Facility Evaluation Report

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of documenting a deficiency observed during the investigation of complaint 22-AS-20230804111101 at the facility. LPA had been greeted and granted entry by facility staff after introducing himself and the reason for the visit. Administrator Theresa Kholoma was notified by telephone and arrived later to assist with the visit. LPA went over the deficiency observed and provided a consultation on resident records as three recent admission agreements were observed to be missing an administrator signature.

One Type B deficiency is cited on the attached form LIC809-D. A Technical Assistance Advisory Note is also issued regarding the Admission Agreements.

An exit interview was conducted and a copy of this report along with appeal rights were provided to facility representative via email due to printer technical difficulties.