Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced Plan of Correction (POC) visit to the facility for the purpose of following up on citations issued on LIC form 809D during the annual required visit on 03/18/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has been cleared. During today's visit, LPA observed medications are secured and inaccessible to residents in care. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87465(h)(5) pertaining to Incidental Medical and Dental has been cleared. During today's visit, LPA observed staff has discontinued pre-pouring medications. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87303(e)(2) pertaining to Water Temperature has been cleared. LPA tested water temperature to be between 110.8 and 113.5 degrees F. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87411(c) pertaining to Required Training has been cleared. Facility provided proof of training. Licensee has complied with the terms of the POC.

Licensee has been advised to maintain all items especially those that were previously deficient in the facility in accordance with Title 22 Regulations.

Copy of this report was provided to the facility.