Facility Evaluation Report

Licensing Program Analyst (LPA) Bethany Mirlohi arrived on 7/22/26 to conduct a follow-up visit after receiving two Facility Action Reports (dated 7/1/26 and 7/6/2026) from ALTA Regional Center. LPA Mirlohi met with Administrator Howard and explained the purpose of the visit.

LPA and Howard discussed the Facility Action Report (FAR) dated 7/1/2026 regarding staffing schedules based on the Regional Center guidelines and required staffing ratio. LPA requesting staffing schedules from April to Current.

Based on the Facility Action Report (FAR) dated 7/6/26 there were several deficiencies observed. There were missing required documents from staff and resident files. S1’s facility file did not have a health screening with TB clearance. Additionally, R1’s file did not contain a signed copy of the Personal Rights LIC613.

There were several discrepancies observed regarding medication management and documentation. R2’s Centrally Stored Medication Destruction Record did not contain symptoms for reason of use for 5 medications. R1 was also prescribed Acetaminophen 500 mg for 15 days in March 2026. The medication is still on hand at the facility. Additionally, R1’s varenicline medication order states 1 tab after meals while it is being administered 1x daily at 8am.

Deficiencies cited on 809-D. Exit interview conducted. A copy of this report and appeal rights were provided.