Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 03/24/2026. 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 NOT been cleared. LPA observed Tylenol and Ibuprofen unsecured in resident room. Licensee has NOT complied with the terms of the POC. CIVIL PENALTY ASSESSED.

*Deficiency cited under Title 22 Regulation 87465(c)(3) pertaining to PRN documentation has been cleared. Licensee provided proof of correction. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has NOT been cleared. LPA observed both doors in R1 and R2's rooms still open with difficulty. Licensee has NOT complied with the POC. CIVIL PENALTY ASSESSED.

*Deficiency cited under Title 22 Regulation 87411(f) pertaining to TB test has been cleared. Licensee provided proof of correction. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87412(a)(11) pertaining to Health Screen has been cleared. Licensee provided proof of correction. Licensee has complied with the POC.