Facility Evaluation Report

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/2/25 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. Administrator/ Licensee was present to assist

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Medication pre-pour practices discussed. Emergency drills were not recorded.

LPA reviewed 3 resident and 2 staff files. Resident and staff files requirements were discussed and advice provided.

LPA requested the following documents to update the facility file: LIC 308 for designees for each shift, LIC 500 for current staffing. To be submitted by fax by 9/9/25. Training material provided.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Exit interview conducted with Administrator and copy of report and appeal rights left at the facility.