Facility Evaluation Report

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for a deficiency issued on 01/17/2025 during the required annual inspection. LPA was greeted and granted entry by staff and discussed the purpose of the inspection.

LPA toured the facility to check the deficiency has been corrected with staff. Five out of six residents were found to have bed rails. Two out of those five residents did not have bed rail orders on file. R1 and R2 have been identified as not having bed rails orders.

The Plan of Corrections has not been fulfilled by the assigned POC due date of 01/18/2025, thus not clearing the deficiency.

Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.