 01/15/2025, 08/18/2025,09/10/2025, 09/12/2025,and 09/16/2025. LPA has never met or observed the facilities Administrator to be present at this facility despite there being multiple complaints since 08/2025. LPA interviewed multiple facility staff who all stated they have either never seen or rarely see the facilities Administrator.

LPA Hurt observed Resident 2's appraisal has not been done since 08/2021.

The following deficiencies are being cited Per Title 22 Regulations, and a copy of this report along with appeals rights provided.