Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of a Plan of Correction (POC) visit based on deficiencies cited on 09/15/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87202 pertaining to Fire safety has NOT been cleared. Licensee did not ask for an extension however stated on 09/22/2025 that LPA would receive the document on 09/23/2025. During today's visit, Licensee stated it had been sent via email on 09/24/2025 but is not able to show LPA that the document was sent. Licensee provided the document during the visit. Licensee has NOT complied with the terms of the POC. CIVIL PENALTY ASSESSED.

Exit interview conducted and a copy of this report was left at the facility.