Facility Evaluation Report

Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of issuing a deficiency in regards to complaint investigation control number: 22-AS-20240731232601. LPA met with Executive Director Mike Marion and explained the reason for the visit.

The investigation in connection to the complaint mentioned above revealed that the level of care for Resident #1 (R1) was reduced from a level 5 to a level 1 on October 25, 2022 and increased to a level 3 on November 22, 2022. The facility failed to ensure that R1 was enabled to make informed decision and choices for their level of care. The investigation also revealed, based on the care assessments, the facility proceeded to provide a level of care that R1 had not signed for or consented to.

Therefore, a deficiency is being cited on the attached LIC809-D.

An exit interview was conducted with Executive Director Mike Marion, and a copy of this report including the LIC-811 and appeal rights were provided at exit.